The SHOEBOX Online Journey: A Q&A on Our Innovative Hearing Screening Solution

In an interview with Vanessa Gauthier-Davidson, SHOEBOX Online is introduced as a self-administered hearing screener designed for adults to assess their hearing health using various devices and consumer headphones.

AudiologyOnline.com: What is SHOEBOX Online?

Vanessa Gauthier-Davidson: SHOEBOX Online is an innovative, self-administered hearing screener designed to make personalized hearing healthcare more accessible. This tool is ideal for individuals who are curious about their hearing health. It categorizes results into three distinct groups: normal hearing, hearing loss, and significant hearing loss.

One of the standout features of SHOEBOX Online is its ability to work with a variety of Internet-connected devices. The screener works seamlessly whether you're using a desktop, laptop, tablet, or mobile phone. This includes compatibility with any consumer headphones, a feature we carefully researched and developed to ensure screening accuracy regardless of the headphones used.

Additionally, SHOEBOX Online can be used in telehealth settings. Whether a person is at home or in a healthcare environment, such as a hospital, this remote screener provides a reliable assessment of their hearing ability.

However, it's important to note that SHOEBOX Online was developed exclusively for adults. We recommend that only individuals over 18 years old use this online screener. By lowering the barriers to entry, SHOEBOX Online aims to empower more individuals to take the first step towards better hearing health.

AudiologyOnline.com: Now that we understand what SHOEBOX Online really is, what can you not do with it?

Vanessa Gauthier-Davidson: First, SHOEBOX Online is strictly a screener; it's not a diagnostic tool or medical device, nor is it meant to replace a comprehensive hearing test.  At SHOEBOX, we offer a range of products that cover the full audiology care spectrum, from screening to diagnostics. For example, SHOEBOX Consult is an audiometer focused on diagnostics, and our tablet-based audiometer, SHOEBOX Pure Test, is an automated platform used for hearing evaluations.

However, SHOEBOX Online is designed to be a user-friendly and accessible initial step in the hearing health journey. It's important to understand that while it provides valuable insights into one's hearing status, it doesn't replace professional diagnostic tools or services.

AudiologyOnline.com: What inspired the development of SHOEBOX Online, and what makes it different from the other screeners?

Vanessa Gauthier-Davidson: The development of SHOEBOX Online evolved from an interdepartmental collaboration, bringing together our research and development team, product management, research team, developers, and audiologists to ensure clinical validity in the screener. Recognizing the sensitivity of the term "accurate" in the context of hearing screening, we preferred to use the term "screen accuracy" to distinguish it from a comprehensive evaluation.

Initially, there was some healthy skepticism about the project, particularly from those of us with clinical experience. However, this doubt was quickly dispelled once we saw the rigorous planning and visionary approach that went into SHOEBOX Online.

We understood the complexity of different devices and headphones that users might own, so we conducted extensive trials with a diverse range of computers, mobile phones, tablets, consumer headphones, and multiple browsers. We meticulously tested and created presets for various combinations of sound output, ensuring that SHOEBOX Online delivers reliable results across a wide range of user configurations. This thorough testing and dedication to quality set SHOEBOX Online apart from other screeners on the market.

AudiologyOnline.com: Is this all to ensure the accuracy of the online screening program?

Vanessa Gauthier-Davidson: Yes, that's correct. We found that different types of headphones, such as over-the-ear and earbuds, produce different sound outputs. This difference is especially noticeable when comparing wired and wireless connections and using various devices like computers and mobile phones. To address this, we extensively tested our product design with both people with normal hearing and those with hearing loss to ensure its screening accuracy.

At SHOEBOX, we prioritize accessibility in all our solutions. Our screener is currently available in 28 languages, making it highly accessible and setting us apart from the competition.

Now, let's discuss the validation process. We internally validated our product with 98 adults, examining 196 ears. The participants included individuals with normal hearing and those with hearing loss, and we used previously obtained audiograms for comparison. Each participant could use their preferred device, whether it was a laptop, phone, or any type of headphones, including Apple AirPods. We had no restrictions; our goal was to validate the hearing screener in real-world conditions. We compared our results with conventional audiometry, focusing on thresholds at 1000, 2000, and 4000 Hz to match the screener tones.

Our validation demonstrated a screening accuracy of 93%, meaning 93% of ears were correctly classified as having good hearing or hearing loss. We achieved a sensitivity rate of 95% and specificity of 91%, showing high reliability based on threshold-based audiometry. We used a threshold of 30 dB to define the hearing loss category, which in conventional audiometry typically classifies mild hearing loss. For our validation, any threshold at 1000, 2000, or 4000 Hz hitting 30 dB or more was considered indicative of hearing loss. Conversely, thresholds 25 dB or better were classified as normal hearing. Our classification system was designed to match these standards.

It's important to note that SHOEBOX Online does not test low frequencies below 1 kHz, as these frequencies are most sensitive to background noise. Therefore, any isolated low-frequency loss would not be detected in our validation. This distinction is essential for understanding the scope and limitations of our screener compared to a full audiometric evaluation.

We understand the challenges of online screening, such as uncontrolled environments and uncalibrated headphones. Factors like background noise from a nearby highway, a loud refrigerator, or an air conditioning unit can impact results. Despite these challenges, our validation process was crucial in building trust with users and ensuring they received accurate and dependable information about their hearing health.

AudiologyOnline.com: How does SHOEBOX Online ensure accuracy?

Vanessa Gauthier-Davidson: Our team has identified four key factors that work together to ensure screening accuracy. Since this is a self-directed assessment using consumer headphones, we needed a multi-layered approach.

The first factor is device and transducer compensation. We analyzed various headphones and compensated for variances in sound output depending on the combination of the device and headphones. This ensures that the screener delivers reliable results regardless of the equipment used.

Next, the hearing screening has a structured yet adaptive flow. It starts with basic demographic information, followed by a dynamic questionnaire. This questionnaire probes into the participants' perception of their own hearing ability and adapts based on their responses. For example, depending on your answer, subsequent questions will vary to delve deeper into your hearing perceptions. This dynamic approach is beneficial for clinicians reviewing the results later, providing insights into the patient's perceived hearing loss.

The third factor is our patented test methodology within SHOEBOX Online, which includes a dynamic range assessment. This method helps identify each individual's comfort level while listening to a speech file. We know that as hearing loss increases, the range between a comfortable level and a perceivable level decreases. Based on research by Francis Kuk at Widex, this dynamic range logic uses relative measurements independent of the headphone type. This approach is ideal for an online test where we can't control the headphones, ensuring a reliable measure of hearing abilities.

The fourth component is multifrequency tone detection. We present warble-tones at 1, 2, 4, and 6 kHz to estimate the participants' hearing per frequency. We focused on speech communication and everyday life frequencies, avoiding low frequencies that are highly susceptible to background noise in uncontrolled settings. To further enhance screening accuracy, we prompt users at the beginning of the test to ensure they're in a quiet environment and to avoid using low-quality or children's headphones.

These four factors: device and transducer compensation, a dynamic questionnaire, a patented test methodology, and multifrequency tone detection — collectively help us determine whether a participant has normal hearing loss or significant hearing loss.

AudiologyOnline.com: Why are clinics implementing hearing screenings like SHOEBOX Online?

Vanessa Gauthier-Davidson: There are various reasons why clinics are opting to implement SHOEBOX Online. One of the most compelling reasons is its ability to raise awareness and promote hearing health. Remember, this test can be conducted by almost anyone, almost anywhere, from the comfort of their own home. We understand that hearing loss can be an emotional journey, and taking the first step to address it can be intimidating. Conducting the screening at home provides a comfortable, private environment, which can help break down barriers and encourage individuals to take the next step in addressing their hearing health.

SHOEBOX Online also functions as an educational tool. The test is highly customizable, allowing clinics to include call-to-action pages before and after the test. This helps clinics educate patients about the impact of hearing loss on quality of life, provide information on assistive devices, and more. It's an excellent icebreaker for audiologists; knowing that a patient has completed an online screening allows the audiologist to review the results and start a conversation with, "I see you've done an online hearing screening. What prompted you to do it?."

Audiologists also have control over the information provided to patients, ensuring that it is evidence-based and tailored to their needs. This controlled dissemination of information enhances patient education, builds trust, and fosters a more informed dialogue between the patient and the audiologist.

Clinics are implementing SHOEBOX Online in various ways. It can be easily embedded on their websites, making it accessible to anyone visiting the site. It also functions as an effective triaging tool. Clinics are often busy, and hearing tests can range from 30 to 90 minutes, depending on the complexity of the hearing loss and the testing required. Having initial screening results can help allocate testing time more efficiently. For example, knowing whether a patient likely has normal hearing or significant hearing loss can help prioritize appointments and resources.

Moreover, SHOEBOX Online can be sent as a direct link to patients, allowing them to complete the screening before their appointment. This provides the clinic with preliminary information about the patient's hearing ability, helping to streamline the appointment process.

Additionally, SHOEBOX Online is a powerful marketing tool. It can be customized for branding, allowing clinics to incorporate their logos and colors. This makes it a valuable asset for digital marketing, social media, and print advertising campaigns. The software also includes secure data management functionality. Once a test is complete, the results are automatically uploaded to the SHOEBOX Web Portal, where audiologists can review them. This automation ensures data is managed efficiently and securely, enhancing the overall patient and clinician experience.

AudiologyOnline.com: How are the results kept confidential and HIPAA-compliant?

Vanessa Gauthier-Davidson: That's a fantastic question. Confidentiality and security are of the utmost importance, particularly in clinical settings. Every test conducted using the SHOEBOX Online screener is automatically uploaded to our web portal, a privacy-protected cloud data storage system designed to synchronize and securely store data used with all SHOEBOX products.

Our web portal can be accessed via a browser on any computer and is fully HIPAA-compliant, ensuring that all data and results are securely backed up. Patients have the option to email their results directly to themselves, and these results can also be remotely reviewed by a professional through the web portal. This system allows data to be assessed at a later time when the patient visits for a hearing assessment, maintaining both security and convenience.

If a patient completes a hearing test on a clinic's website, the data is securely stored, and the clinic can control what demographic information it collects. Our SHOEBOX Online test is highly customizable, allowing clinics to decide which demographic information is mandatory during the test experience or optional. While patients can input any information they want, if a field is marked as mandatory, they will need to complete it to proceed with the test. This ensures that their privacy is always respected while allowing clinics to gather the necessary data for better service and follow-up.

The SHOEBOX Online screener is highly customizable, allowing clinics to decide which demographic information to collect and which fields are mandatory. This customization balances patient privacy with the need to gather essential information for an effective early patient experience. Additionally, SHOEBOX ensures that each clinic uses client information solely for hearing care through a clear and explicit privacy policy and permissions system.

In summary, security, confidentiality, and HIPAA compliance are always top of mind at SHOEBOX. We are committed to providing a safe and secure platform for both patients and clinicians, ensuring that all data is handled with the utmost care and integrity.

AudiologyOnline.com: What kind of developments do you foresee in the future of this online hearing screening program? Are there any projects at SHOEBOX that are being kept under wraps?

Vanessa Gauthier-Davidson: The SHOEBOX software-based products allow for continuous adaptation and improvement based on user and clinician feedback. We are always listening and enhancing, making continuous improvement one of our biggest strengths.

Today, I've mainly discussed scenarios where the hearing screener is done at home, with the patient independently deciding to do the screener. However, we've recently launched an onsite mode in response to customer feedback. This mode is designed for situations where customers want to assist participants in person using their own tablet or device in a controlled environment, such as a clinic's front desk, allowing for an online test using a clinic's computer or iPad.

In this onsite mode, we have streamlined some steps to make the process quicker. For instance, if the same headphones are always used, we can skip the step of choosing headphones and setting the volume. We've also added a restart button for convenience, allowing multiple people to take the test one after another without seeing each other's data. This enables a real-time interaction where the participant can receive immediate feedback and assistance with the next steps, such as booking an in-person appointment for comprehensive testing.

Using high-quality headphones like the DD 450 or DD 65 in this controlled setting offers optimal attenuation for background noise, ensuring the screener's accuracy. The new onsite mode leverages the strengths of both self-directed screening and controlled environments.

We're continuously innovating and have many exciting developments in the pipeline.

I invite everyone to visit our website at shoebox.md, where we have a SHOEBOX Online test demo right on the homepage. Our development and product management teams are continually working hard to improve and evolve our offerings, and we welcome everyone to try out the demo and see firsthand the dedication and effort we've put into making SHOEBOX Online a valuable tool for hearing health.