In 1876, Alexander Graham Bell and his colleague Watson experienced the very first telephone call in their Boston lab. The call wasn't clear or crisp, but it was the end of the telegraph and the beginning of modern day telephony. Today, the smartphone has further revolutionised the way we see a telephone. It integrates multiple technologies in the palm of your hand; communication is crisp and clear and reaches across the world, it even provides access to the world’s knowledge and photography worthy of a pro. Who, in the 1800’s, would have imagined that this level of technology would be possible?
In the late 1950’s portable audiometers were first developed in an effort to reach those with no access to hearing healthcare. A portable audiometer, in those days, was fairly rudimentary and comprised a stripped down audiometer with a handle. It also needed to be attached to an electricity supply to operate which was surely a technical hindrance, not to mention the additional need for a sound booth.
Fast forward to today where we have fully functional portable audiometers that not only comprise the full stack of diagnostic technology but also don't need a sound booth to operate. They are easy too use and move and, can run off of the power supplied by a laptop. Like the telephone, audiology has now been truly revolutionised. Unlike the telephone, medical devices are under a lot more scrutiny and can take much longer to reach and be generally accepted in the clinical space.
Dr. Dirk Koekemoer is no stranger to bringing medical devices to market. He is also directly involved in shaping the future of audiology through his innovations. His groundbreaking invention of the KUDUwave™, the portable audiometer shaking up the industry, as well as many publications addressing tele-audiology and taking healthcare to all make him the perfect candidate for a Q&A session this month.
Dr. Dirk Koekemoer, MBChB (UP), is a Medical Doctor, Software Developer and Managing Director at eMoyo in Johannesburg, South Africa. eMoyo is a biomedical engineering company, that researches, develops and manufactures medical technologies specifically designed to change the accessibility, cost and effectiveness of primary health care. Dirk is passionate about the development of medical devices and software tools to automate, speed up and improve the quality of primary health care examinations in a society with little health care resources.
Diving straight in, a lot of people are wondering; why the name ‘KUDUwave’?
Dirk Koekemoer (DK): During the initial stages of its development the device used to be called the Audiograph. But after some time, I started looking for a new name. One that represented Africa, more specifically South Africa. I also wanted a name that is easy to pronounce in all languages. Until one day, I stumbled across a picture of a kudu, an antelope species, with huge ears. We couldn’t register the name Kudu so we decided to add the word ‘-wave’ to it and ended up calling it the KUDUwave.
What type of audiometer is the KUDUwave? Is it the same as a smartphone-based audiometer?
DK: First of all, a smartphone is not an audiometer, it is a cell phone with a headset and it could possibly be certified as an audiometer. But the KUDUwave itself is a device with headsets which have built in audiometers on both sides. It’s a certified diagnostic audiometer, and not just a screening device. It’s conveniently laptop based and portable, providing air and bone conduction, speech audiometry and many more other tests.
Why should audiology services be provided through such audiometers if traditional audiometers/sound booths have always worked?
DK: If we look at a developed country like the USA, there still aren’t enough people benefiting from hearing healthcare services, nevermind the rest of the world. Millions of people across the globe do not have adequate health care services, and little to no access to audiology services. In the whole of Africa only two countries train Audiologists, which are Egypt and South Africa, leading to a shortage in qualified practitioners. It’s a big problem that needs to be solved. Typically a soundbooth is an expensive piece of equipment that cannot be deployed into areas where the help is needed most. Therefore light, portable equipment, that can be easily serviced are paramount when seeking to address this problem. The KUDUwave was the most fitting solution to take healthcare to all of humanity.
Is this technology only for the benefit of people in rural and remote areas?
DK: No, not at all. It is a top class diagnostic audiometer. People in very advanced centres would benefit immensely from using it. From hospitals, to clinics and even universities, its application goes beyond healthcare services for remote areas. It replaces both the soundbooth and traditional audiometers in all spheres of life. To such an extent that there are audiologists who have sold their traditional equipment in exchange for a KUDUwave.
On that note, what would you say to an audiologist debating whether or not to trade in their traditional equipment for something more advanced and portable like the KUDUwave?
DK: I would play open cards with them, explaining the real benefits of the KUDUwave. It gives you mobility and the freedom to go to your patients instead of having them come to you. You could go to old-age homes, and schools and extend your services to the community at large. It could also be used inside a soundbooth, should you insist on having one, and that would increase your ability to block noise exponentially. It’s especially appealing to audiologists who are just starting up, it just makes sense to have a KUDUwave.
The patient benefits of the KUDUwave are very clear. But how does the KUDUwave maximise the health professional’s experience?
DK: First of all they are mobile, they can have the patient sitting next to them, not in a soundbooth, isolated from them. Providing a much better patient-practitioner relationship. More especially when you look at the people who have hearing problems, whether it’s an elderly person or a young child that doesn’t understand instructions, it’s better to be with them. Another benefit is that a practitioner can extend his or her reach by deploying these machines to other healthcare professionals like GPs and nurses going out in the field locally and even internationally. Via tele-audiology they can see people over the internet, and deliver quality services even in remote areas.
The adoption and implementation of tele-audiology has been growing exponentially and is adapted fully into the KUDUwave package. Can you define tele-audiology for us? And the models used to deliver services?
DK: Tele-audiology is healthcare over a distance, particularly hearing healthcare. It means an audiologist could be sitting behind their table somewhere in the world and they would be able to see a patient thousands of kilometers away inside a primary healthcare clinic on the other side of the world. As a matter of fact, I would say audiologists are used to tele-audiology, they just probably never realised it. They sit behind their table and the patient sits inside the booth. They then talk to the patient through technology, while looking at them through a glass window. Sounds like tele-audiology to me [chuckles]. The KUDUwave simply makes use of digital video and that’s how we were able do the first transatlantic hearing test in 2010 from Dallas in the US to Diepsloot in South Africa. But essentially that’s just one part of tele-audiology which makes use of real-time synchronous testing. Asynchronous teleaudiology is the other part that works more like an email. For example, you do an automatic test, the results go up to a central server where an audiologists will interpret the results from across the world and send back the interpretations along with recommendations to the health practitioner with the patient.
Vetting and constant clinical validations of medical devices is paramount. Is the KUDUwave clinically validated? What two clinical studies would you recommend one reads for clinical validation results?
DK: The KUDUwave is a medical device which carries the necessary certifications and markings such as the CE mark for Europe. We have even higher standards for our products where we added extra technology to the equipment to increase its reliability. Features that enable calibration verification and ensuring that it’s quiet enough when testing. There are no particular standards for that, but we created internal standards that are being audited by BSI. We did multiple clinical trials, there are 10 publications solely on the validation of the KUDUwave in international journals. Not just articles that say the KUDUwave was used, but scientific validation studies on the actual device. There are two major studies, the one is where more than 149 children were tested inside a soundbooth and again in the classroom and the KUDUwave yielded exactly the same results. The other study was to demonstrate the accuracy of the KUDUwave tests as compared to a traditional audiometer. This experimental study was done with the audiometer in the soundbooth and the KUDUwave outside the booth.
Surely, if the KUDUwave can conduct automatic diagnostic audiometry and provide assistive interpretations, will audiologists be replaced by such technology?
DK: Not at all, but just to clarify things. The KUDUwave cannot do a full comprehensive diagnostic test at the moment. It has the ability to do many of the diagnostic tests needed, like pure tone thresholds, bone conduction, speech audiometry, word recognition etc. However, not all of them have been automated. The software also has assistive interpretation on the results which help the audiologist or healthcare professional to make sense of the test results. Now, to answer your question, there are 3.5 billion people in the world still without adequate healthcare services, there aren’t nearly enough audiologists to cater to the needs. Audiologist would have to spread their wings and increase their coverage and what better way to do it than with tele-audiology. We actually seek to extend their reach by helping them take their services to those who need them most.
You know you cannot get away without answering this one. A sound booth is important for obvious reasons. Why is the KUDUwave not used in a sound booth? How does it attenuate ambient noise during testing?
DK: The aim of a hearing test is to find the softest sound a person can hear and that is why it has to be extremely quiet when conducting a hearing test. Traditionally, a person had to be inside a soundbooth to get tested. This ensures that the individual is not distracted by ambient noise. Nowadays you will see cell phone apps that claim they can do testing, but what’s sad is that they don’t mention that the person still needs to be in a soundbooth for accurate results. We do know that relying on the headset alone for attenuation is insufficient to produce reliable test results and often ends up in elevated thresholds. But the KUDUwave is the only audiometer in the world that can test outside a soundbooth, even in a very noisy environment. Simply because it uses Ambi-dome technology that is inhouse developed by eMoyo. This technology blocks sound at two-levels and monitors the noise levels in real-time and will not test when the environment is too noisy. In a nutshell Ambi-dome technology enables you to escape the use of a soundbooth.
Any future plans for the KUDUwave™?
DK: We are currently developing and perfecting a tympanometer for the KUDUwave that will test the integrity of the eardrum and the middle ear. We will also have an OAE, an otoacoustic emission test, in the same KUDwave, that will actually test the sounds created by your cochlear when a sound is played in the ear, which is particularly important for newborn children who cannot respond. We are very excited for the future.