This week on the Future Ear Radio podcast, I’m joined by the awesome Audiologist, Jill Davis, owner of Victory Hearing & Balance in Austin, Texas. I met Jill down at the Florida Combined Otolaryngology Meeting (FCOM) in Naples, Florida earlier this year where I saw her present about how she implemented Cognivue’s computerized cognition screener into her private practice. Cognivue has been on my podcasting radar for a while, so I figured Jill would be a great place to start to share her perspective of implementing the screener and some of the major takeaways she’s had from doing so.
During our discussion, Jill walks me through all the major details of her Cognivue process. She shares her initial motivation for wanting to incorporate the screener, how the device works, the patient experience and feedback, and how she communicates the screener’s results to her patients. The purpose of Cognivue is to help screen for signs for what might be the early onset of cognitive decline.
The thing that really jumps out at me is how Jill describes screening for cognition as being another, “piece of the puzzle,” that helps to paint a more wholistic picture of what’s going on with the patient. There’s a full battery of tests that Jill is pairing Cognivue with that goes way beyond the Audiogram in helping her to understand what the patient is experiencing.
Additionally, we also talk about how powerful of referral generation tool Cognivue has been for Jill’s practice. In two years, physician referrals have skyrocketed to the top of Jill’s referral sources, providing her with a steady stream of patients who are coming through Jill”s doors via their primary care doctor’s recommendation. That’s huge for a private practice.
This whole conversation really ties a bow on the hearing healthcare themed discussions I’ve been having on the podcast this year. We are in the midst of a wide variety of new tools and methodology emerging in this industry that cater to the Audiologists’ demand to differentiate themselves and their services in the market on the basis of Audiological expertise.
As I continue to learn more about these new methods that Audiologists can utilize to elevate themselves in their respective markets, I increasingly feel confident that the sky is the limit for the professional, and that the only limiting factor across the coming years will be apathy or the decision to adhere to the status quo.
-Thanks for Reading-
Dave
EPISODE TRANSCRIPT
Dave Kemp:
Hi. I’m your host, Dave Kemp. And this is Future Ear Radio. Each episode, we’re breaking down one new thing, one cool new finding that’s happening in the world of hearables, the world of voice technology. How are these worlds starting to intersect? How are these worlds starting to collide? What cool things are going to come from this intersection of technology? Without further ado, let’s get on with the show.
Dave Kemp:
Okay. So we are joined here today by Jill Davis. Jill, tell us a little bit about who you are and what you do.
Jill Davis, AuD:
Hello. Thank you so much for having me. I’m a private practice audiologist in Austin, Texas. So I’ve owned my clinic since 2019. Yeah.
Dave Kemp:
Well, awesome. Thank you so much for being here. Yeah, I’ve gotten to know you a little bit. Over the last few months we met down in the FCOM in Florida, the Florida Combined Otolaryngology Meeting. And I think that’s what FCOM stands for. And I know that when I was down there, I saw you present on Cognivue. So this is a really cool and interesting company. And the reason I wanted to have you on, is, I could and I probably will eventually have somebody from Cognivue, the company, but you are a private practitioner using Cognivue and I think that’s super interesting to talk through. And so I wanted to just understand how this all came to be and what the experience has been like. And as we have this conversation, just helping to share with us how this whole thing works.
Dave Kemp:
So why don’t we start, so you’re based in Austin, Texas, you have Victory Hearing & Balance is your private practice. So help me to understand because I know you were working at an ENT before that, but when you started Victory, were you immediately looking for new ways to enhance the overall patient experience or what ultimately led you to Cognivue or did it find you?
Jill Davis, AuD:
Yeah, a long story, but actually I was looking for a solution for my patients that struggled to hear in background noise. That’s it where it all started, that it was a consistent complaint with everyone walking in the door, and hearing aids didn’t seem to help with everyone. So we were looking into auditory training options with them and I started creating a music based auditory training program for those patients. And that took a lot of reading literature on neuro musical research and finding that people who play instruments actually have better memory and executive function than those who don’t. And I wanted a way to screen that.
Jill Davis, AuD:
So it actually, just by chance, when I started working on this program, Cognivue was at the ADA Convention that year, in 2019. And I said, “Ah, perfect. I need that one because that looks really easy.” Where the other cognitive screeners that I was looking into, you had to do a training, you had to paper and pencil test. And it just looked a little overwhelming that I just put it off where Cognivue, self-administered patient does it themselves. It’s not much more that I had to do. So I signed up because I wanted to use it for those patients who were struggling to hear in background noise as a pre-imposed training outcome measure. So yeah, it was a funny way that that happened.
Jill Davis, AuD:
But I also, I was counseling my patients on that ear to brain connection. So I had learned about the Johns Hopkins in 2011 when he said hearing loss leads to cognitive decline. And that that was surprising for us. I think we already knew it, but to see it in the literature, it really, I wasn’t comfortable explaining that connection to my patients yet until I saw Anu Sharma present her research on cortical reorganization that occurs with untreated hearing loss. She showed those beautiful functional MRI studies and I was sitting there and the light bulb went off like, “This is what’s happening with my patients. This is what they’re telling me when they’re feeling like they’re struggling.” Now I could make that connection. And it just completely changed the way that I counseled and we talked about what they were going through.
Jill Davis, AuD:
And so I had been doing that for quite a few years, and then once the cognitive screening was available, it was like, now I have a way to show them what they’re feeling instead of just explaining what could be happening with them when they feel like things are starting to change and they’re more forgetful, I could say, “I have a test that we can do to see how you’re doing.” And so that was a game changer to actually have a number and a report to show them how they were performing. Because they feel like things are changing when you start to talk to them about that ear and brain connection.
Dave Kemp:
Yeah. I find this whole thing to be so fascinating. So when you say you had this light bulb moment, clearly this was something that you and probably many other audiologists were you knew that there was something there, but like you said until you started to see it from different research entities like Johns Hopkins and it’s reported within clinical studies and it’s in the literature then it really does become apparent. And I’m curious, so you had mentioned that you were sitting in this presentation, the light bulb goes off. What exactly was it in simple terms for somebody like me to wrap my brain around, what was it that was a really clear connection in your mind of what was happening here?
Jill Davis, AuD:
Yeah. So she first, so Anu Sharma in their lab in Colorado, they looked at patients with severe to profound hearing loss and they did functional studies of the brain when they would present visual and auditory and tactile stimulus to these patients. And they did that with severe to profound hearing loss, and then again with mild hearing loss. And what they found was someone who has hearing loss when they presented a visual stimulus, the hearing part of the brain lit up and that’s not supposed to happen.
Dave Kemp:
Interesting.
Jill Davis, AuD:
When they presented a hearing stimulus, the frontal lobe lit up and that’s not supposed to happen. And so the way that I explain it to the patients is that with just a mild amount of hearing loss, your vision takes over your hearing. And that’s why you hear better when you’re looking at the person. And from there, your hearing actually gets pushed to the frontal lobe and that’s where working memory and recall is. So when you’re hearing with the wrong part of your brain, you’re working harder than you should have to, and you’re going to become a little bit more forgetful. And so these people are more tired at the end of the day. They really have to look at the person and that’s why masks have caused such a problem for our patients because they’re finally realizing how much they relied on that visual cue. And I just tell them, “It’s not your fault. Your brain starts to change to compensate for that loss and you’re just working harder than you should have to.”
Dave Kemp:
So what’s really interesting, now this takes me back to a conversation I had, Dr. David Eagleman. I actually had him on the podcast before. And his book, Livewired, the whole premise of the book is that you, whether it’s aging or if you’re born, maybe with some disablement, so if you’re blind or you’re deaf, the way in which your brain live, he refers to it as live wiring. It’s like the neuroplasticity of it is constantly evolving and adapting. And everything that you’re describing is basically that, where as you age and as your hearing depreciates, certain portions of your brain overcompensate for that. And so it’s truly like your frontal lobe is basically playing the role that historically a different portion of your brain has. And that’s the first thing that stands out in my mind with that, because there is neuroscience that really speaks to this whole theme. And that so much sense in my opinion, which is, again, just a testament to our brains are these amazing and mysterious things that there’s so much happening below the surface that it’s like, “Aha, now that really does make sense.”
Jill Davis, AuD:
And patients feel it and they know it. And it’s more common for someone to tell me they have a difficult time hearing when they’re not looking at the person, or if they’re in the other room, than a patient to just offer up, “I’m starting to be more forgetful and my memory’s not as sharp.” They always usually introduce the eye connection and that’s how I can keep it all together and make it make sense because of those study that big presentation. I say it every day, all day.
Dave Kemp:
Yeah. Well, but this is what’s so interesting, and this is why I really latched onto your presentation and immediately was like, “Can I please get you on the podcast?” Is this idea that I feel like one of the most exciting paths forward for audiology is this domain of being the liaison between the world of hearing and hearing loss and really trying to identify some of the underlying things that are going on. Because I think that what’s becoming really apparent is that it’s not just the knob gets turned down on your ears. There’s so much more that’s going on here. And I’d be really curious whether it’s Cognivue, but based on your presentation, it sounds like there’s a whole battery of things that you’re doing. So can you walk me through what this evaluation looks like? I know that it probably starts with a hearing assessment, but can you help me understand all of the different things that you’re trying to do within the patient experience today within your clinic?
Jill Davis, AuD:
Yeah. What I’m trying to figure out before we get started is will I be working with a problem with the ears or the brain or both? Because everyone that walks into my clinic is usually explaining a listening difficulty. They talk about hearing loss and a listening difficulty, and those are different things. And so I want to check the whole central auditory system so that I can address their hearing and their brain.
Jill Davis, AuD:
And so we start by handicap inventories because I want to know how they’re feeling about their issues. And a lot of times we can have a pretty significant handicap with no measurable hearing loss. So something is causing them to struggle and I need to help them figure that out. So for example, 10% of the people that come in, they complain of difficulty hearing a noise, but they have normal thresholds, technically normal on the audiogram and they don’t pass the cognitive screening. So those are the folks that need an auditory processing evaluation. We talk about maybe hidden hearing loss, super threshold listening disorders and they benefit from auditory training.
Jill Davis, AuD:
And so the handicap is my first step to seeing their motivation, but I also need to talk about comorbidities. So we do a screening for me to understand what else could be impacting their scores today? Do they have diabetes, hypertension? Are they on multiple medications? There’s a lot of things that look like hearing loss when they’re actually other medical conditions. We do the whole hearing test battery, including speech and noise, which is very important, because that is the central auditor test that we start with and then the Cognivue.
Jill Davis, AuD:
And so they’re going to come in, we review their history. We talk about that ear to brain connection. We go in the booth after otoscopy tympanometry and then speech and noise testing. I have a Cognivue set up in a separate room. And so after we get through the booth test, I just walk them over there and I explain the instructions on what they’re about to do. It’s not a separate test. It’s not something that I introduce as a cognitive screen. It’s just part of my battery, just like speech and noises and bone conduction. It’s just something that I do on everybody. And I do that on everybody because I’m not looking for dementia, Alzheimer’s, I’m looking for a listening difficulty and I’m looking for the brain’s ability to process speech. And so Cognivue is calibrated for everyone over the age of 18. So I’m going to do it on all of those patients just so I can understand how they’re functioning real world.
Dave Kemp:
I love that because it’s like another piece of the puzzle, right? It’s just like helping you fill in the blanks of your own assessment of what’s going on with the patient. You’re making a way more informed assessment and a recommendation based on this more comprehensive evaluation. And again, one of the big reoccurring themes on the podcast over the last four or five, six months has been this idea of as the traditional brick and mortar model of hearing care, if you will, where it’s very linearly focused on selling hearing aids, and that’s not to say that that’s what everybody does, but that’s the perception in the market. And you have all of these new access points of care, going back to the dawn of Big Box retailers in Costco and the like, and then now you have all these on online channels. And so it’s easier than ever to sell something that resembles a hearing aid.
Dave Kemp:
But it doesn’t really speak to how you, as a audiologist can provide an entirely different offering. That’s not commoditized, it’s rooted in the evaluation of what’s going on in that whole brain and ear link and everything that’s going on there as well. And so I think that again, this is what’s really exciting to me, is that this creates a totally different path, that you’re not having to compete in any sense of it’s not really based around the price of hearing aids. It’s just totally different. You’re going and you’re seeing you as opposed to someone that is primarily focused on selling hearing aids. I think that that’s what’s really encouraging is that there is this seemingly under undercurrent of a lot more equipment and tools that cater more toward how you can be this more comprehensive medical professional. And that’s what really speaks to me about Cognivue. And I want to get into Cognivue but wanted to just get your thoughts there.
Jill Davis, AuD:
Yeah. So the cognitive screening piece really dictates the treatment plan and there is a place for over the counter direct consumer products when we are screening these patients to know, do they fall into that perceived mild to moderate hearing loss range? Can they troubleshoot a device and figure out how to take care of an over the counter device based on that cognitive function?
Jill Davis, AuD:
So how I have 10% of the people that have no measurable loss, they may be great candidates for a device and amplifier that they could wear as needed in those challenging environments. And then 30% of the patients coming in have just hearing loss with normal cognition. Those are the great patients. Those are the ones that I know, no matter what we do, they’re going to be happy, they can figure it out. They like the technology, they don’t come back for repeat appointments over and over. Those are the ones that if they do fall into that mild to moderate, maybe we do start talking about over the counter and P gaps. And I’m okay with that for them. If that’s what takes them getting started sooner than later, then that is a great solution for you. Now, we started looking at the data to see how many patients in that mild to moderate hearing loss range actually passed the cognitive test, and it’s anecdotally not as many as you would expect. And so-
Dave Kemp:
Interesting.
Jill Davis, AuD:
… that’s why we think it’s still important to be evaluated and to get that piece. Because even if you fall into the hearing loss range, maybe there’s something that’s going to get in the way that this is not going to be a good fit for you. And you need something that’s more verified that we know is creating the stimulation that you need to improve your cognitive function. And so there’s a place where it fits if we know the cognitive piece and what we’re working with. There is definitely ways that we can create a better treatment plan for them once we know that.
Dave Kemp:
Yeah, for sure. So with Cognivue, I guess let’s get into a little bit about what this is. So it almost looks like an arcade game. It’s like a briefcase size or a laptop size device and you have this screen and then you have a joystick. I actually did it when I was in FCOM. I did it. So it’s measuring-
Jill Davis, AuD:
Memory, visual, spatial and executive function. And then there’s also two speed performance parameters. That’s looking at reaction time and processing speed, which is unique to a computerized test. So we don’t do that with paper and pencil tests. We can’t look at reaction time. So the benefit of Cognivue, so it’s adaptive psychophysics. So the little Cogno wheel that you use to answer questions, it’s calibrated for your vision and dexterity first, before the test even begins. And so there really isn’t an age difference. The test gets presented to the person after that calibration based on how they answered. So if they may have been a little bit slower, they’re going to make the answers a little easier. If their vision was really great, they’re going to make it really difficult. And so that’s what’s unique to Cognivue.
Jill Davis, AuD:
But my main draw on why I present this to physicians is why computerized, self-administered screening is best, is our patients have hearing loss. And the other cognitive screens, those paper and pencil, they have to listen to instructions and they have to repeat out words that they may or may not have heard correctly because a lot of times we’re doing this before they get treated with hearing loss or hearing aids.
Jill Davis, AuD:
And so we completely remove the ears out of the equation with the Cognivue because they’re reading the instructions. There’s nothing that they have to listen to. There are videos, but they’re captioned. And so then we know we’re isolating cognition and the ears are not getting in the way. And I think that’s huge, especially if hearing loss is the number one modifiable risk to dementia, like how do we know that we’re not testing dementia through a hearing loss? And so that’s my big thing and how I tell physicians why they should send to me because I have this where we don’t have to rely on the hearing.
Dave Kemp:
So that’s a piece too, that I found to be just absolutely fascinating. I’m actually looking on my second monitor here. I took a screenshot or I took a picture of one of the slides that you had, which was around referral sources. And you have this just massive jump in referrals that you had gotten from physicians. And I’m really curious about this. So it seems to me that as soon as you can make a physician aware that this thing exists within your clinic, that they’re going to be sending people your way, but help me to actually understand how this whole thing has gone down. Are you doing the outreach or are they seeking you out? Or how have they become aware of the fact that you have Cognivue, and on what basis are they typically sending people to you?
Jill Davis, AuD:
So when I bought the practice, it was a pretty sweet setup where I rent from a group of primary care physicians.
Dave Kemp:
That’s nice.
Jill Davis, AuD:
So I was able to talk to them about this and get their feedback where I know a lot of private practice audiologists don’t have that setup. And so I got to learn what they thought of me doing it, which they were like, “Yes, that’s great. I don’t have to because I’m too busy to do that.” However, when you took that screenshot, when I bought the practice, the previous audiologist spent a lot of money in advertising. So we were looking at where the referrals were coming from and mostly were online. The reviews. We did get some primary care from the Victory Medical Group and then insurance was a big one and patient referrals.
Jill Davis, AuD:
And so all I did after I got Cognivue was those patients that were coming to me from online referrals, from other patients, from insurance, I would just ask, “Can I send a report to your doctor?” Because I was already sending them to the doctors that were referring to me, but I wasn’t sending them if the patient just found me off the street. And so I just did more reports and what that was, the audiogram, the findings, a short little line that said cognitive screening today, the results were outside of normal. We’re going to treat the hearing loss and test again. Now when we tested again, after I treated their hearing loss, I would send an introductory letter saying what I was doing, what we found and my recommendations for further testing.
Jill Davis, AuD:
And so without even nurturing those relationships, I started to see outside referrals. So I was getting groups of primary care that I had been sending to and I hadn’t called them or anything. I was just sending those out. So they saw my name, they were getting more reports. And then I took the initiative to call and say, “This is what I’m doing. And this is why I’m doing it. Cognivue computerized takes the ears out of the equation.” And so now when they send referrals, it says hearing loss and cognitive screens. So they have patients that they’re asking and patients are asking them about cognitive screening and they’re sending them here because they don’t want to do it. And so yeah, this year I was shocked at how many outside physicians were sending, but also I’m getting audiology referrals and I was able to drop all of my third party for insurance, for hearing aids. And that’s huge.
Dave Kemp:
Which again, it speaks to the fact that you can do that is a luxury of the fact that you have so many patients that are seeking you out otherwise. And again, I think that’s part of the power here of moving more in this direction where that’s how you seemingly would differentiate from the pack is that, again, this isn’t really the same offering as all of these other avenues. It’s something that’s way more comprehensive. And I think that for a portion of the market, that’s going to be really appealing, regardless of whatever happens with OTC. And like you said, there’s definitely a role for those products to play. Nobody’s disputing that. But I think that the question is, how does the private of practice audiologists remain viable in a scenario where they’re competing? Their legacy business is just competing on so many different fronts.
Dave Kemp:
And it’s like, well, one way that you can compete is completely double down on your audiology expertise and move into more of these areas. Like you said, where you’re now presenting their physician with here’s their hearing assessment and here’s their cognition score. And knowing that there’s this link between hearing loss and cognition, it seems really appropriate. This is what’s so exciting is, I feel like we as an industry and audiologists as a profession have opportunity to really stake a flag in this ground and say this is our domain. This is one thing that we’re really uniquely suited to screen for.
Jill Davis, AuD:
Absolutely. So when you have the partnerships with the physicians, you can spend less in advertising. You don’t have to worry about putting it out there as much. But also there’s that modifiable range. And so that’s what the Lancet article said is, if we can treat hearing loss midlife, we should possibly be able to stop the progression of cognitive decline. And so sometimes I get asked, “Well, what’s going to happen if you find it on somebody? Is the doctor going to do anything?” But yes, because there’s that, the beauty of Cognivue is it’s sensitive enough to mild cognitive impairment, which could be reversed possibly. And so where the tests that the doctors are already doing most that I talk to, they do that MMSE, which is only sensitive enough for dementia. So you’re missing all of that mild. And a lot of our patients, I test people under 65, it’s not dementia. It’s something that’s making them work harder. They’re on lots of medications. They’re not treating their sleep disorder. They have heart disease that’s not under control in.
Jill Davis, AuD:
And so all of that presents hearing loss. And so if we can empower them by going over those things to go talk to their doctor about, “Am I on the right medications?” Then maybe we can improve their performance. And so that’s what’s separating you, you don’t have to be the expert in those other comorbidities, but just having that conversation with the patient, for them to understand there’s a lot of things that look like hearing loss and we’ve treated your hearing loss and we’ve done the best we can for you, now let’s get your doctor involved and see what else we can do to help you.
Dave Kemp:
So is that typically when you do one of the or you have a result that comes back where there’s poor cognition. What are those scenarios like? Are you usually redirecting them back to their primary care doctor or other specialty doctors or are there things that you, as the audiologist are able to do or are you primarily just screening for it and then making that recommendation as to where they go next?
Jill Davis, AuD:
Yeah. So 55% of the time people don’t pass the screen the first time. And so I felt-
Dave Kemp:
Wow.
Jill Davis, AuD:
… this was after I screened 300 patients and the average age was 60 years old. And so I felt like a lot of people were not passing. And so we looked at their results and it was like, yeah, a lot are not. And so I’m having this conversation a lot where they just come in for hearing loss, but they don’t pass. And I say, “It looks like we’re starting to see some change here that was a little harder for you than we want it to be. And that makes sense, because you have this hearing loss that’s causing your brain to change, to compensate. And the good news is that we can treat your hearing and we’re going to test again and we’re going to see what happens then.”
Jill Davis, AuD:
And so we’ve already prepped them that the number one thing to do is to treat your hearing loss, because of that modifiable risk. But also if I’m sending them anywhere else, they’re going to have to listen to the instructions, a full cognitive work up or a doctor visit they’re going to have to communicate. So I want to make sure that their hearing is ideal for that. So I test them again after their trial window, which in my clinic is 60 days. And I just want to make sure that yes, it is time to refer. Because some of those patients get back up to normal. It was just their hearing loss. And they just were having a bad day and they didn’t pass the first time, but I want to test them again. And then from there, they’re ready. We’ve already prepped them for, I’m either going to pass or not, or something’s going on. And then we revisit those comorbidities that they’ve told me they have and say, “Well, maybe it’s time to talk about all those medicines. It’s not good to be on 13 to different medications.”
Jill Davis, AuD:
So at least they have a plan for when I call the doctor and send over that report, that there’s something else they can look into other than, “Oh, my gosh, I have this memory.” Because it’s just a screener, it doesn’t diagnose anything. I always tell them that, “This is not telling us too much, but you are working harder than you should have to.”
Dave Kemp:
I feel like too, you hear these stories and I’m curious to get your take on this, but you hear these stories where someone goes, whether they’re coming into the clinic, kicking and screaming and they walk away and okay, maybe they get fit with hearing aids, but they just put them in the drawer and they never wear them. Part of this, and I don’t want to confuse this with fear mongering, but it seems like it’s a little bit more of a sober conversation, almost. Like a little bit more serious in terms of, “Look, this is,” like you said, “this is a modifiable risk. And so we need to take action.” And I feel like one positive aspect of that is that you’re able to at least get the patient to buy in to this premise of there’s more going on here than just the fact that your hearing has depreciated a little bit. It could actually be the onset of something a little bit more serious.
Dave Kemp:
And so you using the recommendation of the provider, it just seems like a, again, it goes toward this theme of a little bit more medical, a little bit more of a, this is a true doctor recommendation in terms of something that we’re looking out for the betterment of your overall health. And not just like, if you can’t hear great then wear hearing aids. It’s just, again, it’s a different conversation that you’re having.
Jill Davis, AuD:
You’re right. Yeah. So when we look at the different categories of results that you could have, so you have your normals and those patients have hearing loss and they have the cognitive ability to fight through their hearing loss. They can compensate, but Heidi Hill says it best, “At what cost?” What are you sacrificing to hear? And it’s your frontal lobe, your working memory. You’re working harder. So we need to treat your hearing loss sooner than later, before things may progress because you’re using that cognitive reserve that should be going somewhere else.
Jill Davis, AuD:
And so patients with the normal cognition in my clinic is 30%, they usually go forward with technology sooner than later, because we’ve had that conversation of we need to get started to stop anything from changing the ones that are in the mild range, those are the ones that we need a little bit more counseling, because they still may struggle in background noise. We need to take into account the fitting that we do for them, because there is evidence and research that shows proper techniques of fitting hearing loss based on their working memory scores. And so those take a little bit more time and more testing to see what the right fit for them. But you talked about the people that put the hearing aids in the drawer, you can actually make someone work harder than they should have to by fitting them with the wrong technology.
Dave Kemp:
For sure.
Jill Davis, AuD:
And so based on that cognitive function, you may think, “Well, this is a mild to moderate hearing loss and they’re in their 60s. This should be a home run.” However, if there’s something cognitively going on, you could actually make things harder for them, and that’s when they say, “All they do is amplify everything else. Not the sounds that I want to hear, they’re too noisy. I can’t tolerate them.” They end up in the drawer. And so we do need to know what we’re working with in order to set it up correctly the first time and then you’ll have more adoption and better outcomes and all also setting up expectations of what they can get. But the fitting that goes along with that score as well can have people more successful with their technology.
Dave Kemp:
So you screen them, they fail the cognition test, all right, let’s get you aided. And then at what point do they come back? Is it about a month or how long is the duration until you give them the chance to try again?
Jill Davis, AuD:
For the retest, it’ll be at their 60 day graduation appointment. So I do see them in between that appointment for counseling and adjustments and such. But I will re administer the handicap inventory aided this time and we do unaided and aided speech and noise testing again and the Cognivue. And the reason for that is sometimes Cognivue doesn’t improve. Sometimes it may get worse. Sometimes it’s not back to the normal like we want it to be. Because I really have a hard time telling them, “You’re going to treat your hearing and your cognitive performance will get better because it doesn’t always do that. But when you can review the handicap inventory that will get better.” How we’ve improved their quality of life. When you can show them their performance and background noise has gotten better as well.
Jill Davis, AuD:
All of that together shows the value of treating their hearing loss so that if the cognitive performance is not all the way back where it should be, at least we’ve done a really big thing by improving your performance with your hearing. And now we need to go talk to your doctor and see what else we can do.
Dave Kemp:
So how often, what’s the, I mean, rough percentages of that. So if you had, I think was it 55% are having hearing loss and low cognition? So then when you then fit them with hearing aids and they come back, roughly how many are still failing the cognition portion after they’ve been fit with hearing aids?
Jill Davis, AuD:
So we did a statistical analysis on this and 79% of the time, their scores improved, but not always back up to normal. So it is 50-50 if they’ll get all the way up to normal. And so yeah, that makes you think, can we really reverse things? I mean, there’s a lot of other stuff going on in these patients. The hearing is just one small piece of that cognitive puzzle.
Dave Kemp:
That’s really interesting though, because I guess at least it is encouraging that almost 80% are having at least a semblance of improvement. And so there’s that. But to your point, I think, again, it does speak to, it’s not just about hearing loss. Hearing loss is just a small little piece of this whole puzzle. And what you’re doing now is you’re helping to assemble a more complete puzzle. It seems previously if it’s just limited to the audiogram, that’s a really small portion of what’s… That’s a really grainy picture and you’re helping to make that a little bit more higher definition and zooming in a little bit of, here’s what we’re actually looking at.
Jill Davis, AuD:
I can move completely away from the audiogram with this formula, to know the best plan for the patient, looking at the handicap inventory, the cognitive screen, the speech and noise testing and their comorbidities. It’s so clear what I’m working with were pure tones, word discrimination and quiet. It just doesn’t give me what I need to understand what my patient’s going through.
Dave Kemp:
Yeah. I mean, do you feel like Cognivue is just one example of a broader theme here? Because whether it’s, I don’t know how [inaudible 00:34:35] is, but it feels like I’ve heard that a lot lately too, and just this whole theme of going beyond the audiogram, but this idea where you are making a much more comprehensive evaluation and I’m not sure what other tools go into that, but the more the merrier, I would imagine. And obviously cognition plays a big role in this whole thing. And so Cognivue plays that part, but are there other things that you’ve been incorporating over the last few years as well, that fit into the same bucket?
Jill Davis, AuD:
Yeah. Well, what we’re finding is that connection between the speech and noise in Cognivue, how closely connected QuickSIN specifically is to the cognitive performance. So you can actually predict how the patient’s going to do on Cognivue based on their aided QuickSIN. And so-
Dave Kemp:
Interesting.
Jill Davis, AuD:
… we are running through some data at the moment on that, but if someone is not performing in the normal range with an aided QuickSIN, then you can bet that they have some cognitive problems going on. And one thing about audiologists implementing this is patients love it. They’ve done surveys to see through all different age groups, like what are the top concerns compared to arthritis, heart attack, stroke and cancer. And people are worried about Alzheimer’s. And so whether they’re 40 years old or 70, they are appreciative that we’ve at least done this because it is something that they’ve thought about or there’s a family history of it. And so it’s really not a hard conversation to have with them because people are thinking and a little worried about it. Not that we’re looking at Alzheimer’s, but to just have a baseline and a screen to know how they performed, they really do enjoy it. And so my patients, some are like, “Oh, I got to do this again.” And other ones are like, “Okay, here we go. Let’s do it again.”
Dave Kemp:
Yeah. I actually took a picture of that slide too, of the gentleman that was presenting alongside you down at FCOM. And the thing that’s shocking is not that necessarily Alzheimer’s is the number one disease that people are most worried about, it’s like two to one. It’s cited well up into 50 to 70%, whereas cancer number two is down below 35%. So it’s yeah, it’s one of those things that it’s a horrible, horrible disease. But I do again, think that it speaks to this theme, which is the audiologist has a real opportunity here, not to fear monger, but to at least show that, I am a resource for you to help screen not necessarily for Alzheimer’s, but some of the may be worrying signs that might be indicators. And so I think that’s at least the silver lining here is that there’s more and more ways that people can at least try to detect this. And I think the audiologist is really well suited to do that.
Jill Davis, AuD:
Yeah. You mention Dr. [Grazel 00:37:47] who presented in that-
Dave Kemp:
Grazel. Yeah.
Jill Davis, AuD:
… FCOM with me and he is doing amazing research on cochlear implant outcomes based on their cognitive performance. And so what he’s finding is that if they have normal cognition, they should do really well in quiet and in noise after implantation at six months. But the folks that have poor cognitive performance, they can improve their auditability, their CNC and quiet gets better, but their performance in noise actually gets worse. And so we never want to not do the implant, but at least setting up those expectations before going through that process is amazing to see that connection between the two.
Dave Kemp:
Yeah. That’s super interesting. So what’s the actual implementation of Cognivue like? How long did it take for you to put this into your clinic, get trained on it, feel comfortable using it? Help me understand the logistics behind that portion of it.
Jill Davis, AuD:
Yeah. So I got it probably end of 2019 in December. And then starting January one, I said, “I’m going to figure out.” So I started with just my existing patients that were coming in for follow ups, and I said, “I have this fun new tool. Can you play with this, and tell me what you think?” And the feedback from them helped me prep other patients and talk about the results better. And so it took a good four weeks probably of doing it on as many people as I could before I was comfortable with the report and comfortable with prepping them how to do it, because they all complain that the wheel acts funny and it does not, it’s supposed to.
Jill Davis, AuD:
And so after that I started charging for it when patients were coming in, just including it on all of the new patients, but also anyone coming in for a follow up. I wanted to what was going on. And then from there, pandemic hit and March of 2020 came and we all were quarantined. And that’s when Cognivue reached out and said, “Can you help us put together some webinars?” They went to the early adopters and said, “We want to figure out best practices and look at the flow.” And so we started recording a lot of stuff during quarantine to try to figure out what best practices were to do this.
Jill Davis, AuD:
And so then back in the clinic, I probably put it on the back burner just because I was trying to get my clinic back up and running in these new protocols from COVID. And then it was towards the end of 2020 that it was like, all right, I’m going to just, we wanted to start to data collection process. And so I just did it on as many people as I could. And so that’s the key, is just running it and it is new and it’s different and it’s tricky to have those conversations, but the more you do it, you see the trends and it’s just part of the protocol, is just like doing bone connection. It’s just like doing speech and noise. It’s not something that we just isolate and only talk about. It’s just part of it.
Dave Kemp:
So it’s part of your standard scope of care now. So you had mentioned you started charging for it. So are you unbundled or are you bundled? What’s your practice like?
Jill Davis, AuD:
Yeah. So I unbundled during quarantine as well. And so we would just tell the patients that there’s a charge for a test that’s not covered by your insurance, but it’s necessary for diagnosis and treatment plans. And so a lot of them were cool with that. And then towards the end of the year, when everyone met their deductible, they didn’t want to pay anything outside of what their insurance covers. They were declining it and I didn’t know what to do because I needed that score. I can’t function without it, I want to know what I’m working with. And so for a while there, we were back to not charging for it, just putting it in as protocol for the comprehensive audio.
Jill Davis, AuD:
And then that didn’t make sense. So we’ve switched to now it’s an office visit fee. And so everyone coming in pays for my time and my QuickSIN and my Cognivue view. And it’s a set amount that my front desk preps them when they make their appointment that your insurance doesn’t cover it, but we don’t call it a test because if they say, “Well, I don’t want that test.” It’s not that, it’s my time, it’s reviewing the report. It’s the whole office visit. So that’s the way that we pay.
Dave Kemp:
Have you gotten pushback on that, with the way in which you now frame it?
Jill Davis, AuD:
I think it’s because of the referral sources that I have, these patients already are coming to me from their doctor, they trust me. They’re coming from other audiologists, they trust to me. They come from doing their research online. The only ones that I get pushback are coming from their insurance.
Dave Kemp:
Yeah. It’s [crosstalk 00:42:20].
Jill Davis, AuD:
And I don’t take their insurance for third party, for hearing aids, because they’re not really the right referrals. So the ones that they just, sure, they’ll pay for it, but I’ve only had a little bit of pushback and I don’t know if those are the right fit for me.
Dave Kemp:
Yeah. It’s interesting though, because like you said, it’s something now as a provider you don’t really want to be without. So there’s got to be some compromise here, whether it’s the way in which ultimately providers are able to bill for this. If there’s eventually a CPT code for it or the patient expectation, but the fact remains that it’s again, it’s like this piece of the jigsaw puzzle that now… And this is what’s I think a testament to Cognivue, I think that’s probably the thing they’d want to hear most is, “I struggle now doing business without this thing.”
Dave Kemp:
So was it Cognivue or was it even before that when just the whole way in which you evaluate patients changed, when you first started out practicing audiology and then today it just seems like there’s been an evolution. And obviously you had described the aha moment within the presentation where the brain’s obviously adapting and compensating. But would you say that it was recently or has this just been an ongoing evolution of your own personal journey of how you think about what the right way to evaluate a patient is?
Jill Davis, AuD:
It’s probably been in the last year, honestly and I’ve been working with Cognivue for two years. But where I’ve seen the correct algorithm, I remember, I was doing a test, the patient was in the booth and the score he was giving me on the QuickSIN and I was like, “Oh, my gosh, it’s so clear. What I’m going to do with them?” Because I started by, “Let’s give them some options, let’s talk pricing. Based on their audiogram, this is what I think they need.” And then it switched to learning about the ear to brain connection and counseling that way, trying to take the emphasis away from the device and just saying, “We need to get started sooner than later.”
Jill Davis, AuD:
And now based on evidence from research in 2002, I know based on their performance of the Cognivue, actually what hearing aid to recommend. And so I don’t even have to talk about options, I don’t have to talk about pricing. It’s like, this is what we found today, based on these four components, which is your handicap, your speech and noise, your Cognivue and your comorbidity, and this is what I’m recommending for you. And so it’s just less of the giving them options and talking about pricing and features. And I don’t even go into detail of the manufacturers or whatever, because I know what the best fit for them is going to be. And so that’s what’s so great, is getting-
Dave Kemp:
It’s really cool.
Jill Davis, AuD:
… it right the first time. And that just came because I’m learning all this stuff through Cognivue and going back to the cognitive hearing science and Heidi Hill has taught me so much in her CogniHear program, we’ve all just, in figuring it out, because it’s pretty new for all of us. So that’s what’s exciting.
Dave Kemp:
Yeah. I saw the ADA panel when I was at ADA and when Heidi and you and Amina and Lonnie was up there, I think there were maybe a few others. Again, it’s like, I just think this is so exciting. And you can really hear it in the way you talk about it, which is you’ve been practicing audiology for how long, how many years have you been a practitioner?
Jill Davis, AuD:
15 now.
Dave Kemp:
15 and within the last year you’re saying that you have had this game changing moment. And that’s really exciting, I think, is that maybe part of the challenge was is that it’s just that the ways in which the evaluation and the assessment, you weren’t fully equipped. And now you can help people in such a more meaningful way. And that to me is like, when I hear people like you talking, it puts me at ease because I feel like this industry is going to be fine. This profession’s going to be fine so long as they’re willing to challenge themselves to get better and take it upon themselves to push outside of maybe their comfort zone where like you, you had been practicing for 14 years and you could have just continued with the status quo and rode that out for however long. But it’s like you actually forced yourself into this and now you’re probably more fulfilled than you’ve ever been before. And you’ve made a breakthrough in terms of how you’re treating patients.
Dave Kemp:
And that’s so defensible, you’re going to be in high, high demand clearly by the referral sources. You have people that are coming to you left and right. And it seems like it’s elevated the whole way in which you are perceived within your community. And I feel like broadly speaking, that’s the opportunity here, is how do you elevate yourself up above everything else to where you really are in a league of your own?
Jill Davis, AuD:
Yes. Couldn’t agree more.
Dave Kemp:
It’s really cool. So as we wrap up here, I guess my question to you would be, for other practices out there that are looking to incorporate something like this, where did you start? And what’s a good place to rather than just outright determine, “Okay, I’m going to purchase this thing.” What’s the best way to just at least start to familiarize yourself? And what are some of the things about it that you would recommend, “Start here. And this is the best way that I understood how I would implement it,” or the feasibility of actually getting this thing into your practice.
Jill Davis, AuD:
Yeah. There are great resources on audiology online. So we actually put a lot of time into those courses. And so doing those. Or there’s also Cognivue reaching out to them. They have a lot of webinars as well. So you can talk to all of the early adopters and what it looks like, because there’s four of us, Heidi Hill, Noël Crosby, Al Turri and we all do it differently.
Jill Davis, AuD:
And so finding what looks to work best in your practice, whether it’s just like me, one person or you have multiple providers, we have the solution. So looking at those webinars, reaching out to Cognivue, because they can point you in that direction. And then they do trials, where you just get to get one and play with it and see what it looks like in your clinic and work with it and see if that’s the right fit. I love being a resource. Anyone can always… I do see patients, sometimes they get in the way of this passion that I have for Cognivue. But yeah, I like answering questions and I’m always free to talk as well.
Dave Kemp:
Awesome. Well, when you said that you all use it differently and those were the two that I had forgotten was Al and Noel. What are some of those differences? That’s interesting to me.
Jill Davis, AuD:
Yeah. So I use it at the end of the appointment after I’ve gone through the testing, I’ve put the patient on myself, I want to instruct them. But there are offices that the patient will start on the Cognivue, the front desk can administer or start the test. And then they see them after. Some places have multiple locations and they take the Cognivue to the other offices or some have one in each clinic. And so I know Noel charges specifically just for the testing where I think Al may not charge. And so just the ways to figure out the economics too is very different.
Dave Kemp:
How long does the Cognivue test take to perform?
Jill Davis, AuD:
It’s only five minutes.
Dave Kemp:
Five minutes. Okay.
Jill Davis, AuD:
And so we’ve added some videos, like an intro video, Dr. Cliff Olson is the intro video and he talks for about four minutes if you want to run it, but you can take it off. And then there’s a little break in between each test that just adds probably two minutes to it. So seven total. It’s just enough to get the reports ready, get the demos programmed and do things while the patient’s taking the test.
Dave Kemp:
That’s really cool. I really, really appreciate you coming on today and sharing all this. Again, just a really exciting time, I think for audiology because there’s all kinds of new solutions out there that are available. And I feel like people are gravitating toward different ones, but I get the sense that there’s just going to be more and more ways for practitioners out there to make themselves unique in the market and find whichever offering they want. It’s like there’s a lot of different ways that you can piecemeal this and craft it together and come up with the economics of it.
Dave Kemp:
But I think at the end of the day, the one that really benefits there, are going to be the patients. And that’s what’s really exciting here is that I think the days of the patient walking away, maybe frustrated or feeling like they were matched to a solution that isn’t really what they wanted, we’re getting closer and closer to narrowing that gap to where I think they’re overall pretty satisfied with feeling like that was where I needed to go. And I feel comfortable now with the recommendation that I’ve been given.
Jill Davis, AuD:
Absolutely, absolutely. Yep. And also no more… Your hearing’s normal, even though they come in and they had a listening difficulty and they’re not being told their hearing’s normal because now auditory processing, testing, Angela Alexander’s course do it. You can implement that with the cognitive screening, it just makes things so much clearer.
Dave Kemp:
I know. Again, another person in another theme. APD, it’s just seemed to emerge with a vengeance. And Angela’s obviously been at the tip of the spear really pushing that forward, but it’s, I think, again, it’s changing the whole nature of the way in which I think people are looking at the state of what’s going on and trying to make a more complete assessment and formulate a more clear picture of it. So all of this has me really excited and I really appreciate you coming on. So thank you for coming and thanks for everybody who tuned in here to the end. We will chat with you next time. Cheers.
Jill Davis, AuD:
Thank you so much.
Dave Kemp:
Thanks for tuning in today. I hope you enjoyed this episode of Future Ear Radio. For more content like this, just head over to futureear.co, where you can read all the articles that I’ve been writing these past few years on the worlds of voice technology and hearables and how the two are beginning to intersect. Thanks for tuning in and I’ll chat with you next time.
