1. Telerehabilitation Clinical Applications for Assistive Technology: Research, Opportunities, and Challenges Mark R. Schmeler [1], Richard M. Schein [1], Michael McCue [1], & Kendra Betz [2] [1] Department of Rehabilitation Science and Technology, University of Pittsburgh [2] Prosthetic and Sensory Aids Service, Veterans Health Administration

2. Learning Objectives Distinguish the terminology of telemedicine, telehealth, and telerehabilitation Recognize the need and application for telerehabilitation Comprehend at least three examples of assistive technology applications using telerehabilitation Explain clinical and research issues associated with telerehabilitation

3. How do these all relate to each other? Telehealth Telemedicine Telerehabilitation Home telehealth E-Health Telepresence

4. What is Telehealth? Use of electronic information and telecommunications technologies to support; long-distance clinical health care patient and professional health-related education public health and health administration (Office for the Advancement of Telehealth)

5. What is Telemedicine? Use of medical information exchanged from one site to another via electronic communications to; improve patients' health status (American Telemedicine Association)

6. (Winters, 2002)

7. What is Telerehabilitation? Tele  Greek word meaning “far off” Webster’s; “distant, whence, remote, or to a distance” Rehabilitation  “to restore to a former capacity or state” Telerehabilitation  Delivery of remote rehabilitation services

8. RERCTR Mission Research & Develop; – methods – systems – technologies that support remote delivery of rehabilitation and home health care services for individuals who have limited local access to comprehensive medical and rehabilitation outpatient services

9. Our Center’s Mission … This RERC must research and develop methods, systems, and technologies that support remote delivery of rehabilitation and home health care services for individuals who have limited local access to comprehensive medical and rehabilitation outpatient services. Definition of Telerehabilitation

10. Impetus for Telerehabilitation Baby Boom Generation By 2020, the number of Americans living with at least one chronic disease will climb to about 157 million, up by 25% from 2000 Rural Areas 25% of US population live in rural areas- 22% of US population are senior citizens (Office of Management & Budget, 2004)

11. Addressing Unmet Needs Shortage of skilled professionals Underserved populations Isolation from medical advancements/technologies Lack of funding Earlier discharge Mortality/disability rates Distance between client and facility experts Transportation & accessibility issues Time management Educational benefits

12. Barriers/Limitations Funding and Reimbursement - Insurance policies User acceptance Technology design/human factors Scientific Evidence Legal and Ethical Issues Awareness Standards and guidelines Education & training Cost-Effectiveness Credentialing/Licensure

13. Background Bridging “The Gap” – Advanced telecommunications – Information Technology (Kinsella, 1998 ; Cooper et al., 2001) Expanding Technologies – Internet – Communications (Cooper et al., 2000) Challenge: feasible and effective methods to deliver services

14. Medical Deployment cardiology (Cheung et al., 1998) dermatology (Lowitt et al., 1998) neurosurgery (Pareras & Martin-Rogrigues, 1996) pathology (Ballis, 1997) radiology (Boland, 1998) oncology (Allen, 1997) Since the 1950s, smaller-scale feasibility projects, and later in larger-scale clinical deployments Rehabilitation field gradually integrating “tele” into clinical practice

15. Diversity of Clinical Applications Assistive Technology Prevention of Pressure Ulcers Virtual Reality Speech-Language Pathology Seating and Wheeled Mobility – Preliminary Findings

16. Stance on Telerehabilitation Varies by Professional Association; -American Occupational Therapy Association (AOTA) -American Physical Therapy Association (APTA) -American Speech & Hearing Association (ASHA) -Commission on Rehabilitation Counselor Certification (CRCC)

17. AOTA Position Paper on TR (Wakeford et al. 2005) – Evaluation – Intervention, Planning, and Follow-Up Care – Consultation – Education – Supervision of Students Definition: clinical application of consultative, preventative, diagnostic, and therapeutic services via two-way interactive telecommunication technology

18. Assistive Technology/OT (Burns et al. 1998) Supporting AT in home; Four specific case studies – Seating evaluation – Home accessibility – Set-up of computer access systems – Augmentative communication device training Technology used-low cost video telephones – Reason- participants had access to phone line

19. Case Scenario Results (Burns et al. 1998) Advantages – expanding availability, accessibility and affordability Disadvantages – audio and video not ideal due to insufficient bandwidth – dim lighting, and lack of training with technology

20. APTA Assessments – Minnesota  Range of Motion (Durfee, Savard, & Weinstein, 2007) – Emory University  pressure mapping Board of Directors Position on telehealth & electronic communications – Overcoming barriers of distance and time

21. Pressure Ulcer Literature Highly documented from prevention to promoting pressure relieving activities Philips et al. 1998- TR intervention to promote skin and other self-care activities – Technology: video phone with still images over POTs line – Result: diagnosing through verbal alone not reliable Philips et al. 1999- examining discharged SCI patients via telephone, video, and standard care – Results: video group highest number of re-admittance and standard of care lowest

22. Virtual Reality VRs’ capacity to allow for creation and control of 3- dimensional built environments offers clinical assessment and rehabilitation options that are not available with traditional methods Examples: – Architectural accessibility (Kim & Brienza, 2006) – Assessment and training for power wheelchair users (Harrison et al. 2002)

23. Virtual Reality (Lewis, Deutsch, & Burdea 2005)

24. ASHA Telepractice  (ASHA, 2005) “the application of telecommunications technology to deliver professional services at a distance” Published formal position statements, issue briefs, and technical reports summarizing evidence and discusses future directions

25. Speech Language Pathology Mayo Clinic- SLP teleconsultations (Duffy, Werven, & Aronson, 1997) National Rehabilitation Hospital – RESPECT Telerehabilitation Research Unit at the University of Queensland, Australia – Lee Silverman Voice Treatment Tripler Army Base in Hawaii- voice therapy Remote dyshpagia evaluations Augmentative communications devices

26. Functional reading task with video window Following directions task (shared whiteboard) with video window RESPECT: REmote SPEech-language and Cognitive Treatment (Brennan et al., 2002 ; Brennan & Barker, 2004)

27. Lee Silverman Voice Treatment (Telerehabilitation Research Unit at the University of Queensland)

28. Seating and Wheeled Mobility Promoting community re-entry and improve quality of life (Philips et al., 1999) Glenrose Rehabilitation Hospital in Alberta Canada (Liu & Barlow, 2005) – three methods: IP within region, IP outside region, & out of region by telerehab – Multi-disciplinary team & proper visualization

29. Seating & Wheeled Mobility Comparing POTS vs ISDN lines for eight wheelchair evaluations (Malagodi et al., 1998) Reliability testing – Wheelchairs owned and recommending (Cooper et al., 2002) – Inter-rater reliability for mat assessments between IP and TR (Allegretti, et al., 2004)

30. Case Scenario-Evaluation of Remote Wheelchair Prescription Specific Aims Create a TR service delivery model ; Reliability testing of the FEW-C ; Measure difference & perceived function ; Measure satisfaction ; & Evaluate equivalence In-Person & TR

31. 31 Service Delivery Process for CAT- UPMC and TR Assessments “ Good Clinical Practice ” 1 st Phase Intake/Interview Physical Motor Assessment Mobility Related ADLs Goals Clinical Trials 2 nd Phase Home Assessment Final Specifications Documentation Funding Approval 3 rd Phase Fitting & Delivery Follow-up / Outcome Aim 1

32. 32 Remote Wheelchair Prescription Aim 1

33. Wheelchair Service Delivery Protocol (In Press, Accepted into Telemedicine and e-Health)

34. 34 Aim 1

35. DuBois Regional Medical Center Located in DuBois, PA – 103 miles away – 2hrs. 10 minute drive First ever TR clinic on November 22, 2006 Clinicians gained valuable experience related to education, training, and assessment INDEPENDENTLY RUNNING

36. Charles Cole Memorial Hospital Located in Coudersport, PA – 180 miles away – 4 hour drive First TR clinic on May 24, 2007 Able to connect via wireless connection INDEPENDENTLY RUNNING

37. Challenging Issues Containing costs (i.e. cost-effectiveness) Promoting access Assuring quality (i.e. patient and practitioner satisfaction)

38. Clinical & Policy Issues Clinical Concerns – How and who is going to pay for this? – Who is qualified to perform TR assessments, treatment intervention, and routine service delivery? – How is quality assessed? – How are the issues of confidentiality being delegated?

39. Telerehabiltation Impact Access, Quality, & Capacity of Service Delivery new models of care & delivery shifting population needs home telehealth creative workforce options aging population services to rural areas geographical barriers travel costs clinician & client education administrative events

40. Telerehabilitation Opportunities Continuous technology improvements Potential advantages for Telerehab: – services in the home – monitor transfer of training – enhance compliance with protocols – patient-driven proactive healthcare – clinician support & continuing education Clients will expect (and demand) high quality, technology-enabled healthcare