Event ID: 1167660
Event Started: 11/17/2008 12:48:01 PM ET
Please stand by for realtime captions.
Hi, I wanted to let you know we'll get started in a few moments, right
now our audio is muted. We'll be back on in just a couple of minutes.
Hello, ladies and gentlemen, from around the world. This is Kate
Seelman, welcome to this this state of the science telerehabilitation
conference. We're doing it from the research center on
telerehabilitation. It's my pleasure to introduce Dave Brienza and Mike
McCue.
Thank you. What a great opportunity we have here today
and the rest of the week. We have registered for this conference about
250 people from 14 or 15 countries, and from 37 states around the
United States. One of the reasons I feel this is a great opportunity
for us is together with this very diverse group we can engage in a
discussion on the state of the art of telerehabilitation. The
professionals and consumers around the world recognize the need for
access, available and affordable services. Because of the percentage of
the population disabled increases every year. In turn if our society
does not adopt changes and appropriate strategies that curb costs,
costs are looking to be unsustainable levels. Telerehabilitation
provides cost-effective ways for face to face needs. And how we can
more integrate consumers.
We will engage you in responding and encaging to the outcomes of the conference and will help to set the future.
I will bring you through an overview of our system here. I would just
like to say we do know something about telerehabilitation, however
we're not novices when it comes to virtual conferences, this is our
first attempt. We're learning as we go through this. Our objectives, we
want to present and discuss the state of the art in telerehabilitation.
We want to explore current issues in technology, enuser usability [
Interference ]. We want to identify barriers. And identify and
prioritize future research and strategies.
We started this
process, preparing for this conference over a year ago now. Back at
that time we had an internal meeting. We had many discussions about
what topics to cover during this conference. After some deliberation
decided on a set of four topics we would present and use as the content
of the conference this week. We assigned internal staff members to
those topics. The center staff developed ideas for white papers on each
topic. These authors were directed to solicit additional experts from
outside our center to serve as coauthors. These coauthorrers provided
initial drafts of the white papers. These were distributed to many of
you via email and are now available on the website for our
international journal of telerehabilitation.
The initial
drafts were reviewed by the panels. And additional changes were made.
And they were posted to the website and distributed. Today we have
these papers to be presented by the authors. And most importantly, we
want to have discussions on these papers and the topics of the papers.
This is perhaps the most important part of what we're trying to do, as
a community get together and [ Interference ] these papers. The way
we'll proceed to do this, we'll have our discussion during the
conference today, the conference will proceed by the presentation of
the white papers, response from preselected expert pan pannists and an
open discussion which all of you will be able to participate in.
After the conference we will have established a blog site in which we
can use to continue the discussion online for probably until the end of
the year. The information from today and this week and the information
from the blog site will be used to revise the white papers and produce
a final draft. Final draft will be published in our -- in the premiere
issue in April of 2009.
I also would like to tell you this
conference telecast will be available for viewer offline within about
24 hours after the conference ends today. We will post the address, and
we will send you an email with that information on how to access the
archive.
Another important aspect of what we're doing today
is offering CEUs and those are available to you, for those of you that
are interested in CEUs. In order to receive the CEUs you must complete
the post conference evaluation, we will get you more information on
that when the time comes.
What I would like to do now is give
you a short overview of your screen and the layout that you have in
front of you. This will be the layout that we'll be using for the
majority of the time here. On the upper left there is a video feed,
which you are seeing the three of us right now. I will just jog this so
you can see the video window. In the upper right is the pod where you
will see slides from the presenters. This will be where the PowerPoints
will be presented for today. This is in the upper right corner. We have
available to you, um, the documents. Those are the lower right. Just to
the left of the far right. These are various support documents that be
available to you to download and view on your own computer on our own
time. Very important window in the far lower right of the screen,
that's the chat window. We would like to you to use the chat window to
interact with us and ask questions. The expert panelists who are not at
our location will be on a telephone call, that call is bridged into the
system that we're using and streamed out to all of you. We don't have
any mechanism for you to give us your audio feed, that would be
unmanageable. We would like to communicate with you through the chat
window. Will be offline moderating throughout the day and responding to
your questions, or forwarding the questions to the presenters. In the
lower left of the screen is the closed captioning window, which will
contain the text of the audio stream.
Okay, that is a tour of
the screen. I have a few reminders for you. Continuing education
information is there, the website that you will need to go to is on
your screen, and I have the conference blog address up there, as well
as the conference website.
Just want to make sure I didn't
forget anything here. We have technical support, should you need it.
There's phone support for those of you in the United States, or those
of you wishing to make an international phone call. You can email our
technical person at.
I want to remind you that you are part
of this conference, stay alert. We have some interactive elements to
this. Maybe I will just see if you guys are out there, and ask you to
respond to a short poll here. Tell me what country you are from. If you
would just go ahead and select your country of origin. We will get a
sense as to where you are located.The countries listed in my polling
question are the countries that we know people are registered from.
We're seeing who is out there. If they're having trouble selecting,
just click on the radio button associated with the country. It looks
like we have about 38 people, of the 68 people, currently online that
are responded. 42, we're getting closer. Is everybody awake? Maybe I'll
just add a couple of thank yous. First of all, I would like to thank
the funding source of the conference, our center is responsed by part
of the Department of The United education. I would also like to thank
our center's advisory board. We have a dedicated group of people who
show us the way, and give us advice. They've been instrumental in
planning this event.
Also here, locally, putting on this
conference we've learned quickly is not an easy task. We have a great
technical support team here in our school here at the University of
Pittsburgh, thank you to you. Some of the most undesirable tasks fall
to the students, no exception here. Many of the tasks have fallen to
our students in our center, I thank you. I would like to thank the
support we've received from Adobe and Dave. Dave has really given us --
taught us how to do this. He's online right now supporting us, thank
you for everybody you have done.
As we planned this event and
worked towards this day there's no two people that have worked harder
than Ashley and [ Indiscernible ]. They've worked on this 40 hours a
week for the last month. Every time I talked to them they were working
on this. Thank you to Kate and Ashley for that. Ashley is off-camera
here. I would also like to thank all of the presenter and panelists.
Obviously a key role. We're looking forward to your contributions.
Mostly, all of you out here online getting the stream. You are the
reason we're doing this. We would like to have your input and have you
participate.
Mike, I think I will leave it at that. And turn it back over to you, so you can introduce today's presenters.
Thank you. Welcome, everyone. I would like to second Dave's appreciate
to all involved. I would also like to encourage the audience to give us
feedback about the content and also about the mechanism for
communicating through this. Any feedback you can provide is of value. I
had the privilege of introducing of authors for our first paper today.
Telerehabilitation state of the art from an informatic perspective.
Here at the University of Pittsburgh we like to talk about the PIT
model. It's based on an architecture that was developed through this
grant, through the work of the authors of this paper. We want to
acknowledge the importance of the basic informatics architecture that
goes into the delivery of telerehabilitation programs and services.
With that, our white paper authors are Bambang Parmanto, an association
professor at the University of Pittsburgh. His Dr.S areHe is a
principal investigator for a project that develops technologies to
mitigate barriers to computer and internet use. Dr. Parmanto leads my
health bits, funded by Microsoft research. This takes on the challenges
of managing and records every bit of daily information related to our
health. He is a coinvestigator of the research center on
telerehabilitation. Andi Saptono is a student within the department of
health information management here at the University of Pittsburgh.He
was a primary architect of my health bits. And the primary developer
for bottom line people. He also has experience in usability studies on
hand held devices such as PDAs.
I would also like to thank and
introduce our expert panelists for this paper. David Brennan is a
senior research associate at the National Rehabilitation Hospital. Over
the last nine years with funding with the national institute on
biometcal engineering, [ Speaker/Audio Faint or Unclear ] his work has
focused on the development of interactive computer-based tools for
delivering telerehabilitation interventions. Mr. Brennan has presented
at international meetings and authored numerous articles. He is the
outgoing chair of the special interest group on telerehabilitation of
the American telemedicine association where he sits on the standards
and the guidelines committee.
Our last panelist is Sajeesh
Kumar. His research focuses on the design and development of
telemedicine devices, applied health informatics, rural and remote
healthcare service.Dr. Q Sajeesh Kumar has won several awards [
Speaker/Audio Faint or Unclear ] we have an excellent paper for you
today. Please listen and participate with us in this first of four
papers. With that we will break for about 60 seconds to get our authors
set up and we'll be back very shortly.
Hi, welcome everybody to
day one session today. Thank you for a great introduction. With me
today on my right-hand side is Andi Saptono, that will be presenting
with me for this session. And then on the left-hand side is Dr. Sajeesh
Kumar. Joining us from the National Rehabilitation Hospital is Dr.
David Brennan. You will see him momentarily. Okay.
Hi.
Yeah.
Instead of covering the entire session with presentation and discussion
at the end, would we plan to do is to divide the session today into
five minisessions. At the end of every minisession we'll have a short
discussion, and also comments from the panel, and also we'll invite
participants to provide comments and questions, as well. At the end
we'll have discussion for everybody, after the panel discussion.
The goal of the day one today is to provide systematically [
Interference ] especially from the informatics perspective. You have on
your screen, on the slide there, those are the items we'll be
discussing today.
[ Audio Cutting In and Out ]
[ Audio Cutting In and Out ][ no audio available to caption ]
[ captioner standing by waiting for live audio ]
We are still testing the audio system.
[ Speaker/Audio Faint or Unclear ]
Okay. I'm sorry for the -- for the problem. We lost the audio system.
Right now it's on. I will repeat. As you can see on the screen, the
outline of day one session will be dividing into five minisessions. We
try to establish the relationship between [ Indiscernible ] with [
Speaker/Audio Faint or Unclear ]. And then the second minisession we'll
try to review the state of the art deliveries. We'll be doing with two
or three of you from the past decade. We'll try to give examples of
services that we have that are state of the art. And the third
minisession we will introduce a new model from an informatics
perspective. After that we will discuss and review the issues and
challenges as a result of new technologies. The last minisession we'll
discuss the potentially new technologies, discuss new technologies that
can be used to develop new services and the problems associated with it.
We have done this introduction, we will move on. We'll move on to the
first minisession. The goal of this first minisession is we will
discuss telerehabilitation, why it's important, and the differences
between [ Speaker/Audio Faint or Unclear ] and telerehabilitation and
telemedicine and the similarities. [ Speaker/Audio Faint or Unclear ]
to otherwise unserved populations in rural and urban areas. That also
can be applied to telemedicine. What are the differents? And what will
the similarities? The first thing is to review the definition of
telerehabilitation put out there. We came up with four good
definitions. These come from the tens of [ Indiscernible ] that we have
reviewed. These are the four definition that we think are a good
representation of the definitions that have been around out there. The
first is the delivery of rehab services over telecommunication networks
and the internet. It's a good one, a short one. It provides a good
component. Especially with the network and the internet. We don't know
what rehab services is. A similar definition can be applied. We can
change the rehab with medicine or health. The second definition is from
the RERC on telerehabilitation, which is our center. The remote
delivery of rehablecation and home indicate care services. There's
something new here, the home health care services.
The third
is from AOTA position paper. It's the clinical application of
consultive, preventive, diagnostickic and therapeutic services via
two-way interactive telecommunication technology. It includes
consultive, diagnostic and therapeutic.
The last is from a paper by R.
C Ricker etr. There's something interesting here. The focus on a person
with disabilities, and subcomponent of telemedicine. We will discuss
about it. And then it's also the new type of services of assessment.
From this definition we'll try to list characteristic of
telerehabilitation. The first one is range of services that includes
consultive, preventive, diagnostic, assessment, support, intervention
and therapy. Also we saw telerehabilitation has a great interest in
home healthcare and individual with disabilities. What is missing is
what are rehab services. We take into what makes up rehab services.
What we learned is rehab services, a main characterric includes
enabling individuals with disability and restoration of individuals.
We came up with the long definition. This one is not elegant. Long
definition is very lengthy and very tiring, perhaps. I think this
capture more precisely what telerehabilitation is. It's the application
of telecommunication network, and the internet to deliver consultive,
preventive, diagnostic, and therapeutic services to enable individuals
with disabilities and to restore individuals physical and psych social
functions.
We would like to invite your input. Before I
forget, I would like to mention that the white paper that we have put
out there is still a rough draft. What we plan to do is to based on the
discussion today, we'll revise the state of the art paper and put it
out there and revise it again and publish it. Please provide your
comments and feedback.
Once we define telerehabilitation the
next thing we would like to do is to discuss what type of services,
what are the examples of telerehabilitation? What are the services that
provide it under telerehabilitation? To do that there's an excellent
paper from Jack Winters from 2002, we will use it as a starting point
for the discussion today. This paper is an excellent one, it's old by
now, it's been six years. Informatics six years is quite a long time.
What we want to do throughout the discussion today, especially in the
third minisession we will expand the model to make it more flexible and
to frame the telerehabilitation, to be able to capture the latest
technology, as well. The first thing, this model first tried to list
the services that are provided under telerehabilitation. And then this
model also tried to establish the relationship between
telerehabilitation and telemedicine as well as e-health. Those are the
four type of service delivery. They're listed there on your screens for
you.
This is a good diagram that tries to establish the
relationship between telehealth, telemedicine, telehealthcare, and
e-health. There's an intersection between telemedicine and
telerehabilitation, but not all telerehabilitation therapies are under
telemedicine. There are surfaces that resembles [ Indiscernible ],
especially the [ Indiscernible ] one. This one is -- this model, and
also by observing what is out there the main characteristics we tried
to come up with the main character of telerehabilitation, especially
from the informatics perspective. The differences between telemedicine
and telerehabilitation, the first one is what we observe from the
intensity of the information exchanged between the two sides. Either
from clinics to home or clinics to clinics. Telemedicine has a very
intensive session. While telerehabilitation the information exchange is
less intensive. We're talking about the majority of telerehabilitation
services.
Then the second difference that we observe is that
telemedicine usually has a long-term, a continuous encounter. Sessions
are briefThe encounter is over a longer period of time. Those are the
two differences. What we will use these two main characteristics as the
basis for the fourth quarter model that we will discuss in the third
minisession.
The last point for this minisession is why
telerehabilitation is important? The first one is because of the
technology push. The technology is available, or will be available.
Because of that it will allow us to develop new rehab services that
otherwise cannot be done using previous technology. Among the
technologies worth mentioning is the broad band connection, it's
available in most homes in the United States. Also the availability of
high speed technology to provide mobile services. The second one is --
because of this it will allow us to deliver services to homes that
previously would be done because most homes only have slow connection.
The same thing can be said about mobile technology. The second one is
from the software perspective with web 2.0 technologies and with the
ease of use of the development of [ Indiscernible ] technologies that
otherwise cannot be done in a previous technologies.
[ Audio Cutting In and Out ]
As we observe it is expected that the need for rehab services will grow
over time. This especially, the key is for advanced countries such as
Europe, United States and Japan. The population is getting older. The
rate of disabilities will grow with that. And then, also, from the
provider-perspective the number of providers will not be growing. We
face the problem of more need and more available services with the
technology, but less available providers. These are the reasons which
it's more and more important in the coming years. That concludes the
first minisession. We'll have panel discussion. I would like to invite
Dr. Sajeesh Kumar and David Brennan to comment.
Sorry, could you adjust? Yes, thank you.
Thank you.A wide range of definitions were mentioned. He included the
definition from RERC. The definitions with the technology used, the
methodologist used, the stress is methodology. It should be
patient-focused also, other than technology. A little bit of shift
towards the patient attention. The end user is the patient. We're doing
all this technology. The definition must reflect the need of that. AT,
definition of telemedicine, it says to improve patient health status.
There's a stress on patient health status. We can include that to
include this the definition. This is included in the long definition. I
would love to hear your comments on focus on patient, maybe you can
send it back to us. Another point I noted is as Dr. Bambang mentioned,
the 2002 paper, it's outdated now. Telementoring was not mentioned in
that paper. This is coming up new. Telementoring, not just for
newcomers, but those already in the field, training and medical
education purpose, telementorring is another thing to look into.
And the last slide is about whether [ Indiscernible ] will grow. Dr.
Bambang aptly put some points. I would love to hear comments from all
of you. We had to check, the fact is not just country wanting to grow,
the growth, there are other factors which are like various [
Speaker/Audio Faint or Unclear ] growth. You know the cost. The issues
of cost and reimbursement, legal issues. And so many other things. This
will be a topic which will be discussed in coming days. We have to take
these barriers as opportunities in the future. Reimbursement, local,
cost issues these have to be seen in the light of an opportunity to
discuss and bring us as a community together and to show the way
forward. Over to David now.
Thank you. Thank you.
Hi, Dave.
How you doing? Thanks again for having us. Hopefully I wasn't able to
clean my office, I apologize for the clutter. I see we're starting to
get questions in. That's the point of this. I want to leave it open to
others to give their questions. A few comments regarding definitions.
You did a very good job of tackle an issue of what is telerehab,
telehealth, telecare. These have been debated for a long time. I think
the [ Audio Cutting In and Out ] the definitions you came up with are
by far -- for me the most important thing -- I teach a class in
telemedicine. You can take any word and put tele in front of it and it
means do it at a distance. It is all about the patients. Implying
moving information, not people. There's benefits. We're finding more
and more benefits, we don't have have to move the people. There are
benefits to the organizations, to the caregivers. We will hear a lot of
examples over the next couple of days. Secondly, the last point, the
final slide, I think [ Indiscernible ] will grow. I think we all hope
that telerehabilitation will grow. The population is getting older. A
lot of chronic conditions. I think we recognize that. The last day
we'll get at this. Unless we work at changing policy and generating the
body of research that shows that this works -- we've been working on
this for close to a decade, we hope it will continue to grow. I think
there are a lot of obstacles in our way. I think we need to address
them and move forward. With that, I think -- I'm not sure how you want
to handle taking questions from the audience --
Okay. We'll open questions from the participants. You can do it through typing in the chat window.
If you would like to participate with us, please type your questions into the chat room pod.
We will wait for another 60 seconds before we move on, for any questions to be entered into the discuss before we move on.
I'm seeing a couple of questions. Do you have that window open on your screen? I can read them out if you would like --
Sure.
The first does the patient obtain the same level of care as going to a
facility? I think that will be addressed later on. The goal behind
anything in telemedicine is providing at least the same level of care.
I think there are number of benefits that could arise from services
remotely. There's potential pitfalls and problems that also might
arise. Hopefully that answered that question. Did you get that window
yet?
I would like to add to the point from Dave. In
telerehabilitation -- [ Audio Cutting In and Out ] -- usually what we
do we have any project is to compare the telesession with the in-person
session and see if there's differences. That's easily part of the
classic research. The answer is that's always part of the
consideration. Usually to have a valid telerehabilitation services we
have to prove that the quality is as good as the in-person session.
Second question -- asking if --
I will -- do you want --
No, no.
The second question, wondering if there's opportunities built into
telerehabilitation. I'm not sure what opportunities -- I'm wondering if
there's opportunities -- opportunities built into telerehabilitation.
Looking at this question, I think it's my duty here, I take the chance
to give a case scenario. I think there's some questions followed
requesting for more about the service. I will give a case. People
listening can give others. Let's take a case of a lady staying in a
remote area, let's call her Maggie. Maggie she got [ Indiscernible ], a
recent stroke. The right-hand side, she has pain in the right shoulder.
She goes to the local hospital. The OT takes care of her. This local
hospital OT who is taking care of Maggie, he decided to let us have a
second opinion from a neural [ Indiscernible ]. They decide to do this.
Using videoconferencing they talk to a specialist in OT in neurological
disorders, 45 minute high-tech videoconference. They had a
consultation. During that the specialists asks them to demonstrate the
pain areas and assess the condition. Everything occurs within 45
minutes. The difference between the areas could be 200 or 300 miles.
The decision is there is changes in the intervention plan. They decided
to go for a functional stimulus for her right shoulder. It improved the
condition of Maggie. This is a simple case scenario that I give.
Are there any comments?
Thanks.
There's quite a few questions.
One of the questions is about the definition. Have any funding agencies
come up with definition? Again, I would like to mention that some of
the questions might be answered in the following minisessions. Also,
some of the questions might be relevant to the next few days of
sessions, instead of this one. Most of the definitions that we came
across, that we observed from the federal agencies or from other
sources usually fall into one of the four that we discussed. They
represent the definition by the organization or paper that we quoted
but also are similar to definitions from agencies.
The short
answer for the second part of the question, right now telehas been and
reimbursement is one of the biggest challenges. I believe that will be
discussed on day four. I don't know off of the top of my head, I don't
recall, what services close to telerehabilitation are funded by
Medicare and Medicaid. There are some home health applications that may
come close. As a rule of thrum reimbursement through Medicare is
challenging. For now the answer is no.
Thank you, Dave.
Anything --
The next question that we have right now is what are your suggestions
regarding who should be on the research team for telerehabilitation
projects? This one is connected to the other questions, which mention
that in their health service telemedicine is a service provided by
doctors and nurse.
Sajeesh is the expert in this area.
It looks like a very general question. If you are looking from a
telerehabilitation [ Speaker/Audio Faint or Unclear ] it's a broad
area, again. Most of the research goes into OT area, PT area -- [ Audio
Cutting In and Out ]. If you are doing an OT focus, have an
occupational therapist. The previous question was on associations
involved and their definitions. This applies to the research areas.
What we need is a white paper, or a position statement from each
association's perspective. A definition was given just now in the first
session. Physical therapy's perspective, what is their definition. You
can have research people involved in their particular areas.
I will add to that. [ Indiscernible ] uses a term called telepractice.
It brings up a final challenge. The reason they chose that term is that
the providers of speech and language pathology don't always practice in
healthcare. Some practice in school, would never use the word rehab,
they use the word therapy. The issue of link gis particulars and
semantics, it seamless major. Can you look at it on both sides. For
some its splitting hairs. [ Speaker/Audio Faint or Unclear ]. Just to
keep in mind, the terminology has a lot of similarities.
That's very good point, Dave. Thank you for that. We will revisit that
issue. In the second minisession we'll be discussing that. That's part
of the problem we face with the term rehab. There's a question about
what kind of technology needs to have to make it accessible. For
tomorrow's session we'll be discussing that. I'm sorry, Wednesday. I
would like you to join us for Wednesday's session. We will have
discussion and survey about these issues more in depth than today.
Please ask the question for Wednesday's session.
Thank you
for all of the questions. I'm sorry we cannot answer all of them. We
will try to answer them over email, if possible. We'll move on to the
next minisession. What we try to accomplish in the second minisession
is try to review the landscape.To do that we will review using the
framework that has been provided by Jack Winters. It's worth mentioning
that, of course, by focusing on these we have -- we miss many of the
areas, as mentioned by Sajeesh. There are many surfaces, many papers
published out there that we can actually categorize it as
telerehabilitation, but it doesn't mention telerehabilitation or rehab.
What we plan to do, first we tried to review all of the papers
that related to telerehabilitation. The first one is to retrieve the
papers from pub med. We searched in the past ten years of all papers
related to telerehabilitation. These are the terms that we used. The
problem is telerehabilitation is very new term. Many of the papers that
actually telerehabilitation doesn't use this key word. In order to
mitigate the problems we use the key wordless of teleconsultation and
rehab, et cetera. We also used more specific words such as
telepractice. We found that most of the support key words have been
included in the search that we used with the five possible key words.
Now what we found is there are 238 papers related to
telerehabilitation. That's a very, very small fraction, compared to
more than 8000 papers if you use "telemedicine." The word is still not
widely used. Many papers did not use either the telerehabilitation or
rehab terms or key words. We did the search again with Andi this
morning, if you use telemedicine and rehab there are about 500 papers.
The distribution is very similar to what we have.Even with 500 papers
that we retrieved it's still between 1.5% of the overall papers in
telemedicine. That tells us how small telerehabilitation is compared to
telemedicine. That tells us that telerehabilitation is still not
popular. And the key words of telerehabilitation and rehab is not as
popular as telemedicine. They still use the term telemedicine. I would
like to turn over the discussion to Andi, Andi will present his review
of papers from pub med and the examples that represent rehab services.
Thank you.
Thank you. This table shows us the distribution of
the telerehabilitation-related paper review that we did. We categorized
it into five different categories. The first one is the
teleconsultation, mainly focused on the face to face model of
telerehabilitation. We found 61 papers that can be categoried into
teleconsultation. One example is the paper from Brennan in 2004. The
focus is in the speech and language therapy.
The second is
telemonitoring. We found 36 papers inside in category. An example for
this category is the paper from Piette. It talks about heart failure.
The data is then used to help build a care management for the
particular client.
The third category is telehome care. We found 36 papers. An example from Hoenig.
The fourth is teletherapy. [ Audio Cutting In and Out ]. We have 68
papers. The brain injury people [ Speaker/Audio Faint or Unclear ].
The fifth category is the other telerehab service. We found 45 papers that can be categorized in this area.
The first category is teleconsultation. Defined as the standard face to
face model. [ Audio Cutting In and Out ]. Consultation is
videoconferencing, because of the need of interactive of realtime
communication. Very good examples are accessive device prescription and
[ Audio Cutting In and Out ].
This slide here show us an
example of an AT. It's a product that we have. [ Interference ]. The
clinics are in the rural area. They will expand the availability of
service. In their assessment the experts will communicate and talk
directly with the clinician and help them to identify potential
problems or steps that are missing from their assessment. This
consultation can be applied to many, many fields such as wheelchair or
augmentive communication devices.
Next is a similar process.
The main focus is in education of the rural area of therapy. The idea
is the rural area therapist will gather the data and send it to an
expert in the metropolitan area for a second opinion. The data will be
transferred back to the rural therapist, they will have personalized
options for the clients themselves.
The second category is
telehome care. It's a coordination effort to deliver service to the
client's home. There's inhome teletraining, home modification.
In the home teletraining the main focus is to deliver training of tasks
such as daily living tasks, without the therapist going into the home.
The therapist can see the clients doing their training at home and are
available to provide feedback during the training session. Usually it
also has a nurse to help the client to do their training in their home
setting.
Second example is would we call the home
modification assessment. Architects can gain a model of the client's
home and give suggestions on how to make their client's home more
accessible, or fit their device into their home setting. This one here
is a project from our RERC which builds a model of the client's home
environment that can be used by the architect and experts to navigate
and build suggestions on how to change their home setting, or their
home environment.
The third example is what we call the
telesupport network. Which is built through a peer to peer network that
supports information or resources from another person that also
encountered the same problems, and probably already has a solution.
That way this network aims to reduce the social isolation, allowing
them for information into the healthcare or the possible healthcare
they can gain.
The third category is telemonitoring. This is
done usually through an unobtrusive assessment technology. The main
difference between telemonitoring and home care is this covers the
entire daily living of a person. They don't just focus on the home, but
they also focus on the job setting, or their social setting. An example
for this is the personal telemonitoring and job telecoaching.In
personal telemonitoring the device can be a simple emergency call
button all the way to a robotic engine that captures the data of each
person and transfers it to the therapist or their clinicians.
In this slide it's done through the use of a shirt that has many
sensors that can detect changes in the cardio or bodily signs, it gets
transferred to the therapist.
In job telecoaching, providing
of feedback for the client so that they can learn to do their job even
without the need of a therapist that monitoring them every single
second. In this slide we have an example of a remote behavioral
assessment and job coaching using video and monitor technology. The
idea of this slide is that a certain client with a brain injury can do
their tasks, in this picture it's hamburger grilling, and getting
feedback to remind them to [ Indiscernible ] so that they can perform
their job in the most effective way possible.
Finally, the
fourth category is the teletherapy, which is the most sophisticated
branch of telerehabilitation. It's in the clinic or home setting. They
are managed by therapists.
The main focus is to digitize what
a therapist can find in a face to face environment and send it through
a telecommunication network, the main advantage is that usually the
digitized information is more sensitive.The slide is a virtual [
Indiscernible ] that transfers the rate of motion that can client can
have through the internet.
The teleaudiology is in the area
of speech and language pathology, which has seen a lot of success. This
slide here shows, um, the therapy being transmitted through a very low
band width network. The idea is the use of a store and forward method
to mapture the data -- capture the data from the client and transfer it
to the therapist. The focus is to capture the facial remarks and the
gesture of the user.
Finally, the post surgical teletraining
focuses on the self training of a client of a person that has been
admitted to surgical, or a certain trauma. The focus is to use many
applications to help users gain their training in an attended way.
Those are the examples of the telerehabilitations that we have reviewed
in our paper. I'm going to hand it back to Dr. Parmanto.
Thank you. Those are the categories from our literature review. Those
examples we consider [ Indiscernible ] examples of every category that
we defined in those four rehab services.
As it progresses the landscape also changes. For example, the availability of inexpensive -- [ Audio Cutting In and Out ].
will make the, I think, we'll the disbetween telehome care and telemonitoring.
The second one is the advances in mobile telemonitoring. [ Interference
]. There will be more applications in that area. This topic and the
next minisession, I will skip the discussion and move on to -- we don't
have much time -- to the model of telerehab services from informatics
perspective. As we mentioned before, the intersections intersections [
Speaker/Audio Faint or Unclear ] sorry with the slide, just wait a bit.
Okay.
I will just continue. We will use the points
that we mentioned in the previous discussion about intensity and
duration. [ Speaker/Audio Faint or Unclear ] between telerehab and
e-health are in home care and telemonitoring.
Okay. We will
use these two characteristics to develop new model and we will use, we
will develop four quadrant model. Instead of hierarchical you will be
able to see the services in a different spectrum. We will move it
around. Also, we can explain why the surfaces are not good for low band
width.
Okay.
Okay, I'm sorry. Problem with -- this is
not the last version. Okay. I'll move on. There's a slide missing, in
addition to intensity and duration we can also view the different
approach to telerehabilitation, mainly the realtime connectivity and
also starting forward. We will revisit this over and over again. Let me
just mention, in this model we put -- we tried to map all of the
different telesurfaces, telemedicine, e-health into the intensity and
duration axises. What intensity means, as we mentioned in the previous
If they require blocks of intensive information exchange between two
sides, that we consider it as high intensity service. While if the
service is -- we can be done over e-mail, over fax, telephone lines,
and exchange that service is considered with low ( indiscernible )
intensity. On the duration side, we side, the easy way to view it is
that for example acute surface that's when mainly on the short duration
side while the if it is chronic, done over time, even lifetime, that
would be long duration service. As we can see in this nicely along
those four terms. For example, surgery requires intensive communication
twoan two sides because the surgeon on one side need to conduct surgery
remotely, that will be very, very high intebs -- intensity service.
Because surgerily easily is done in a matter of hours and can be done
on the one time, then that easily we consider it as a short duration
type of service. As we observe in this picture, most of the medicine
fall under high intensity low duration services, and let's go back to
the ( indiscernible ) half. Most of the ( indiscernible ) surfaces are
lower off the quadrant. It means that it is mostly ( indiscernible ) we
have require high intensity, for for for for example, teletherapy more
resembles e-medicine than other type of tele rehab, so this will be
able to map any of the teleservices nicely and how it will relate to
other tele service, for example, we can see there that if there is any
new services off the rehab and we can map it very, very nicely. This
model can also help us ( indiscernible ) surgery will require very high
( indiscernible ) and mostly will require interactive communications
with ( indiscernible ) of service.I cannot view it right here.
Most telerehabilitation services will fall under low intensity and high
-- yeah, that's very good, low intensity and high and long duration,
so, for example, the teleideology, for example, all can be done over
even plain old telephone network and whether it requires repetitive
services, so that will fall under a long duration and low intensity
telesupport network is the same thing. In-home teletraining can be done
over the web, easily low intensity and can be done even using plain old
telephone networks. We can combine this model with a model of (
indiscernible ) forward, so, for example, tele methodology although it
is high intensity, but usually doesn't require intertiff connection
between the rural clinic with hospital, for example, so even high
intensity network can be delivered over slow connection if the
therapies can be done using starting forward methods, so this map can
be used in conjunction with store and forward interactivity model of
delivery to analyze any type of surface that we know, so this provides
a good and flexible model that is I think better than the fix (
indiscernible ) model as previously proposed by winters. This is --
this repeat the one we just mentioned, that model can analyze can be
can be used to analyze service delivery and in addition to the mode
that the transition can be used to analyze any type of surface that we
-- that it currently available or will be available in the future.And
the example that we have that most of the surfaces for example chronic
service in telemedicine, while the traditional telemedicine for example
acute therapies require high intensity and short duration while the
chronic telerehab requires low intensity and long duration. And this
four quarter model can also be used to analyze the dynamic interaction
between the technology that is available out there and the rehab
services, so if we have new infrastructure available that will afford
us to deliver different kind of telerehab services or if we have slow
connection and certain type of surfaces need to be delivered we can
analyze it whether it can be delivered using store forward for example.
So I will ask Sandeep to provide to discuss the telerehab services and
( indiscernible ) into the quad rant.
Okay. Yeah. Thank you,
Dr. Parmanto. As we have discussed before, the telerehab communication
may need three quadrants. ( indiscernible ) LD quad rant. This quad
rant -- the characteristic of this quadrant is low intensity fraction,
between the client and the provider, so the data transfer between the
client and the provider is actually quite small small. Doesn't always
talk about the size of the data that is being transferred or the
information that is being transferred between the sites. However, the
therapy is done over a long time, somewhat -- some of this
rehabilitation service are done for over the lifelong. Good example of
telerehabilitation service that falls into this quadrant are the
telehome care and heel monitoring. -- telemonitorring.
The good thing about this, define range from ( inaudible ).
Captioner: Audio is cutting in and out. Audio also sounds at times like it is being "fast forwarded."
It has to be able to retain the rehabilitation data over time. We are
talking about services that will stick with the client for probably
more than two but over their period of time is lifelong service.
Therefore, the best structure to support this kind of need is to store
and forward synchronous infrastructure. Why? Because the store and
forward infrastructure allows data retention. Store and forward
infrastructure data is forward and before forwarded to the purpose that
meets the data and even at the service side of the data is stored in a
way that is easily manageable and easily re retrievable.
In fact, using the store and forward we can transfer very large data
from one side to another site in a smaller chunk, meaning that even
though a big dated a can be split into smaller files or smaller data,
and transmitted over a period of time. Therefore the bandwidth
connection required is a low to medium band citd connection --
bandwidth connection. What is needed by the network, however, is a
network that can support multiple type of data and can be interfaced
easily with the devices that is used for the telerehabilitation
service. An example of the network that can support this is the plain
old telephone system. The wireless network such as the ( indiscernible
) currently available connected to the iPhone, for example, and also
the internet.
The second quadrant that is used by the telerehabilitation service is
the high intensity and short duration quadrant. The main characteristic
of this quadrant is that there is an intense active interaction between
the client and the provider, and usually it is done in a short period
of time. In a sense this is similar to the traditional telemedicine
service and an example of this is a fairly intensive teleconsultation
between two clinics, two clinicians that is ( indiscernible ) about the
best therapy for a client or even a direct ( indiscernible ) where they
need to analyze the gestures or the behavior of a client.
Therefore most of this quadrant is in the clinical setting where the
network can support an information ( indiscernible ) bursts. The
requirements realtime interactivity. [ audio cutting out ] most of the
service in this quadrant use high quality conference with realtime
interaction tools such as white board or a screen that the clients or
clinicians can do the work. Therefore the bandwidth connections to want
support the infrastructure is medium to high speed bandwidth
connection. The network requires a reliable and secure network, and an
example of this network are ISDN, APM or even internet ( indiscernible
). The third quadrant that in the telerehabilitation service is the
high intensity and long duration quadrant. It is similar to the high
intensity and short duration quadrant in which there is an intention
fraction between the client and the service provider. However, it is
done in short sessions when conducted frequently over time.In
teletherapy it can range from delivering therapy to the client's home
all the way to clinical setting. IfIt can utilize synchronous and
nonsynchronous network. Therefore, the requirements to support is a
network that is flexible because the need of the teletherapy is
directly connected to the therapy it is providing. The network has to
be able to accommodate with whatever therapy that is being delivered.
For example, a therapy that needs (audio cutting out) realtime
interaction network ideology can use a medium to low bandwidth
infrastructure to support them. Also the network has to be able to
accommodate integration of multiple systems. Some therapy may need post
conference and forward data transfer. So the ideal network to support
the teletherapy is by using internet.
Yes?
Thank you, Andy, and I would like to apologize we have a problem with
PowerPoint, and we didn't have the last latest version, but as we will
fix it so we will have the latest version in the next two meeting
sessions, and we will have discussion, panel discussion and also
question and answer from participants while we ( indiscernible ) to
provide comment. Could you pull up --
Yes.
Yes, how are you doing?
(multiple speakers).
Captioner: There is a very distinct echo. Very difficult to understand what is being said and a lot of feedback.
I think it is very hard to generalize even within --
I am sorry, could you turn off the speaker?
I am sorry.
My apologies.
Is that better?
Better.
I forgot that.
Captioner: There is still a lot of echo.
It is difficult to generalize the quadrant model you specified and did a fairly good job.
Is that the case?
Yes.
I believe we are still receiving your audio. Through the microphone.
( inaudible ).
Captioner: If they are still speaking, I cannot hear anything at this
time. It looks like David is speaking, but I cannot hear him.
Captioner: I am not hearing any audio.
Okay. Please go ahead, David.
The point I was trying to make when the audio was cutting out was that
I think there are a lot of different applications of telerehab, and
that may happen within the same patient within the same session by the
same therapist that a lot of different modalities may be used, so
perhaps a live audio video consultation may be used for some part of
the session and the therapist may switch and pull up something like a
white board, do some cognitive tasks, if physical therapy is involved
might be using some sort of electronic senz ors, a groom teres or other
data devices to capture other information, so I think while the
quadrants do a very good job of breaking down and helping to visualize
the way the different modes of services all interact in terms of
information technology, I think it is just really important for
everyone to remember that a lot of times they do kind of move around
within those four quadrants, and I think also despite having some
fairly poor information technologies, someone before was talking about
technology push, and I think a lot of the early work in telerehab
really was driven by what was available (audio cutting out) even
generally in telemedicine back in the 50s when they started doing
teleradiology or telepathology, they were using equipment not designed
at all for telemedicine, just supplied it to telemedicine. If you look
at the early work in telerehab people were using ( indiscernible )
phones not because they wanted poor blocking video but because it is
all that was available. Now we're at a point where I think we're
starting to see telerehab drive technology a little bit and doing
pushing rather than just pulling what's available, so that was one
point I wanted to make. The other thing I wanted to add in in
telemonitorring there are definitely other examples and we're seeing
some of this come out of the ( indiscernible ) where tell monitoring
living environment I think we'll see a lot of growth in that we already
have with some smart data, algorithms and wearable sensors and other
technologies related to that. Those are my main points.
Thank
you. That's why I agree with all of your points, and I probably (
indiscernible ) points in the white paper mainly first is that the
definition of the services, it has changed with the newer technology.
For example, as you mentioned that monitoring telehome care can change
becoming more intensive or less intense active with available
technology and also I think we will mention in the next session about
the I think more and more services will be integrated services, so we
will have different modalities, different type of services, in one
single clinical service, so we'll also have that discussion as well in
the white paper. Those are excellent points.
I would like to ask ca ( indiscernible ) to provide comments as well.Sajeesh to provide comments as well.
( indiscernible ) went to the literature first, and it is really
reflects the state of art of our telerehab ( indiscernible ). It is
really interesting to see the technologies really progressing at
dramatic pace but doesn't really reflect in the published literature.
By going to lited sure ( indiscernible ) came with about 200 and maybe
less than 300 people, and (audio cutting out) this morning just few
hours back when before coming here I was searching my favorite search
engine, Yahoo, and 800 sites, but that doesn't reflect in the
scientific journals, so what's lacking here is scientific publication
in telerehabilitation. More so for engaged in ( indiscernible ) and
other activities, but this published research, if you go to the 238
research publications, most of them come from very few limited areas
like publications from occupational therapy, physical therapy, and
sleep language pathology areas, stroke areas, and even if very small
numbers of subjects, and ( indiscernible ) randomized controlled
studies, these are the things we need and two words scientific
positioning of our telerehabilitation. Journals, journals has to be (
indiscernible ) service, so I think if there was an international
journal of telerehabilitation coming up, and alot of opportunities are
there, and we need a scientific base of (audio cutting out) all this,
and the main complaint from the patient's perspective is that still go
for face-to-face preferred because they feel ( indiscernible not just
satisfied but given an opportunity to go face-to-face what is lacking
here is something called human element missing human element. The
technology is trying to overcome by saying, okay, video and audio, so
we can see, we can talk, you can ( indiscernible ) kind of virtual
attach feeling of attached, and the other sensory organs like even
pretty much going on smell transmission over the net, so that the
difference sensory or stimuli can be used in this environment. (
indiscernible ) technical expert, and he is taking questions from
audience.
I think because we don't have much time, so what I
plan to do is to go over the two related (audio cutting out) sessions
because it will be short, and then I will have ( indiscernible )
questions at the end so that we accomplish -- we can finish everything
by using the time that allocated to us. Then we'll also do poll, so
we'll discuss what are the new opportunities and what are the
potentials more or less the problem with a new technology that we can
anticipate in the next few years? The first one is imagine that in
face-to-face sessions the session itself is usually not recorded, and
while in telesessions everything potentially can be recorded, so (
indiscernible ) information for research and information previously not
available for monitoring, for outcome, now that we have all this
information we can go back and evaluate. We can see all what have gone
wrong or what ( indiscernible ) can be done for that. That's potential,
and also the potential for data mining ( indiscernible ) data, and
unprecedented, and then imagine also the potential for education, so
instead of doing shadowing our students, interns, and residents, for
example, can go offer the sessions, and if you have thousand of
sessions we can categorize so it is more of life library of the
clinical sessions, what happened in the past years using this type of
information, and also potential by having recorded sessions and by
having more information available to us with telerehab and not to
mention thing that we have mentioned at the beginning with potential of
new service or potential of reaching under served population with
availability of broadband technology and mobile technology, for
example. Those are the potential that we see in the future, but with
gross potential we also have emerging challenges and problems as well.
The first one is the problem with privacy and confidentiality. Again, I
am sorry we have problem with the PowerPoint. It is not synchronizing
for web participants. The participant is like frozen or it is not
moving too.
Okay. Too many things going on.Okay. So those are
the challenges within the next few years. First is with those
potential, also problem with we need to address the privacy and
confidentiality, by having everything recorded happened, and I heard
about colleague in medical centers having problem with that, and so the
lawyers and privacy officers reviewing and don't want the recording
happen actually, so that's the first challenge, and then the second
challenge is as we move the services more toward consumer, then we'll
have problem with the consumer because currently system not designed
for consumers but for clinicians which usually more professional than
general population, and then the third challenge is with (
indiscernible ) information how to manage this complex information, so
this just to give you an example of the type of media that we had
dealing with, so from video, voice, images, and ( indiscernible ) so
first challenge is managing complex ( indiscernible ) advances and this
is especially true for the rehab because the ( indiscernible ) over a
long period of time, so the data is complex and repetitive, and we have
to manage it over time, and the question is how would we organize this
kind of information? How would we organize it so that we can gain
insight to it, how clinicians can view the data nicely or better than,
and I mentioned at the beginning about the potential for education and
( indiscernible ). How would we represent this information to students
and to interns, for example, and how would we organize the data so that
it can lend I itself into mining good information out of the data and
as well as the problem with privacy and confidentiality, so as I
mentioned that telerehab will generate new information that previously
not recorded, video monitor devices, ( indiscernible ) with the
availability of internet, this can be stored centralized and will have
enough information, and the problem is how would we deal with privacy
and confidentiality, and the second problem with the security and/or
with all of this monitoring devices transmitted over public connection
because we envision that internet will be used for most of this
services, so how would we protect the system, and then problem is as we
where bring more and more services to homes and to consumers, we have
the challenge of how to design the system that is more usable. We have
human interface problem that we need to address that previously not
that important because previously we are dealing with clinicians and we
can ( indiscernible ) them and their numbers, and trend them easily and
come back and we have to trend house and consumers at home, so those
are the challenges that we will face in the next few years.
We'll move on with opportunities in technologies, and we list the thing
that I think will have profound effect on telerehabilitation services.
The first one is the high speed interfet. As some of you know internet
will make internet speed much faster and also will deliver current
service that previously not available in the current internet service,
and in the second one is the availability of broadband connection
almost anywhere right now, the penetration of broadband services can
reach roughly ( indiscernible ) people 90% or close to 100% in some
Asian countries like Korea and Japan, so that will allow us to thrifer
more and more services to home -- deliver more and more services to
home that previously cannot be done, and the third one is the web 2.0,
and advantagement in software that loss to more integrated services
like what Dave Brennan mentioned previously, so more and more services
will be integrated not only just teleconsultation but teleconsultation
as well as tell therapy, as well as teleeducation, for example. That
can be bundled bundled together into single service.
( indiscernible(audio cutting out) with emerging of these two hyping,
high definition and high bandwidth that would allow us to deliver a
better ( indiscernible ) as we can see that our videoconferencing is
very chop choppy, and the watt quality is not as good. We have more
problems, so this thing that I think as we are in this session today
for this, and this kind of service will get better and better by day.
Somehow we will to stick up the signs like this, and in much better
format like come back to what we have today. So those are the -- one
thing we would like to mention is that you're telerehabilitation
services are based primarily on the internet because the internet will
be better and better, so everything will be delivered over the
internet. The one thing is that ( indiscernible ) off the internet
because internet is currently available just to provide quality of
service, or teleconsultation to homes or other clinics. We don't want
the connection to drop so that it will be frozen like what we have
today or some of the suddenly the connection is cut off. Those will be
( indiscernible ) for some of the clinical services. We expect that we
in the future or the next few years this type of connection will be
better and better, and will allow us to deliver services because the
internet will provide sort of minimum current service so the connection
will be -- won't drop slower than certain speed, and then also recently
in the past few months, a lot of discussion about dib computing meaning
SEC and Google we can store everything over the internet, and we can
store massive amount of data including videoconferences and
videoconferences and everything over the internet, so with cloud
computing, so the location of the server doesn't really matter any
more, and we'll see more and more data will be stored in the cloud, and
( indiscernible ) thoroughly, and it is available any time, 24/7. And
also we'll observe that another reason why telerehab is not delivered
over the internet because we want (audio cutting out) close system that
we can control. There are a lot of drawbacks with that kind of system,
so we'll expect that more and more service will be delivered over the
internet because the internet will provide more open system and more
flexible and allow us to deliver integrated services, offer more
proprietary technology, and I would like to turn this to Andy to
discuss a bit about the potential of the internet and also the one of
the challenges with evidence-based medicine.
Thank you, Dr.
Parmanto. As Dr. Parmanto has stated and also been support by our panel
of experts, the development of telerehabilitation service right now is
pointing toward a multi-data service delivered over multiple
telecommunications applications, but it is integrated to support the
telerehab service that they provide. In this kind of setting the
internet opened potential of doing such things. The availability of web
2.0 technologies allows the users from therapies from clinicians pool
their resources together to deliver the service. In addition to that,
the open source initiative gives us the basic modules or the (
indiscernible ) to build a solution to deliver telerehabilitation
services. The idea is that the integration will create a single point
of access, a single communication channel for ultimate I am
applications. For example, the service that requires both
videoconference and also physician support system can be integrated
into one application instead of using the systems in a separate
parallel way which is happening right now. The idea from inte
disbraition that the data can be exchanged between the systems easily
without multiple best of my best of my bridges between the systems to
share the data, for example, from the videoconferences, to the
electronic health records or from additional support system to a
videoconference.
The internet is ideal network to support
this because of four advantages. The first is the use of access Dr.
Parmanto has already talked about the ease of access because of the
high rate of penetration of internet hey bandwidth internet in the
world. Second one is because it is expandable. We can create new
modules or new applications or new systems to deliver a new services
without having to reveal the entire infrastructure. We just have to
build a moderate yelt and plug it into the system that is currently
available. Third one is that it is capability, meaning ( indiscernible
) or new services can be deployed easily and interact directly dish
telerehab service that is currently available without a lot of hassle
because all of those services will be built using the same protocol,
and the availability of the open source initiative and the web 2.0
technologies also can ( indiscernible ).
The second potential challenge and opportunity as well is the need of
evidence-based telerehabilitation services. The idea is any technology
or any service can only be adapted if it has proof that the service is
actually delivers or actually over ( indiscernible ) has been done in
the regular. Idea of creating an evidence base for telerehabilitation
service has been there for awhile, but I believe that there is a need
for telerehabilitation protocol on top of the standardized telemedicine
data in the sense this data protocol will help detract or
evidence-based telerehabilitation service because this dated a can be
used in research or many other research study to support or create
evidence on telerehabilitation services. An example of the data set
include our list in the PowerPoint here I am going to focus on the
telerehabilitation. First is the function of independence measure that
may share for example the ability or function of capability of the
client or even a geriatric ( indiscernible ) for other older adult
population, and the secondary is interim that is designed to assess the
current condition for person with rehabilitation condition.
Before we move onto the panel discussion and as from participants, we
would like to do polling, so I would like everybody to answer the poll.
I think there are like five, right, the first one is what we have, what
do you think if telerehabilitation is ( indiscernible ) or separate
intersects with telemedicine.We have there that it is as of now we'll
close the first poll.
Yep.
Okay. So as we close, 85%
think that it is a separate and 15% think it is ( indiscernible ).This
probably also. The second poll. Which area that you are working on,
either working on or interested in, we would like to know.I like that
it is realtime.
Right, right.
People have changed.
Okay. We'll close the poll. We'll close the poll right now. It is
interesting that telehomecare is not as popular among participants as
we thought.
Somebody comment you can only choose one.
I see. I got it. We can only choose one, then, yeah, that's probably
explain that most of us were interested in general telerehabilitation,
but interesting that teletherapy is very popular and then followed by
teleconsultation and telemonitorring. Thank you for the poll, and then
can we pull out the third poll?
The first one?
The third one.
We have five, I think.
Right.
So what kind of connection do you use for your current telerehab system or telerehab that you know?
( inaudible ).
Sorry about that. Sorry about that.
We'll close the poll in a few seconds. Please. We'll close the poll.
So, well, as we probably believe that internet becoming more and more
dominant, but what interesting is it is plain old telephone still very,
very popular, and I think that's partly I think because availability of
internet and hopefully the services will change to the internet once
becomes available, and ISDN getting probably less and less popular than
the internet, still part of the telerehab services right now. The next
question is which part of quadrant that can characterize your current
telerehab services or telerehab services that you plan or that you
know?
Okay. We'll close in two seconds. Thank you. This is rather surprising.
We thought that most telerehab or the majority of it will be part of
low intensity, intensity, long duration, but it turned out that the
number one is high intensity long duration, and teletherapy, so similar
to that, and the second one is low intensity long duration. That's also
that we didn't really expect. So that's really interesting. So, wow,
that mean that is we need to explore more of this area and why is it
the case? While high low intensity -- well, low intensity long
duration, the second one which makes sense, and then high intensity
short duration that's also interesting, and if we sum it up, many of
the telerehab services working on the high intensity one, which quite
surprising, and that means that more and more telerehab services are
very advanced because that requires high intensity connection between
the two sites sites. Thank you.
Okay. We close that one, and then how about the fifth poll? Which technology you think --
This will have multiple answer.
Thank you. We'll close that one. I think we have another question, but
I think the question is -- slight mistake in the question. Actually,
what are the main issues, can we pull out that one?
I don't know which one you're talking about.
The 6 one, number 6. I am sorry. There is a slight mistake there. Web
2.0 there is privacy and confidentiality, so what are the problems that
we will face so use web 2.0 as privacy and confidentiality there that
we will face in the future.We'll close it in five seconds.There is a
question about can we repeat the survey in the blog? I think we will
accommodate that one, and I think can we -- we repeat it on the blog.
The poll. The answer is because we found that the research of very
interesting in the sense that a lot of it we didn't expect it, so I
think that we can use it as a basis for discussions, and it is also
interesting that usability is probably one single issues that is the
most important for our future telerehab services. Thank you, everybody,
and again we will put the poll in the blog, and thank you for that
suggestion. I think it will be an excellent one, and we'll move onto
panel discussion, and then we will have question and answers from the
participants, so I would like to invite Dave from national rehab in
Washington, D.C. Dave, I hope you're not sleeping.
Still awake.
I am still awake. I took all the poll questions.
I would like to get your comments.
Great. Let me go through. I wrote some notes here. Great discussion of
the future. I think even since the four years you have had the RARC, I
am sure you have seen tremendous amounts of change in the area of
inform attics and web 2.0, and the very fact we're able to do this with
I don't want to say fairly minimal effort because I think I know what's
going on behind the scenes, but the fact we have 82 people able to do
this with not too much difficulty I think speaks worlds to where
technology is. I will go through my thoughts in at least the order that
I had written them down through your slides and talking about new
opportunities, you were speaking with -- about potentially with things
electronically things are able to be archived for training purposes,
and another application we will see more of, remote supervision of
therapy training students, and I think this puts a lot of opportunity
putting therapists into someone with an onsite supervisor who can do
remote supervision, and I think a general trend in terms of the some of
the privacy issues you were talking about, I know -- I mean, I have
gotten calls and I am sure the folks at Penn have as well how do we
solve the HIPAA challenge, what do we do for telerehab with HIPAA, and
the fact of the matter is there is nothing specific the guidelines
state relative to telerehab other than just the bear bones but don't
lay out exactly what you have to do. Now that I think information
technology is really driving so much of generalized healthcare and
generally liesed rehab, I know our rehab hospitals finally after a long
delay launching the full electronic medical records system in the first
of the year, so I think as we're seeing a lot more IT get involved in
general healthcare, some of these issues of how do we go about securing
data, data, how do we go about privacy, when do you need a VPN to
access the network, certain issues like this, I think telerehab will
benefit from that by being able to leverage kind of momentum going
behind the healthcare industry as a whole.One or related comment, I
would be curious to get your take on it from your end as you do more of
the internet application, and we're seeing a lot more consumer centered
services in healthcare, things like Google and Microsoft health really
putting healthcare applications into the hands of patients, and that's
sometimes a good thing, sometimes a bad thing. I think trends will play
out, but we're seeing alloted more even home care devices, the
continual alliance and other related providers taking medical devices
like blood pressure, blood pressure devices, weight scales, and
essentially letting you buy those straight from CVS with the ability to
plug into the computer and up load the data and manage it yourself. If
consumers are able to manage that themselves, the healthcare providers
could benefit as well.
From a consumer centric side of things,
Andy, I know you talked about open source. We're seeing things like the
iPhone, the Google phone, very, very high tech devices that essentially
released to the general public, here is a software very easy to use,
write your own application. For researchers, I think we see a
tremendous potential rather than having to fight against the stream of
manufacturers it really let's us build technology that we need that our
consumers need and not that they tell us we need. We're still for
better, for worse using technologies developed for business conferences
that are developed for the corporate tell commuter and not necessarily
for an elderly patient living at home trying to access their speech
therapist, so with open sourced technologies we can really solve some
of these usability issues right at the point of development rather than
having to kind of put a band aid around a system and some duct type and
hope that the consumer at home doesn't click on the wrong button
because it could crash their application. I think some of the audio
issues we had today may have been inadvertently caused by me
accidentally clicking some of the wrong buttons, so I think we're
seeing this trend kind of putting the power into the hands of
consumers, and I think from the -- we need more research to drive this
field forward, and I think from the technology side of things we're at
a point where we can really build the applications we need to move
forward.
Thank you, David. Sajeesh.
David, I agree
with the comments you made, and coming back and looking at the service
we just had, it is really interesting and really reflects the state of
the telerehabilitation and services. The survey showed almost 70% of us
still prefer internet and our main concern is to have public use of
friendly devices. That's really reflect -- just the other day was
reading a report by forest, and they came up with this new survey on
U.S. on line uses of healthcare products, and list on there more than
50% of the people still not aware of healthcare technologies available
on line osh healthcare on line services available, and those who really
know about this technologies less than one person of them use this
technologies on line. That's are where we stand now. The public are not
aware of it even if they don't go beyond that limit and Les than 1% of
them really use is it, so there is immense potential to go into that
kind of market and to communicate with consumers, the potential
consumers and I think there is a high area for us telerehabilitation
practice measure educate the community and availability of the service
and make ( indiscernible ) for user friendly. I think that is a human
and computer interaction research. A lot of research is going on using
smart pens and voice interactions, and I think along with the time the
cost of the devices, hardware, it is not just the fiber optic
connections or internet web tool, and the device people are (
indiscernible ) service from the people's perspective, so I think
eventually the devices will be more portable and more affordable and
that will be our stepping stones towards potential for
telerehabilitation, and I am seeing a bright future for us.
Thank you, Sajeesh. We would like to open questions from participants,
and then we'll discuss the questions and we'll comment and the panel
will ( indiscernible ). I would like to ( indiscernible ).
We have three questions pending.
Okay.
The first question is are there any government agencies participating in the rehabilitation?
The veterans administration, well, I guess we can go back to
terminology for a second. The veteran's administration is probably one
of the largest current providers of some as spekts of telemedicine, and
what they're doing is in the area of telehomecare. They do some degree
of live consultation, but what the veterans affairs -- what the
veterans administration is doing relates a lot to remote management of
chronic diseases, so diabetes, congestive heart failure, COPD. They do
have some patient who is are receiving rehab follow-up care using
in-home messaging devices. I know they have contracts with a number of
vendors. They have I believe over 10,000 different in-home messaging
devices they're currently collecting data from, and they're finding
tremendous benefits both in terms of patient outcomes and cost
reductions for them. I know in speaking to some of the folks I know at
the VA the disease management protocols that they use for diabetes care
for example which would be a series of questions that are delivered to
the patient at home on a small messages device, the patient answers at
a predefined interval. I believe they have finalize and had have
approved a series of questions for rehab, and it is fairly generalized,
and I don't know specifically what patient population they're
targeting, but they're getting more involved in rehab as we're seeing
more of our Iraqi war and Afghanistan veterans coming home,
transitioning from the DOD healthcare service into the VA health
service, we're going to probably see a large growth in terms of what
they're doing with cognitive rehab as well, so we'll see some areas
there.
Thank you, David, for a comprehensive answer on that.
I think in addition to VA, DOD is probably also moving towards that
direction. We know of some of us participate in the COMA projects, the
goal is to provide monitoring and connection between soldiers who coma
patients and with their families, but that's -- my impression is it is
not as well established as one in the VA, currently one of the largest
services in rehabilitation.
Question is how about the state government agencies?If you would like to take that question, Dave.
I will try. Maybe from the questioner, can you clarify what government agencies?
How about the state liable government agencies doing the sort of thing --
Rehab agencies. I see.
(multiple speakers) to be honest, I don't know vocational rehab
offices. To be honest, I don't know, that's not unfortunately one of
the areas I am too up on. I know there are some initiatives in states
in terms of telemedicine. I think we're seeing a lot more growth in the
rural states obviously than more of the urban states with demonstration
projects. Unfortunately I don't have any specific information on that.
There is a session tomorrow that will be appropriate for that, and we
have an expert on that, Dr. Mike McCue has been involved with we are
service for quite a while. Another thing I would like to mention some
of us also involved with a state agency with Pennsylvania Department of
Health providing services for children with autism. That is part of the
here the hospital here provide services to rural areas. That's through
State Department of health, and again please ask the question tomorrow
to Dr. McCue. He has been involved with state VR agencies all moving
towards that direction providing telerehabilitation services. Thank you
for the question. Move onto the next question.
The next question is similar ( inaudible ).
Yeah. Yeah. We have answer to that question about state agencies, so
some of us involved with department of health and also please ask the
question tomorrow to VR agencies of the state.Probably be more
appropriate for tomorrow. Comments on that.
There was a comment here from earlier about the long-term care industry.
Yes. That's the comment that long-term care industry will be more interested in EITM homecare than CRC.
( inaudible ).
Certified rehabilitation counseling. That's what we would expect, and
that's one of our main interests as well, and we were rather surprised
that telehomecare is not one of the --s want --s it is not really
number one had it comes to the side of polling, so but from our
observation that's probably one of the greeing field out there. The
next question is about wireless video camera and availability.
Okay.
Which one?
( inaudible ).
I will repeat that. In OT, I need to assess the patient within multiple
views of their environment and performing functional activities.
Therefore I am looking for wireless video cameras with verbal
communication to accomplish the task. There is access and have any
other ideas on how to -- I would like to defer this to Andy who has
been playing around with ( indiscernible ).
(multiple speakers).
There are a lot of ways to capture the video or the video camera with
verbal communication communication. One of the cameras we're using
right now is a Panasonic camera which can be used to streamline
basically the video and the verbal communications from a remote site,
and that will be discussed tomorrow during the clinical applications of
the white paper, and also we have seen several other wireless networks
that may will be able to accomplish this such as the use of iPhone and
the 3G network, and also probably ( indiscernible ) phone. I have seen
a couple of applications on top of the iPhone that is able to
streamline the video and also audio from a remote site and quality is
quite nice, using the 3G network, so the coming of the 3G network
allows us to have a wireless connected activity with a very big
bandwidth that is not available before, and I am sure that a lot of
applications are being ( indiscernible ) right now on top of that
network, and I believe we will have a lot more discussions on the
technology, especially on the --
Wednesday.
Wednesday where we will talk more on the technology and also possible
solutions to the telerehabilitation services. I am not sure what
wireless that connection that you mention, that you're referring to,
Andy mentioned about 3G, usually if you have wireless internet
connection, the speed usually is even better, so I think if it is not a
problem with 3G connection, it won't be much a problem with wireless
internet connection because the speed easily is much better than even
3G. So you can send an e-mail to Andy about ( indiscernible ).
( laughter ).
For the discussion.
I saw there was also a question that somewhat related I think about how
many people don't use the computer and don't have one. What would be
your thoughts on the fact that a lot of what you talked about has been
internet-based solutions, and I think I know where your answer will
likely go, but traditionally enter net meant a computer, and I think
we're seeing that kind of shifting away. I heard a story on NPR I think
last week, and they were talking about the fact that the iPhone which
is still a fairly pricey commodity for a lot of people are actually
being used by a lot of folks in lower income. [ etds as their -- berk
ets as their even internet device. You can essentially buy all of that
in one for 40 or 50 or I am not sure what the monthly plan is. What
would be your thoughts from the informatics side in terms of where, how
do you get on the internet and how will that impact telerehab in the
future?
Because when you first mentioned about somebody
without computer, two things somebody without computer, without any
connection or somebody like in very, very poor rural areas or somebody
actually moving to the next group area in terms of technology which is
what is called near computer, so I would like to answer the second one,
and then to answer the first one Sajeesh is the expert on that. So I
think the next growth will be what disw something called near computer,
actually the what you mentioned something like iPhone, PDA, will be
more and more powerful, and will have more and more feature of a
computer, and also as we can see the price of this kind of devices
almost as expensive as computer, but I think also the price will go
down as technology matures, and I think that will be the growth area
for everything, not on the telerehab but also internet application,
mobile application, so I think we'll see more and more people use that
one as a primary as you mentioned, primary communication and primary
computer yet of having right now we have two, PDA, computer, and
iPhone, and in the future I think the iPhone is the computer, and I
think more and more services will move to that direction. I think right
now in infancy, but I think that will be the next growth area in terms
of neck -- technology as well as in terms of services as well as the
area of telemedicine and telerehab.How are you ensuring telerehab for
low income families who may not have access to computing or technology,
and I would like Dr. Kumar to answer that because Dr. Kumar is a long
experience with dealing with very low rural under served population in
Australia, so I would like him to comment on that.
That's a
big issue in telemedicine itself. We have to do a lot of cost
comparison studies. In giving service to low income groups, telehealth
really has one of the case where we had was older community with
three-year ( indiscernible ) needed a power wheelchair, but in
consultation with a city-based research group, what they could do was
using the video technology we assessed what was her need for powered
wheelchair, and luckily for her case we had one extra wheelchair lying
around, and we could just 1EU7BDEsend it to her for trial, and from
that case they can decide which wheelchair, and we had to do a little
modification on joy stick and all those things so they can at least in
terms of rushing to or making financial decision they can try all this
available means around the world and not just in one place, so this is
high tech. It is not high tech thing you need for all of this, simple
video camera, and coming back to the position thatd technologies are
available, it is not just internet because you can see the third world
countries, David, never had any even plain old telephone system, so
never had the infrastructure for internet-base, so what is now
happening is really jumped into the wagon of satellites, look at India,
China, they're going to ( indiscernible ) last week, India planted a
flag on the moon, and China is also, and they're using satellites for
healthcare, people in remote areas are getting mobile messages in case
of accidents, what to do and how to talk to specialist in the city
area. So the countries that the landscape is changing is not just
internet-based or technology there in hand. It is coming more towards
something called ( indiscernible ) technology, want normal based on
laptop or desktop systems, people want everything in their hands, and
this is amazing that third world countries can get their marketplace,
what price to sell their product, what price they're to give to the
healthcare provider, so they can compare and they can take best
decisions, so a lot of opportunities in case in terms of the
technology, the only thing is the cost, and a lot of studies needed to
be published also in COLARIS compare -- cost comparison. It has been
publish and had what we are looking for is cost base studies and maybe
large case studies on randomized studies covering all as pex aspects of
telerehabilitation and involvement of people is also a big issue, to
get more and more people involved in telerehabilitation as such and
writing and publication maybe journals and discussions like this must
go. Thank you.
Also comments from participants that to combat
the issue of families not having computers when the local school system
changed computer at times they need to be updated, but we have people
that will fix them and so it is basically transferring the -- from home
to -- from schools to home.Okay. So we exactly three hours from now, so
we 4:00, so we accomplished what we need to do today. Again, if you
still have questions, please send us e-mail, and also please make
comments on the blog, so we'll post it there and then so that we can
continue the discussion, and thank you to the panel. Thank you to Dr.
Kumar, and thanks a lot to Dave from National Rehab hospital in
Washington, D.C., and it has been really productive discussion, and
thank you, everybody, for participating, and thank you for being the (
indiscernible ) for the experiment today, all of us, and thank you for
being patient that we went through the problems that we have and we
will fix the problem and hopefully we will be much better tomorrow, and
I will see you all tomorrow. Thank you. I would like Dr. McCue will --
I will say a few things.
Dr. McCue, will say a few words, and I see one comment that they like your tie.
( laughter ).
Thanks. Thank you, everyone, and I will not repeat the appreciation to
all involved in this. It certainly was an interesting experience and
hopefully something you gain some knowledge from and some insight about
the informatics behind telerehabilitation. Apologies to Chris and
Andrea who had some questions that didn't get responded to but as
Bambang said we will respond to all of the questions. We'll say the
question, include them in your blog and provide a response for you. I
just want to give you a preview, a brief preview tomorrow. Tomorrow's
paper is telerehab clinical and vocational applications for assistive
technology, research, opportunities, and challenges, and that's
authorized by Dr. Smallleer, Rich shine, myself, and Ken dray Betts,
we'll have Barb Suzanne PAONE, Paul Weyman, Steven dolling, thingsling,
topics are pressure ulcer prevention, virtual reality, speech language
applications, vocational rehabilitation. We will have some
illustrations of some work done at our RERC including our wheelchair me
subscription project as well as our robotic job coaching project, so
please tune in with us tomorrow for that paper. As a preview to that
please visit our international journal of telerehabilitation site and
download the paper so that you can preview that before the conference.
That site is HTTP:// HTTP://telerehab.pit.EDU.Finally before I say
goodbye, pleats complete your post test evaluations before logging off,
and we hope to see you tomorrow. Thanks a lot. [ event concluded ]]