Event ID: 1167661
Event Started: 11/18/2008 12:50:36 PM ET
Please stand by for realtime captions.

Hello ladies and gentlemen around the world. My name is Kate and I would like to all commute to this historic state of the science virtual conference put on by the rehabilitation Engineering Research Center on telerehabilitation, and I am pleased to introduce our directors of the RERC. It to my right is [speaker/audio faint and unclear] spec.

Let me add my welcome to all of you, thank you, Kate. We're glad to see you all here today. I have a feeling that many of you are back from yesterday, and I'm going to give a lot of the same information over again. But before I start, of first like to get a feel for how many of you are here for the first time today and how many of you are returning from yesterday. I have placed a polling question up in the right right hand portion of your screen if you would just can complete that. If you are unfamiliar with the polling questions, just click the radio button on the entry would like to select. Currently, we have 73 people on line and so far 37 with 30 of you have voted.

Well you are voting, I think I should tell you that we have more than 250 people that have pre registered for the conference, and out of those 250 people, we have 14 or 15 countries represented and more than 36 states and the United States. We have an extremely diverse audience here today and it should give us the perfect venue for exploring some of the venues in telerehabilitation. This is fantastic opportunity. [speaker/audio faint and unclear] accessible, available and affordable quality rehabilitation services. Because the percentage of the population increases disabled with age, the health care services are projected to increase dramatically. In turn, unless society develops strategies to curb costs, [indiscernible] health-care spending to unsustainable levels. This brings us to several fundamental questions that we should address during our time today and the rest of the week. First, does telerahbilitation provide a cost-effective and efficacious alternative to face-to-face Services? Second, what are the problems and training needs? And the third, how can will more fully integrate consumers of rehabilitation?

We're going to try to address these issues of in some detail over the course of our conference. Conference objectives are two present the state of the art and tell her telerahbilitation and present the evidence we have today. To explore technology and clinical service delivery and usability and acceptance in public policy.

In order for us to successfully explore these issues, we need your participation. The reason for us to have a conference is silly can have an interaction where you can express right Diaz, we can give you information and express hours and together, we can help to achieve these objectives.

The 12 a identified deficiencies in the use of telerahbilitation products and approaches and services, and finally will want to prioritize future research and training and disseminate these strategies. We started the process of preparing for this conference more than one year ago. At that time, we selected representatives from our center, and assigned the task to those authors to solicit additional experts to help them authored a white paper on their assigned topics. We will be discussing one of those topics today.

Each team produced an initial draft that was reviewed and commented on by additional outside experts. Based on the feedback, a second draft was produced. The second draft was finished on the order of month ago and distributed via e-mail and made available through the web site of our new journal, the International Journal of telerahbilitation. Now today, will have these papers presented by the authors, and a response presented from predetermined panel of experts, and then discuss them in an open session. And again, it is during this discussion where we look like your input and your participation.

After the conference, will maintain a block site where we can continue the discussion and continue the exchange about ideas. We will keep that blog site open for a couple of months, probably until the end of the year. At that time we will take all of the input and produce final drafts of these white papers and these white papers will be published in final form in the premiere issue of our Journal, the International Journal of telerahbilitation. The conference session itself will be archived and available for viewing after the conference is over, and we should have this archive available within 24 hours. The stream of the session from yesterday is already available.

To give you some orientation, of like to just show you around the screen and the layout you see in front of you.

In the upper left of your screen, there is the video feed window. This will be used used to show that presenters as they present power points and other information. The power point slides will be presented in upper right hand corner of the screen. Immediately below the power point Port hour to additional windows. The one on the left contains a list of files that you can download to your own computer and in this list is endless of post test devaluations in several different formats and the evaluation forms. These forms are very important to us so we can get feedback on the conference in its format and content and important to you in terms of the Post test because that is what you need to complete the award at the CEUs at the end of the conference.

At the lower right of the screen is the chat window. Through this window, we would like you to interact with us. Just to give you a little background technically on how our presentation is being produced, the panelists here in Pittsburgh along with the panelists who are at remote locations are communicating over a telephone conference call. The audio from the telephone conference call is being bridged into the Adobe Connect software, and streamed out to you along with the video feed and other information.

Generally, there will be no opportunity for you to come into the conference call, so that is when you look like you to communicate with us over the chat window. I will be monitoring the chat window over the course of the proceedings here, and when a question entries into the presentation, I will pass the question on two the presenters or respond to you directly, depending on the question.

To your left of the screen is the window that contains the closed captioning. Now, yesterday we learned a very important lesson. We find that the audio feed is perhaps the Achilles heel of this type of presentation. And at times, the audio feed was dropping out. I'd like to just let you know that when that happens, if you it is a word or the audio feed drops out for a second or even a minute, if you would look to that (audio cutting out).

(audio lost)

(audio lost).

It appears the captions are now working, either.

Okay. We are holding for audio.

Okay, it is back.

Okay, I am told we have audio back. Glad to hear that. I should also -- I told the group yesterday that we do no quite a bit about telerahbilitation, however, we're complete novices at the telemeeting and teleconferencing, so we are learning as we go and hopefully it will be better than yesterday and hopefully tomorrow will be better than today and please bear with us as we educate ourselves.

Finally, I like to thank several groups and people. First of all (audio cutting out) disability and research in the U.S. Department of education.

Secondly, I would like to acknowledge our advisory board for our center. We have a dedicated group of people who helped to evaluate our process and point us in the right direction. Thank you very much. You're at the University of Pittsburgh, we have a team of people who have worked through many of the technical issues and putting on this meeting, and those are Kip [indiscernible] and Joe Russian oil and [speaker/audio faint and unclear].

The most hard-working perhaps a group of people and our rehabilitation engineering and research center are our students, and they do all the things we don't want to do, and they do it with a smile, at least to me anyway, and willingly. So thank you to them for all the hard work they do.

I would also like to acknowledge Dave picture of the Clarix systems and has been teaching us how to use this system and it's online providing backup right now. Thank you, your help is invaluable.

Finally, the meeting has been conceptualize and implemented by two people who have put in tireless hours in preparing for this event. Those are Ashley Ashley Molinaro and Katherine Seelman. Ashley is in the corner working hard, and we are indebted to those two for this event.

Without further ado, of the to introduce our speakers for today, and the topic of the date is telerahbilitation -- clinical and [indiscernible] aspects [speaker/audio faint and unclear] (audio cutting out) for authors that brought the White paper. The first is Mark Mark smitter. He is the director at the University of Pittsburgh and the director of our continuing education course at the Mac program. He is course director for the International ceding symposium and several other continuing education venues including but based Post education and training.

He has more than 20 years of clinical practice experience and currently practices as an occupational therapist and assistive technology practitioner in the center for assistive technology here in Pittsburgh. His research is in the development and application of functional outcome measures, product development telerahbilitation.

The next author is Richard shame. He has a doctorate in School of Health and rehabilitative sciences. He has been working on telerelocation or his doctorate work has been focused on wheelchair by back -- second master's in public health. I am not sure how you're doing all of this part time. Concentrating in health policy and management at the university.

The third author is Michael McCue. Sitting to my left, he is the is as if professor and vice chair at the Science and Technology University of Pittsburgh and director at the rehabilitation counseling program. Dr.Michael McCue has undergone extensive research in relocation of individuals with disabilities. He is co-director of our center for telerahbilitation.

The fourth author is Kendra Betts. Kantor is it physical therapist and Artie as an a [indiscernible] spinal cord injury and we'll tears and seating and adapted sports. Tundra is currently in the press at its clinical coordinator for that [speaker/audio faint and unclear] in Washington D.C.

At this time, but will turn over the podium two the authors, and if you will just bear with us for 30 seconds to one minute Weller change seats here and we will begin our conference today. Thank you very much.

Good afternoon, good evening and good morning, depending on where you're coming from. I and Mark Schmaler, the author of this paper as state was saying, all three of us have quite a bit of clinical background and have been using the telerahbilitation platform in some of our research activities and seeing how they applied to clinical practice. Quickly, to go over the learning objectives of our presentation this afternoon is one to look at the different terminology or distinguish the terminology between the terms of telemedicine, telehelp and telerahbilitation. Recognizing the need for this application, comprehend at least three examples of assistive Technologies and vocational applications using telerahbilitation and explain the clinical and research issues associated with where we are at this point in the using telerahbilitation as a clinical modality.

So where does this all fits together? It turns out there, such as teleHealth, telemedicine and telerahbilitation, and such a thing as home telehealth, E Health and telepresence. Basically, telehealth has been defined as somewhat the use of electronic information, communications technologies to support any long distance clinical health care application. It has also been used in patient and professional health related education. That is where my background is, a clinician and also involved in continuing ed, and we have also been able to see there is some applications an opportunity in that area, too. And also some public health administration perspective.

Telemedicine under the umbrella of (audio lost) health is the use of medical information exchange from one site to another using electronic communication to improve patient's health status. And that is from the National Association of the American telemedicine as a station. Back in 2002, Jack Winters try to put it all in a format to look at take to helping the overarching definition, and under that coming teleMadison, teleHealthcare and E health and education.

So what is telerahbilitation.

Well, if we break it apart, tele- means far off, or distant or to restore a former capacity or state, and telerahbilitation is then the delivery of remote rehabilitation services.

Our RERC on telerahbilitation 's mission is two look at research and development in the method system, and technologies to support remote delivery of rehabilitation and home care services for individuals who have limited local access to comprehensive medical and rehabilitation outpatient services. It would put it in a diagram here.

Why is telerahbilitation or teleHealth important to us? Well the one incident is pretty obvious, the baby boomers. By 2020, we're expecting that most Americans work a lot of Americans will be living with a chronic disease that will increase to about 25% from where we were in 2000. When you look at the denigrate Democratic Left, the geography, 25 percent of the U.S. population lives in a rural area which is defined by not living in the metropolitan statistical area and 22 percent of our population is considered a senior citizen. And this information comes from the Office of Management and Budget in 2002.

So addressing the unmet needs are probably where we could start here. They're is a shortage of health care professionals, and that doesn't necessarily mean that it is specific to grow areas but it is an issue there. It is also an issue in urban areas as well. Ibid preface that by saying that a lot of times we like to point to rural areas as being underserved, but there are obviously underserved populations in the metro area as well.

There is isolation from medical advancement and technology, depending on where you have access to [indiscernible], funding is an issue which will come up today but probably will be more in detail when the two the session on policy. Patients are being disbursed further from inpatient and the concern is what support is available to them once they have returned to their home or community.

The mortality and disability rates are increasing as our population is surviving catastrophic accidents, diseases and living longer. The distance between patients and facilities and access to those experts, transportation has been no it is expensive, becoming more expensive and also, the accessibility issues associated with transportation.

Time Management, use of the professional persons time can be used and what we are also finding out, one of the benefits related to education.

So some of the barriers, obviously, just to recap here. We still have a funding issue, paying for telerahbilitation services. There are still issues with policies from insurance companies, both public and private. The user acceptance of the technology is still being investigated. The design of the technology itself from the human factors perspective as far as how intuited it is, plug and Play, which is certainly advancing considering the technologies we were using 10 years ago.

Also the scientific evidence, what is the effectiveness of this delivery system, and as we all know, in order to push for policy, we need the scientific evidence to indicate that this is an effective issue.

There are also legal and ethical issues that need to be worked out. Awareness of the technology, standards and guidelines for delivery of telerahbilitation and teleMadison services, teleconferencing as well as education and training on the use of the equipment itself, knowing whether it is cost-effective, and as we all know, there is still the issue of how do we sort out credentials and licensing across state lines and countries and so forth.

What we're on two cover today is kind of the background of where we are with the technology and science and evidence. We do know this technology is bridging, beginning to emerge to bridge the gap. Telecommunications and technology is ever so fast growing, not just in health care but in mainstream of telecommunications. And there has been a lot of investigation in that area. You'll see it with the Internet, and yesterday with the presentation talking about the infrastructure with Internet two and other opportunities. So the talent of the feasible Electric myth of Service delivery, we just need to figure out a more effective way of providing a service.

So teleand medicine from a medical perspective has been used for over 50 years at this point, and when we go back and look at the literature, it is in the areas of Premier Li radiology, oncology, pathology, and when looking at those studies, using a lot of different -- store and forward of images to experts in remote locations for consultation. The neurosurgery perspective has been used again to support people in the field by experts. Rehabilitation, we are slowly starting to integrate this. I wouldn't say which are difficult part behind but that is pretty typical of rehabilitation sciences. We are a little bit of the number science compared to our colleagues in the biomedical sciences, but we're beginning to move in this direction.

So the applications we will talk about today, my area of expertise with Rich and Michael McCue 's technology, and document to we are looking at assistive technology as well as occasional applications. There is certainly the two to go before telerahbilitation across all specialties and rehab, but given that this is our area, with what we would cover existing research in that area and then talking a little bit about what we're currently doing.

That said, I think that our experience and what we're sharing certainly would carry over to other areas of rehabilitation beyond just vocational and assistive technology perspective, but it is a good place to start. And as I said, it is our area of practice.

So the National Association have a variety of position papers and statements and directives and so forth. I will talk about the about those. We have Clarix, [indiscernible] and Commission on rehabilitation certification, CRCC. The AOTA in 2005 released the first position paper from that organization related to telerahbilitation. I was fortunate to work with that group and come up with the first statement by the association. We looked at it as being an opportunity for evaluation, intervention, planning and follow-up care, providing consultation, education, and also discuss a little bit better it might fit with the supervision of students and other trainees, and we came up with the definition that it is the clinical application of consultative, Conn., preventative, diagnostic and therapeutic services via a two-way interactive telecommunications technology, which is somewhat vague because we wanted to leave it open obviously as standards of practice evolved more and also as the technology itself involves more.

Send examples of where assistive technology has been used in occupational therapy, parents and their group, I believe it was out of Shepard, if you look at this, 1998, it was 10 years ago when it was published, so 12 or 15 years ago, it looked at for case studies. And in any area of science that evolves, it usually starts at a case study level. They were looking at a wheelchair seating evaluation, a home evaluation, setting up someone's adapted computer and in other cases, looking at Augmented this communication as the intervention.

The technology that they used at this point in time was a plain old telephone system, or POTS as we call it. Any old phone. And I know myself I have had experience using these around the same time. And the reason that was necessary is because, you have two work with whatever telecommunications infrastructure is in the community or a client's home. It is almost like, we have to go where the weakest link is. In that study is anecdotally based on four case studies which I think has a lot of clinical validity, and it does extend the availability to services and shows potential for affordability.

Obviously the disadvantage of that [audio interference] [audio interference] Today is the audio and video is not necessarily ideal for can be insufficient based on how much bandwidth you have. We have learned as conditions that it is a lot of times about Bert van with. Ten years ago it was an issue and these days it is becoming less of an issue. Other things you have to consider is dim lighting and also the trading on the technology, which again, 10 years ago it was somewhat intuitive but maybe not as much as it could be, and that is sort of the human factor perspective.

The American is a good therapy Association, we have had some things where PT was looked at, things like range of motion and electronically matter and things like [indiscernible] [speaker/audio faint and unclear] and the AT&T board of directors did issue a statement on teleHealth and electronic communications indicating that it has the opportunity for overcoming barriers to distance and also a time management issues. So the pressure ulcer literature, just a little background, we know that pressure ulcers are pressure sores, as they are also called, are issues [audio interference] [audio interference] [ audio interference] minimum. So Phillips and the group at telerahbilitation intervention doing remote [indiscernible] use of video phone with still imaging over a POTS line, which would be a store and forward, is helpful in diagnosing bull's pictures and verbal, a patient or client verbally reporting their is not as effective. And further to that, looking at a population of people discharged from impatient with spinal cord injuries, it would be a telephone video and an in person standard of care. Again, a very small sample found that the video group had the highest number of remissions compared to the standard group, which does bring up some clinical professional issues. When I was looking at those results, thinking that, if the client says, my skin is fine, and the practitioner may say, carry on. The consumer patient says, eyes in his fine and sends a picture of their skin and it is inconclusive, they would say, if you need to come in so we can verify that.

And then we have applications in virtual reality using telecommunications technologies. This is for creation and control of three-dimensional built-in baronets. One of our projects in the four is looking at [speaker/audio faint and unclear] looking at the assessment and training for powered wheelchair users ordering people to use powered wheel chairs, finding that there is some potential to with Harrison and other groups out of Scotland. And I will just turn this over really quick for Rich to discuss some of the other bridge will reality applications in the literature.

The [indiscernible] system that you are looking at now is called a remote Council, to what you are seeing is actually allowing a remote there is to kind of virtually see how their patients are doing from a post surgical treatment intervention program. What is actually happening here is, at the bottom of the screen on the left-hand side, use the custom interface is being built down right here. You are also looking at the 3D and virtual reality dimensions as well, so this is basically allowing the remote therapist the idea for remote training and consultation their actual individuals for this type of program.

Moving on two the American Speech and hearing Association, they did actually release a statement. What they're calling this is telepractice, the applications of telecommunications technology to deliver professional services at a distance. They published this position papers and issued a brief and technical reports summarizing the evidence, and discussing the future direction for teleHealth and telerahbilitation. There has been some work Rich will discuss here in a minute that has been done at Mayo Clinic, and the University of Queensland in Australia, and there has also been some speech applications at military facilities. There has been some work in remote dysphasia evaluations and also with Augmented TIFF and [indiscernible] applications.

Okay, now we're looking at this thing called in a speech language and cognitive treatment. And this allows a there is to be contracted with their clients remotely from a white board as well as functionally [indiscernible] pass through windows. So these are basically true cognitive treatment as well as for traumatic brain injury as well.

The next example is the lead Silberman boy's treatment. This was a product that was taken up by the bidders University of Queensland in Australia. It is kind of a standard treatment for individuals with Parkinson's disease, hovering stomach however having access to the treatment is a crucial moment here because we are engaging distance. So the researchers at that institution in university setting have made this an on-line version so anyone in that area can have access to this type of treatment.

Moving on two seeding and wheeled mobility, which is more my comfort zone, or talked more about the work by Phillips in promoting community reentry. There is also some work that is published and still being done at the Glen Oaks rehabilitation Hospital in Alberta. We get three different methods of providing seating and wheelchair mobility services. That being if the person lives in the region, or in prison for people that have two travel outside of the region and people outside the region through telerahbilitation.

In the earlier work, one study of us involved in in comparing POTS to hide band with lines for wheelchair in violations, a small pilot study sample down there may be improved ability to see images through high-speed (audio lost)

-- clinically and at face value and was worth the opportunity to investigate further. We did another study looking at reliability testing where a sample of people came into the clinical setting with their own wheelchairs' and we ran into assessments. One person over videoconferencing again using the plain old telephone system to see if there was any correlation between the two treatments. Again, inconclusive findings closely due to [indiscernible] issues and sample sizes. Then then the looking at the into reliability of the physical examination system between what a clinician would find in person person is what a commission might find through remote consultation, and again, things were pretty much a inconclusive.

So based on the literature and based on our past experience, when we put together this application with the RERC, we wanted to take what we have learned from the previous studies and see what we could go further and, a project I put together, we wanted to look at the two different delivery models, which we have looked at before but look at it in a different way. Some of the previous studies were trying to replicate a therapist on the remote and through a paraprofessional or cause a trained individual, which created its own issues. What we decided it was, we would use telerahbilitation and wheelchair seating and mobility as a consultation tool, where it their is a therapist on the remote end who has journalist training and is a good clinician, but doesn't necessarily have the training and experience using assistive technology or wheelchair seating and mobility, and this is not to take anything away from the person of a remote and, we just all know that in our clinical training, there is a lot of stuff we need to learn and now that we can't expect to be experts in all areas but at least generalist in most areas so this is a way to bring in another Trading commission. And that way they are trying to take over as sort of a consultant and a person there if needed.

Part of it that we wanted to look at was reliability and testing using function every day in a wheelchair. The wheelchair to -- from an independent safety and quality perspective, the same as what I am saying remotely and then comparing it to what the local clinician is seeing, at majoring the difference -- measuring the difference between proceed function which is done by questionnaire in the two types of settings.

Also looking at satisfaction, and finally, the key thing is, having a sample of clients we have seen in person here at her clinic in Pittsburgh to is similar simple of people with disabilities in the remote clinics, and whether or not we have found the same change in function between the two different modalities.

At this point and will turn it over to Rich to tell you what some of their preliminary findings have been.

So basically, it was describing past results, a lot of the individual reports and evidence have been from a laboratory or in university setting, but says that this application in advanced telecommunications, we need to start extending that out into those on that an underserved areas. This is basically a representation of the western half of the state of Pennsylvania, and you can see the arrows pointing, these are basically wheelchair clinics that Mark and myself and other team members have been able to assist those hospitals in creating a wheelchair clinic and seeing our patients from telerahbilitation. And I will endeavor into two of the case studies on these clinics.

As Mark kind of a pointed out, we do have a kind of standard of in person Service delivery, and I wanted to kind of replicate what we see in person as well as in telerahbilitation as well. On the left-hand side is, what we see in prison, and on the right-hand side is what we're seeing in the telerahbilitation model as well, so what we're doing is basically taking that system and basically in gathering the data from the initial assessment. And Mark and I are basically teaching them to our center we have created here. And we have measured outcome studies as well which has assisted us in guiding the research [indiscernible] themselves.

The first his example is at the Boys Regional Medical center. This was our first wheelchair clinic that we were able to set up. It is 103 miles away from Pittsburgh, which is estimated a little more than two hours away from Pittsburgh. As you can see in the bottom right hand side, and I are located in a small square, [speaker/audio faint and unclear] see in this picture is you have a participant and a family member as well and also the licensed therapist who is taking the hands-on approach for that particular client as well as our supplier taking measurements as well, so we are able to give them both video and audio feeds for these types of evaluations. Again, we have been working with DuBoise for a few years and the conditions are gaining experience and training and will not necessarily need our services in the future and there are independently running and seen patients now without us as well.

A second clinic is Charles Cole Memorial hospital located in Tucker's port. It is about a hundred miles away and a four hour drive. And we were talking about yesterday the informatics, and we're looking to establish a wireless connection, which is more unstable than a traditional land line or ICN line, and we were able to connect our system through the Charles Cole in infrastructure as well. Teenager can point is again working with the information technologists. That is a crucial element in starting up any type of [indiscernible] remodel systems knowing what you can and can't do from that standpoint as well.

Again, the next picture is just some preliminary data that we're able to find from these two facilities. We have a pre and post major on what we call, functioning every day with the wheelchair. Some of the individuals coming into this clinics are given this questionnaire and specific examples of how their present wheelchair or scooter or manual chair fits their needs based from comfort, health, operate, breech, personal-care and so forth. It is on a [indiscernible] scale ranging from zero 2/6, being the highest or strongly agreeing. Sold most individuals have been nearly unsatisfied or dissatisfied, but upon leaving and entering their new ability device, if you can see the range has been significantly increased to almost about six in every category.

The next slide is again, Mark talked about enter greater reliability. A lot of conditions feel they lose the hands-on approach when their assets from that standpoint as well, so what inter-rater reliability is [indiscernible] from the remote site as well as what is traditional happening live and from that participant. And again, the functioning everyday wheelchair capacity is looking at the same 10 criteria of the objectives and this view. These are activities that the client is actually doing in their current ability devise, and again, become major both independents and see an equality of having that in real time as well.

And other secondary objective here as well as looking at the technology we have incorporated into these areas as well, so we are testing what we're seeing but we are also testing into a structure that we are able to establish at these sites.

The next slide is looking again at the satisfaction findings. Again, what kind of created a generic seven question for individuals to go through every time they've observe telerehabilitation. Now again, this is from our participants and not measuring it from a clinical standpoint. It is on a lecture scale from 136. Six been they strongly agree. Some of the questions we raised, question one, I was comfortable being evaluated through these means and we have a high score of 5.5. All of these courts have been high witches and a testament two the infrastructure and also the service that was being provided here as well, and also, we have been able to add some comments as well through the individual. Some of those include, we didn't notice the camera, of love to see this technology expanded. One participant said, we evaluated me and not my disability. Where else are received, thanks so much for your assistance, I learned more each time the do these assessments. Another comment is, it is comforting to be able to insure quality of our participants in our area, and also enhance our education and training not only for myself but also for the students that are having their internships with us as well.

The next slide is looking at distance and time. Basically another huge factor, and again, Marc mentioned, cost effectiveness as well. So how much time does it take for individuals to received specialized medical needs? And if you look at this from the data, and I am sorry, I apologize that is a little skewed, the top diagram is looking at a distance and travel. For right now, are individuals at remote sites have two travel about 21 miles to our site. And again, for individuals coming two the Center for Technology in Pittsburgh, they have to drive to over 123 miles. So when you equate that in two minutes or hours, we're looking at individuals spending almost two and a half hours to drive to Pittsburgh Press is trading only 32 minutes for their services at the remote location.

And last but not least is looking at that equivalent, the increase increases telerehabilitation. As you can see, and officials estimated [audio interference] significant differences between our pre and post stores. Our average difference (audio cutting out) and looking at that relative change%, how much danger missing? We are almost seeing about a 100% change from individuals in a previous appeal terraced versus what they are receiving post as well.

This is just to summarize, and I'll add my own here from the anecdotal things that have come out of this study, we set out with the aim of seeing how effective telerehabilitation is in providing wheelchair is two people in remote locations, and what we have learned is that it is also a great medium for mentoring other practitioners. For instance, the group up in DuBoise and Tower report as the wheelchair was developed with them, we also developed them with remote and continuing education over the Internet and help prepare for the RES NA certification exam, and I believe that DuBoise the conditions and regional -- in the matter of I would say about six months, we grew enough consultation or remote entry or remote internship in having a lot of access to online continuing education resources, we were able to get them premature to set up as an independent -- pretty much set up as an independent clinic. So we were able to access trying to ensure the quality of the services that were provided in distant areas.

At this point, I'll turn it over to Mike. Before that, with like to pull in our polling questions. Mike, if you want to --

I think Ashley is going to.

The first polling question is, what is your current profession? If you could all login pleased to give us a sense of who is out there attending today.

While you are doing that, I have to apologize, I have been getting notes here of people accusing me of being the wrestler, because I am appear rustling papers. -- I am up here rustling papers. I apologize for that and I will try not to do that.

I will have two restrain you then. [laughter]

It looks like we have a majority of others with a close second at rehabilitation counselors. We have eight physical trainers, a couple of psychologists -- and what is that? It looks like we have over 100 people in the room, and we have about 55 responding, so he could take a look at that poll and just vote by clicking on the radio box to the left of the profession category, we will try to get as much of this as we can.

Also, while we are collecting something here, I think we neglected to give you a sense of what your going to go through today, some media will take a minute to do that.

You are born to. The paper for probably another 20 minutes or so, and then we will take a short break and moved to our expert panelists. And we will have each of our panelists react to the paper and the presentation, and following that, we'll take another break and after that we'll open it up to the questions through the Chat window from our entire audience. So that is just a general overview of what you could expect for the rest of the session today.

Okay, I think we have a reasonable sample there. We're hoping everyone will chime in with their votes on this. But close the poll and bring up the second pole. Do you have that, Ashley?

Okay, here is the second pole. Is the term "telerehabilitation" knew to you? And tourism tourism is from, I have never heard of it before, or I am well versed.

Clearly the majority so far have had at least some experience with telerehabilitation, so perhaps we are preaching to the choir. There are still about 40% lower relative novices to telerehabilitation. Now it is evening up.

Okay, but closed that, Ashley, and we we have another one, right, Mark?

Go to number three, please.

This question States, if you have been is using some "tele-" aspect in your current profession, how long have you been doing so? This is a limited sample of those who have been using it. So who is the other "greater than 10 years" other than David Brienza? So we have many people who are just beginning to use it or have been using it for less than five years. That shows promise.

Okay, shall we close that?

Before I get started -- let's not do that one, actually. Let's hold off on that.

Do you want to start?

What I am going to do is change the layout really quickly. I have some short videos to show you what is actually an example of what we're doing Inner in our wheelchair prescription.

Here, this burst the deal is at DuBoise Medical center. And there is audio to this as well. What you're seeing right now is one of our live consultations that is happening. So we have an individual that is diagnosed with mitochondrial myopathy, and Angela [indiscernible] who is the licensed therapist at the site, she is conducting the manual muscle testing and letting market and I know what she is actually finding out here. This is happening to live and in person and Mark can ask general questions to both the participant as low as Angela. And I will stop this and share on more video as well.

This is actually a certified occupational therapy assistant who is helping Angelo with her wheelchair clinic. As you can see, the space is ideal that they are able to store a specific device is that the clients can come in and try different types of equipment as well. This is how the individual is navigating his current scooter through an obstacle course that is very basic. We can now have an idea of how he is actually maneuvering two the scooter, so again, the therapist is just telling him instructions on what to do and basically Mark and I and a remote therapist can score this as far as the independence, safety and also quality of the activity. And I will stop it here. I just wanted to show you some examples of what actually happens in some of our evaluations as well, so I will come back two the previous layout for Dr. McCue to start.

And I will just sat there, it is not just the IP infrastructure, but we deal with issues of lighting and background so we can get clearer pictures of what [audio interference].

And I would like to remind anyone out there that is going to be a presenter, if you are not currently speaking, please keep your telephones on mute otherwise your broadcasting to everyone else. He may get the label of rustler as well.

I am waiting for my slides to resolve on my machine.

I'm going to talk about vocational rehabilitation applications. And these things I will be talking about are more scenarios that have both need as low as potential. Wrinkly because there is limited evidence in the literature regarding the application of telerehabilitation to vocational rehabilitation and employment. There are some scenarios that we envision, and we see is some limited applications existing that are remote rehabilitation counseling and case management activities, certainly consistent with other aspects of telerehabilitation and teleMadison, remote assessments, and then some specific of the stickler vocational application is remote career guidance.

We see some applications of this existing primarily in online approaches. There are a number of computer based resources out there where an individual logs onto an Internet site and is able to go through, for example, career exploration activities, career assessments and also received some input about career choices and career directions. So those kinds of things exist as resources, but again, it is not real clear how these really reflect rehabilitation, which affects both the tele- aspect as Mark mentioned earlier but also in support and remote aspect from the rehabilitation side.

There have been in number of therapies explored remotely. Certainly, telepsychiatry is well advanced and probably one of the most strongest forms of research and a clinical application based approach to take to intervention, both assessment and intervention and counseling. And it is one that has actually achieved sort of the end goal of reimbursement. However, that has not really filtered down into basic rehabilitation practice. So that is a direction that we should probably be alert two it and perhaps learning from the experiences in telesecond entry.

There are a number of areas, for example, in rehabilitation of traumatic brain injury and other cognitive disabilities, and for example, cognitive rehabilitation has been approached from a distance perspective, both from the use of assistive technologies like PDAs and so forth as well as support technologies like using video.

An area that we chose to do some experiment with is providing employment support remotely and job coaching remotely using telerehabilitation Technologies, but I will speak with you in a few minutes about some of our applications.

Another area that is important to note, but again, is an area of which I am not really sure about telerehabilitation, and that is telework, where individuals can become into a working from home and basically telecommute in a sense. It certainly matches the distance standard, but individuals are often working individually stomach independently without eight rehabilitation and business.

All right, someone put their phone on hold, and now we have hold music. It is an error that we may have difficulty recovering from. It was nice music, but let's just wait a second. I think we got them off.

Okay, good.

Bottom line, when you look at what is going on in vocational rehabilitation, we were able to find very little in terms of research in those particular applications.

What I want to do is sort of cover some of the things that exist in the literature, and the first things I would like to cover is sort of the consumer prospective, and there are a couple of studies that look at consumer interest and acceptance of telerehabilitation applications. One through focus groups and wonder a survey. [indiscernible] and her colleagues looked at how interested and willing and how likely individuals with disabilities would accept telerehabilitation applications. And we also were able to do this four focus groups in our RERC on an employment project. Joe record book that a survey approve individuals and acceptance of traumatic brain injury and Internet based interventions for their obstacles in a rehabilitation. And in general, the response has been really quite positive. Consumers have expressed strong interest and acceptance of the potential use of the Internet and telerehabilitation applications, and again, there is some variability in terms of people's exposure to this, but generally speaking, and all three of these studies, there was certainly a positive response from the potential consumers of these services.

The next area that I would like to touch on is recognizing that if we use telerehabilitation, are there specific aspects of the telerehabilitation process that are impacted by characteristics of the persons that we're working with? For example, individuals with cognitive disabilities. We recognize that limitation associated with traumatic brain injury and other connective disabilities could potentially impact telerehabilitation technology. Difficulties with information processing, and good comprehension, attention, impact our ability to communicate effectively and therefore impact the efficacy of the intervention.

David Brennan and his colleagues did a couple of tests on storytelling, and this is a mechanism by which one can determine if there is a difference in an individual's ability to communicate effectively between face-to-face and videoconferencing activities. His work indicated that there were no differences in communication between face-to-face and videoconferencing.

In a pilot study that we were able to direct some funding from [indiscernible], we were able to examine a group of individuals with cognitive disabilities and did a psychological battery under three conditions. One was face-to-face, a second condition was using a telephone line, low bandwidth, about 56K, equivalent to what the POTS technology is, in fact we used a POTS system with that, and then we use a high band with system. And we found that there were some differences between face-to-face and videoconferencing, but we discovered that they have a very complex memory and information processing task. They showed equivalent results on things like comprehension of oral directions, immediate recall influence the tasks. So I guess the takeaway there is that, the studies that exist suggest that in general, people to with information processing and cognitive limitations can participate and benefits as long as the band is not too great cognitively. -- demand is not too great cognitively.

We did another study, and this was another side left able to find several of these pilot studies [audio interference] those with us a little later. But this was an application where, with a group of individuals in a row areas, these teleconferencing with an Internet desktop pushed to provide remote [indiscernible] in the area of career development and identification of educational goals, and we had two sets of results from this study. One was that the protest but ratings in terms of using the technology, accessibility issues, and usability were quite positive, and the benchmarks that we achieved with this project we're generally positive. But in terms of the overall outcomes, we found what clinically we would consider a negative outcome, two the standpoint that, changes in clarity of goals which was our clinical goal in this group was minimal or negative. And I and catcher in to disappointed with that because our face-to-face work with individuals was a greater explanation [indiscernible] drift, and part exploration process may take them away from clarity for awhile but ultimately bring them back. So there are some closed dumb questions about the effectiveness of that study but certainly it is one that include issues of usability. [audio interference]

There was another study that looked at remote technologies for providing in-vivo support, supporting the natural environment, either in the employment setting or the academic setting, and there were three subjects, two in employment settings and one in an academic setting. A single case study designed and using multiple technologies, including PD wireless, PDA, telephone and Internet connection on a computer, and used within the wireless PDA and phone, text messaging. Basically what we found was the usability face suggested that both the clinician's as well as the individual with the disability felt that there were positive ways to support them in a natural environment. We also got information from employers that [speaker/audio faint and unclear] individuals actually benefited from the kinds of support technology, and when we evaluated the various types of technology, which found pretty clearly that the text and instant messaging technology showed a much greater impact as a law as user satisfaction. So those technologies that a lot of individuals to connect in real time with a support person but also allowed them to think and it's sort of reflect on some of the questions as well as the responses and they seem to be the technologies that were the best effective and most effective in that [audio interference].

Mark mentioned earlier some of the professional organizations that [indiscernible] no response to telerehabilitation. With respect to vocational rehabilitation, there are three main bodies that impact vocational rehabilitation professionals, at that is the certification body, the CRC, as well as the American rehabilitation Council and the National rehabilitation Council. These in a sort of a unique show of cohesion, these three groups joined together to establish an ethical code which basically serves as the practice guidelines for the profession. And this is irrelevant to telerehabilitation in the that, although telerehabilitation is not acknowledged -- and mine on the long slide here? I believe I am. [audio interference]

Telerehabilitation is not acknowledged -- where and Mike.

did I miss this slide? It is not in there.

There are revisions to this code in the effect that there is an increased [speaker/audio faint and unclear] the terminology used in the CR C code of ethics is that the telecounseling. So we feel that telerehabilitation has not impacted these practice guidelines yet, but certainly, the services identified in telerehabilitation are those that they're speaking of within this proposed [indiscernible].

As of last week, at the CRCC website, you could post comments regarding the proposed changes, and I subtly encourage all of you to visit that site to look at the changes that are suggested and proposed, and, [indiscernible] with your comments about these changes. That certainly broadened significantly the focus on telecounseling and distance approaches.

So that is sort of summation.

We're finding that there are a few studies that currently exist on the use and efficacy upon telerehabilitation as applied to vocational rehabilitation and employment. We do have a number of pilots that demonstrate a need for and a potential for Broderick information, and the most much ring technologies and we believe support for individuals with disabilities in the employment setting.

[indiscernible] is crawling around on the ground in front of us and putting up clean tags I believe.

At this point, I'd like to pull the audience. -- pull poll the audience. The first one is, have you participated in a vocational rehabilitation for employment related telerehabilitation activity? Anyone out there? Yes or no.

There are some who have. We certainly want to have hear from you. I think one of the things we're finding is, that's a lot of people are doing this but it is not making it to the literature. There may be grants or demonstration support, demonstration projects, and we would like to hear more about that.

One of the things that we have mentioned before is that there is eight blog running, and there is a dog running for this particular paper, and for those of you participating in these types of activities, we would like to very much [speaker/audio faint and unclear]. Let's close that one and we have one related question. That is, are you aware of telerehabilitation activities and vocational rehabilitation? Not necessarily, had you yourself but dissipated, but in were community, in your rehabilitation connections, have you become aware of teleapplications in the rehabilitation?

Again, we don't really have the mechanism with these polling questions to have specific information from you, but we sincerely request that you join our blog and tell us about that or send us e-mail information about anything you may be doing yourselves or are aware of. We certainly applaud like to learn from your experience and share hours as well with you.

It looks like there are maybe 10 or 15 folks out there who Harper put either doing it or are aware in our communities. That was more than we've able to find in our communities, so please share that with us.

If you are still responding, please continue.

Okay, that's close that down. I have one more thing to talk about and Denmark will sum up. -- Mark will sum up. I would like to give you some information about one of our RERC projects, in which we are using activity recognition technologies to support individuals in the workplace. The rationale for this is that, individuals with cognitive disabilities that affect functions like self regulation require that we do assessment and intervention in the natural environment in order to effectively respond to these employment obstacles. We have learned that the kinds of things we do in a clinic or lab don't generalize well in the natural and bear it. So whenever we can assess or intervene in the national Internet, we're much more likely to be effective. Employment is a perfect example of in-vivo intervention, in-vivo assessment and intervention.

Be recognize however that the cost as well as the availability and two some degree, the transparency of things like the support in the natural environment, they weren't that we perhaps look at other means to alleviate some of those potential obstacles. Some of the things with a cat in this work is, test knowledge -- guiding us through a complex tasks are the things that are most important in providing this kind of supports in the natural environment. They're is a tax on the upper guidance that runs from basically runs from cues like a cue card or audiotaped information, say on a Walkman, actually watch and individuals through a task. The problem with this is that it is a one-way communication, there is no opportunity for feedback, no way to check whether or not the individual is performing accurately.

The next level of past guidance technologies is sort of what I would call PR N, or as needed, and a peak a is an example of this. In the situation, the person with a disability has to recognize that they have a problem or have made an error and have to call for assistance by pulling out their PDA and looking up the task gains module that they may have floated. -- tasked guidance module that they may have loading. The bottom line is, they have to recognize when they experience a problem. One of the things they know about this population is they tend to have limited awareness and itself recognition capability diminishes the effectiveness.

But ultimately, sort of the Cadillac of this is to be able to have technology that will do it realtime assessment and monitoring past performance in a realtime environment, this allows you to be able to tell whether or not the individual is performing adequately a task or experiencing difficulties, and then at generating the task guidance to based on real time performance. That is the basis of technology that we're trying to develop within the [indiscernible]. Basically what they're trying to accomplish is whether we are going to use video technologies or sensor technologies like accelerometer is to effectively assessed discreet members of tasks .

In eye robot being, a computer with a complex to perform the individual and determines /WHRORPT that performance is, is adequate or meeting the demands of situation or not meeting the demands of situation. If it is meeting the demands of situation it can reinforce them or do nothing, if the individual is making errors. That database will recognize the specific nature of those errors and then be able to deliver back through the forral to an interface with the individual, specific task guidance. Stop, you did that task out of sequence. We want you to back up two steps and then start again. And this is all done in real time: One of the thin we wanted to accomplish here is sort of a buy in from consumers, as well as vocational rehabilitation professionals so we looked at focus groups that included consumers, VR trainer, job coaches as well as employers like manufacturing, food service, and some other occupational areas. We did on site training, and found that across the board, people were very positively deposed with this. One of the things that we were most sensitive about were bringing camera into a natural environment such as a workplace, but as a rule in general general, people were very satisfied with how this privacy issues were proposed to be dealt with and that did not appear to be a significant /OBS call to any of the constituents involved in the focus groups. So I'm going to shift this and let you see, the application that we picked to do this was a task that actually existed at Wendy's restaurant it is part of our hamburger cooking training and let's see if I can figure out how to do this. I'm going to show this video with audio and I hopefully I'll get a drink of water while this is going on. Is this running? Oh, that's the end. Okay.

If you go to, you want me to get it.

I got it.

I got it. Thank you. . Okay. Audio? Well we don't have much audio here. Is anybody getting audio? So this is and an /PHAEUGS that's created basically from video input of an individual in a natural environment. Now this work is based on work perform an can /TPHAEUGy university. One of our collaborator. Jessica /HOTS /KEUPBZ is a computer expert and basically what they does is take video input and develop, anal /TKPWA rhythm that basically allows them to reproduce that input and create complex basic computer programs that can both recognize as well as, as provide basic feedback and these are just some examples of the, the stimulus item and then the animation that's created from that. So basically what they're able to do is create very complex databases of movement. Now what we hoped to could with our project was to stretch that into establishing a beta base that could den determine the difference between correct sequence of burger flipping activities, and an incorrect sequence of burger flipping /ABG sift, so that with that information we can provide /KWAO*UZ cues to the book on an Nevada O basis. I don't know how they get around this, but Dave just gave me another note that the buttons on my jacket are creating all my problems. I still have to use my arm so I'm going to take this jacket off in a second. So our initial findings were that if you can look at the discrete activity that we identified they included things like picking burgers off the grill, flipping them, salting them, placing them, and and are I forget, I can't see the last one there. You can from this tie Graham you can see that we pretty much can identified those discrete activities from being different from one another. Our initial results were that we were averaging at about 90 some% accuracy on all of tasks which included placing, flipping, salting, pressing, and picking, so this was our first go at it. Just using anal /TKPWA rim inch based on near I see neighbors. We also looked at, we enhanced that technology by using add a boot and if being look at the number of false negatives and false positives in hundreds and hundreds of actual discrete applications, you can see that there's very few false positives and false negatives in terms of our ability to identify those behaviors. So this pushes it up well above 90 degrees, basically across the board. Or 90%. Now, we feel pretty comfortable that if we applied this to making real hamburgers that we could probably determine and support individuals in making a pretty decent hamburger I'm not sure we're at something like live skills because live skills may have some problems if you fell into that 2 or 3% that you weren't accurately providing feedback. Like move your thumb out of the path of the knife. If we weren't able to recognize that, we might be into some problem, but this certainly does show some promise we believe. The next phase was to develop a user interface, so that we take that information and can channel it back both to a job coach in term of real time assessment of the individual as well as store that data for looking at performance over an extended period of time. As well as share that information directy with the individual. And we've looked initially at using headphones or some visual input for the individual, a computer monitor and we've also been exploring using remote handheld technologies like the I phone as a mechanism for providing that feedback to the individual. We find that those technologies have greater potential because while this is a great, we believe that this is a great broach to dealing with certain aspects of task guidance and remote assessment, there are a whole lot of other kind of supports that individuals need in order to be effective in a workplace, and we, I think we believe we can outfit something like a remote handheld device to, to be able to did a lot more than just the task guidance activities that we're talking about in our job coaching. Iliac knowledge that we've moved from primarily using video to primarily using excel roam characters we found that the video perhaps might be somewhat limiting in our applications, it's expensive than we anticipated in terms of kind of camera we needed and the number of cameras in the environment. We decided to take a shot at looking at ACCELEROM text it. er. We placed them on a subject's wrists and on their forearms and we were able to get almost entirely equivalent response and results using the excel rom characters as we did with the much more expensive video. So I'm just going to show you a little bit of the sequence of the individual performing the task, this is from an above, and this is the actual ham bugger flipping task. That involves a complex set of activities. Including taking the paper off the burgers, placing them on the grill, salting and peppering the, the burgers, flipping one row at a time, and then repeating the whole process. So the individual has to complete a complex multi-step task keeping the rules in mind as they go through that process. We actually use this hamburger turning task as a test of executive functioning in one of our clinical programs out in Johnstown, so we are well aware of the, the cognitive demands of this task and are quite pleased with the positive results that we've gotten on our ability to remotely assess this using primarily relatively inexpensive and portable excel rom characters, so the excel rom characters add a feature to, this process that the, that the video couldn't. It's much more portable. It's going to not confine us to a con stricted area of the video's field of view. So we see it as, and the privacy issue seem to be much less with this as well. So so our next step is really to bring this two individuals, we've done this in an experimental setting on usability testing with our own staff. In the next month we're going to be testing individuals with cognitive disabilities, and over the next year, we'll be moving this out actually into some community based environment. So so that is, that's, that's it for the vocational rehabilitation look.

Yeah I'll just take a minute to summarize what we've discussed in this session, and looking at where we are with telerehabilitation as clinical applications to both the assistive technology and voke rehab as Mike was just presenting on you know eve still got some concerns that's why when we open it up to discussion, these are the some of the things that we're hoping that we can take on as, as topics and move forward, but basically whose going to pay for this? And this is not to take away from the session we'll have later on this week that we'll have funding and policy but payment is a concern. Also whose qualified to proforma saysments, treatments, follow-ups, on service delivery. Via telerehabilitation, how we going to assess our quality, and how are the issues of confidentiality going to be addressed? So when we look, kind as opportunities here, we're looking for are systems that are going to be accessible, have quality, and capacity to be followed through on as what we call the golden triangle or here in Pittsburgh the iron triangle we've got new models of care that are emerging, a shifting population of, of people, home telehealth is becoming, is a growing area of healthcare. Creative workforce options, as Mike was presenting. An aging possible /HRAEUGS. Again service in rural areas. Gee graphic call barriers to getting to places. Cost of traveling, educational issues for both clinicians and clients. Administrative events to deal with. And again, what are the potential advantages of telerehab. Obviously it's going to be able to get services into the home where people tend to want to be or into their communities. Monitoring the transfer of training between educators and students, and enhancing compliance with protocols or policy changes, and being able to be a little more proactive in patient driven services, and supporting continuing education. And I think as time goes on, with our population is aging and education that people are going to expect and look for the highest quality level of healthcare services they can provide, and possibly the telerehabilitation and telehealth in general is a vehicle to do that. So with that, are we going to take a break?

We're going to a five-minute break.

Go to a five-minute break and we'll reconvene here, here on the east coast it is two:40. So at two:45 we will -- 2:40. So at 2:45 we will --

Okay. We're back. I got and all at that mate um I had to cut my buttons off my coat or take my coat off, so I took my coat off. I'm going to introduce our expert panel, we're quite fort to have a group of our rehabilitation colleagues throughout the country to participate with us and provide comments on the paper and the presentation. And we certainly are fort and welcome those comments. And I'm going to read the bios for our five panelists and then we'll start with Suzanne and progress in the order that I read them, so Suzanne Paone is a director of the division of information services at the UPMC health systems hee has 20 years experience in the healthcare industry, including work in industrial health and safety and laboratory medicine, with 15 years experience in applied healthcare information technology practice. Her present position is project director of eHealth in the division of information services for the University of Pittsburgh medical center health systems. She's actively involved in the development of the business and technology strategy for eHealth including referrals management, patient portals and customer management. She's also actively involved in the national eHealth community and I sort of just changed my mind why don't we go to Suzanne now I'll introduce each panelist as they step into the room with us. Is that oak Suzanne.

Sure.

Take it away. .

Allright. I would like to applaud my colleagues working hard in a very important area of eHealth and telehealth and thank you for defining those terms for me. I've been working in the field for ten years and waiting for somebody to, to produce a decent definition of those terms so thank you. Although you could have a two-day conference on technology alone in this field, but my, I was asked to, to reactor respond to the paper in addition to address some of the classic questions that come up as we talk about telehealth particularly in this case, telerehabilitation although I would suggest that the questions are similar when we talk about teledermatolology. Tell radiology, many other applications. So first of all, I would like to applaud the work of this RERC group and others and those of you out there who are doing trans /SAEUGSal research in the field the number one thing that I see as a go across the if country and as I do worth in Pittsburgh and try to operationalize these models into practice, is the importance of outcomes based research. You heard several times the panelists talk about measuring outcomes whether they be clinical outcomes, patient satisfaction, or importantly as well, employer based outcomes. And that is key from my experience when you talk with pairs for instance and we talk about reimbursement for services, a pair is typically looking whether they be a government pair or a private insurer, for outcomes based research. So again, I applaud this group, and I would encourage folks doing research in this area to continue that last step of a research project, whether it be pilot or whether it be a more macro study to make certain to capture outcomes in any study very important. That is any first /SKWRERPL observation. I'd like to an address a couple issues that are either deposit as barriers or opportunities in the field depending how you look at it and I tend to look at them as opportunities of a developing science. And the first thing I'd like to talk about has to do, again, with the sustainment model for these kinds of programs. There is definitely a dialog or a receipt owe Rick across the country about lobbying for reimbursement for services. I have seen some many groups be successful in obtaining reimbursement for services and I don't think there's a one size fits all strategy. I do however map back to a couple fundamental principles and one as I mentioned is outcomes based research. I've seen many, many studies fall short of this and it's a shame when a group spends 2 or 3 years studying the science and cannot articulate outcomes in a form that a pair for instance can digest I'll be very specific. You heard my colleague talk about employersment as we sit at the table talking with pairs. Pry private pairs specifically. Employers are very interested in these techologies am they're interested in measuring very, very simple business metric and important business metric in these he con /PH*EUZ such as absenteeism. You can depth Tate to an employer that is contracting through a pair that you can positively effective absenteeism. Loss of productivity in the workplace by using technology such as telehealth, that goes along way in ascertaining payment whether it be payment for an occupational therapist. Consultation service, payment through a private practice physician group, so forth. Second comment I want to make with the payment has to do with the fact that there are creative ways to think about sustainment. Everybody thinks about codes. Codes are very important. At the end of the day, I've seen groups be very creative through things such as contracting, and are in other words, I've seen groups such as therapists, educators in the field of diabetes. Tell radiology, some of these other areas, who will con /KRAT through the professional group on the provider side of their organization and obtain reimbursement for these services through a physician group. So again, I encourage as the science matures or as my colleagues line out in their paper go from the parameter to the mainstream that we need to think creatively about groups of stakeholders working total. That's really a common, a common thread in this. There are providers, there are public pairs. Private insurers, there are suppliers in this food chain, and the most creative ways that, that sustainment model are happening across the states and in some of my experience in other country as well as in Canada in particular, have to do stakeholders working together creatively. A little bit outside the box is a way we think about fee for service today. A couple other areas I'd like to address that were addressed in the paper and the presentation, one has to do with privacy and security. I feel pretty strongly and maybe it's living in an IT place right now in my role here that I'm asked to deploy these kind of technologies into the mainstream, if you will. I don't think this is where healthcare needs to re-invent a wheel. There are well matured industry standards out there for 15, 18 years in areas such as financial services, particularly, when we talk about privacy and security. Policy is another issue. As, as was mentioned putting cameras into the workplace, privacy type issues are one thing, and that is new territory to some extent. Especially in the /SROE vocational re-rehabilitate space as we heard. However when we talk about on-line services we don't need to re-invent security model. 52% of the people in the United States and I believe it's 48% of people in Europe use some kind of on-line financial service every single day. We as an industry in healthcare should be very consistent with those consumer models. People consume all kinds of things. Not just healthcare. So I want to emphasize that when we talk about security. Again I see that all the time. One of the other things I want to point out, and this is very, very difficult, is when we talk about clinical applications, and you saw my colleagues who have developed some fabulous tools around wheelchair alignment for instance in remote provider sites, one of the biggest challenges that I see has to do with integrating into the clinical environment. Integrating into the work flow of the clinical environment, integrating into the technology of the clinical environment. The classic question that's asked all the time is, how does this work with my EMR or my electronic medical record? How do I know who the patient is? How do I gather some basic clinical information about the patient? And I think one of the biggest technology challenges and it's a call for research largely across the community is figuring out and settling on standards that allow these systems to intermingle much the very ineffective for clinicians to use 7 or 8 stand alone systems when they've got 20 to 25 minutes to see a patient and do all kinds of things. It just doesn't work. So that is a barrier and an opportunity today. There are standards developing along all these fields at the national level. I encourage suppliers. I encourage people who are developing custom applications to follow standards. It's not time to develop anything outside of standard, because we have to think of a, of a clinician trying to makes sense of all this in the field so to speak. And lastly, I want to mention an area that I am beginning to see evolve, and as I work with colleagues, frankly outside of the healthcare as well in E services, this is an area of concern, and, and there are about 20 years of research studies in the educational literature on disparities. And I'm talking about the disparities as it applies to the use of technology, and the later research in the last five years talked about digital I know equities and this is a concept that discusses the fact that just because you put a computer on an inter net connection out there, doesn't necessarily mean people are using it. Or using it effectively. So one of the research areas and I would encourage my colleagues doing these studies to think about this. There's a body of literature that talks about race, income, gender, and age as very discrete and documented sociopolitical economic factors that affect the way people use technology. I'd like to see some studies in these populations as we talk about telerehabilitation that are what I call targeted studies that take those factors into consideration, and again, our colleagues in some other industries are very mature into this. If you notice industries that have been telebusiness or E business for years are beginning to segment markets and treat the elderly population frankly differently than a mid-life working population in terms of the way the technology's delivered, usability and so forth. So I'd like to put this concept of digital I know equities out there as an area of research and possibly an area where we can /STRAT Phi some of these populations in these /STUTries and get a little more specific in terms of our targeting. /( so in summary I would like to applaud the work that's done through this center. This RERC and my colleagues, as part of the advisory board here I'm referring to these folks as colleagues and in that they are truly pioneers. I don't think they're novices, I think they're pioneers. Someone called themselves a novice earlier, I will not use that term, I would say pioneers. So thank you very much. And those are any general components on comments on the paper.

Thank you Suzanne. Thank you very much. Your perspective is very much welcomed and it offers sort of a unique look from the healthcare perspective that sometimes we as clinicians and researchers [ INAUDIBLE ] Or never really fully appreciate to begin with, so we pressure input both through this mechanism as well as through advising our program through your volunteering on our advisory board, so thank you. And we're going to anticipate that we're going to get some questions from the audience, so we're going to move through our panelists, but you'll stay with us, and and just us for the open Q and A session. Thank you.

Our next peopler is Paul Wehman, Dr. Wehman is with joint appointment in the essential Ed in the Virginia Commonwealth University. He developed, really he is the father of supportive employment in our country and in the early '80s he developed supported employment at CCU. He's published over 200 articles and authored or ended 39 books. We're very fort that he's got the time to join us today. He's a recipient of the Kendy foundation award in mental retardation in 1990. Presidents commit I have for employment and [ INAUDIBLE ] In 1992, and he's recognized as one the 50 most influential special educator in the millennium by the remedial and special editation journal December 2000. Paul thank you very much for joining us today. And providing your thoughts about telerehabilitation. And hopefully specifically in the area of vocational rehabilitation. Can we bring Paul on?

Paul is trying to get on Mike. Thanks a lot. I don't know my mouse has gone by /STKERBG on me a little bit here I've been waiting and waiting all afternoon. Oh, wait a minute I'm getting up here. I'm close. Let's see here. . Okay. Can you matter he Mike.

We can hear you well, Paul.

Allright. Well, I don't know why I'm not coming on here. Do you want me to give me I T guy or you just want to start listening?

Well.

What's that?

[ INAUDIBLE] .

Okay. Turn your microphone off Paul. That's one thing. You should be coming through the phone. There's a black button down at the bottom that says talk. You want to click that so that it's sort of gray again.

Yeah I've got some on my camera voice.

Here you are. Your coming.

Am I coming. Okay. it really wasn't worth the wait as far as looking at me I know, but I'm glad to be apart of the party. Thank you.

Well we're thrilled to have you joining us. It's all yours.

Well you're very kind with your, with your introduction and I'm sorry my secretary sent you the long version of the audio buying /TKPWRA /TP*EU. As you know you can tell I've been around about 30, 35. Years after a while you've going to have some stuff you've done.

I think everybody knows you anyway, Paul.

Thank Mike. I don't know where to start. I, I just /PHROEPB away by what you guys are doing. When I finally read the paper and got it, and got through the whole thing from top to bottom, I just have to tell you that tip I see more opportunities and more are more incredible things that can be done in the future than, you know, I mean, we're not even in the first /TPH-PBG of this game, it's you know believable I think a lot of my comments are going to be, heavily directed towards applications, clinical applications, I mean, certainly agree that, you know, in our medical campus here at the VC medical distribution they have been using telemedicine extensively for a number of years but the crossover into rehabilitation has been just minimal and I've been really surprised that, to see how little application there is. So because my time is short. What I'd like to do is give you a couple of, of broad themes that, that I think were important not just in a paper, but this whole area of telerehabilitation and then, and then kind of go through some specific points that jumped out at me. Probably more from a clinical perspective than anything else, because of the work that we're doing with persons with traumatic brain injuries and persons with a /TREUSism and veterans, you know that are returning from Iraq and Afghanistan and I keep thinking of the different applications through what you were talking about, and, and, you know, I don't want to, I'm not sure I'll get to it, Mike, at the end, but your, your pilot study as you put it, was a really a bold effort at trying to look at intervention into the workplace culture, and I, I really do hope we can get that published and get that, you know, into the literature as soon as possible. But let me start by saying this: Here's my first take away in a paper, and in listening to all three of your presentations I'm going to make this a challenge to you guys. I think that there are so many clinical problems and issues and challenges and a lot these are vocational assistive technology but even if you just kept it in a vocational realm spilling over into related vocational skills, I would love to see you move in a direction of creating a tech openmy, almost a conceptual model, which showed the interface between the different telerehabilitation intervention modes and the specific types of problems and categories of problems, because what I came away in the paper was, you reviewed the literature, you talked about the different bits and pieces that are there, and you teased us, Okay. A lot of paper was, was a tease about what could be. And I know this might be the second paper, this might be your third paper. But I'd like to see a conceptual model where even if it's theoretical, your telling me these are the different capacities of these different mow /TKALties and interventions and here's some sample and categories of some of the different types of problems that service providers are facing, okay. Again, you teased us with that, but I'd like you to take it to another level and and put this into a tech /OTmy it doesn't have to be even pairically validated at this point but it will give us a conceptual model to be working toward. Okay. That's my over arching point that I wanted to say at the beginning. Now let me just throw out a few real quick points here. Number one, the job accommodation network in W /SR-FRPBLGTS, I mean, when are you going to partner with them? I mean, they get hundreds, and hundreds of calls. You know our research and train centers on workplace supports we work with businesses all over the country and we consistently hear positive thing about the job accommodation network group and how many calls they get for help. Katherine Mccarry the vice president of SunTrust, she works, you know she's the president of the business leadership network. There needs be a connection here. Because as a former speaker said, business has been doing this for a number of years. They get it. The issue is, how, how can we get out of essentially the horse and buggy stage, which is business calling up, job accommodation network saying I've got a problem. Job accommodation network says for $20 dollars you can do, for $50 you can do this. They do ton the phone. Isn't there a way that he can empower ourselves using telerehabilitation into the workplace environments and culture that are right there? That was the first thing that jumped /OT at me. Next things is, I'm saying to myself, state voc rehab they have a limited amount of money. A lot of these state agencies are in order of selection. In Virginia we can't even on a new case after November 15th, because we're in a 15% reduction in the state. Every one of the closures that those rehab [ INAUDIBLE ] He's those precious dollars on, it would be great if there was a monitoring capacity that they could use and I don't even know, Mike, if they need an excel rom character or something as exist /WEUS it as this, there need to be a wet better defined way for communication using some of the telerehabilitation mow /TKALties your discussing here. You talked about support employment and how I was heavily involved with T well I have been and I can tell you that particularly for certain populations but the whole guts of support employment is providing support for people long-term, fading that employment specialist out. They're expensive it's 50 bucks an hour to have an employment specialist into the work site. Again we're talking about horse and buggy. If there's a way that you can use two way PDAs oak we're using PDAs right now with certain special populations and I'm saying to myself what about two way PDAs, is there a way to communicate and this is, we're not even talking about this being rural environments or sparsely populated environments we're just talking about hey case loads and trying to be more cost efficient. So you know when I look at support employment, your showing me the Wendy's case your measuring the number of tasks I'm like saying, wow that's great but I can use right now just, give me more feedback on the amount of hours that I need that employment specialist there, and maybe I shouldn't have cameras in there because it's invasive, but is there some way that I can be getting rapid probes of how well that person's doing and feedback more quickly? Okay. I mean, in a number of states, Virginia's one of them, 30, 40, 50% of the whole case service dollars are going to support employment, which is a fairly, you know, labor significant activity. There's a lot of cost savings that can be done here. Another factor, I don't want to take up anymore, the next 3 or 4 minutes and my next, let the next speaker jump on here, but I get the sense that when you looking at cost efficiencies, that we're not looking at what the optimal dependent measures are. What are the variables that we want to be measuring? You may be making some tremendous, tremendous progress in some of the things your doing, but you may not be measuring the right variables in the environment. I can't let this outstanding conference go by without introducing the power of this technology with the veterans administration hospitals, spread all over the United States. There's 21 pollee trauma. 21 pollee trauma support employment programs going on. There's five pollee trauma major coordinating centers. Richmond is one of them so we're involved with that. We know there's a, a large number of mild traumatic and brain injured persons that are coming in from all around the region for outpatient service, and you've got to wonder, whether we could leveraged up with what the VA is doing to try to use some of those applications for information when those vets go back after 3 or 4 days, into an area that doesn't have as many resources, where is the communication? Where is the follow through in that fashion? And I guess, you know, really, man there's so many other areas. You know, again I can't help but think about analyzing behavior environments for /PWHOF behavior support. I mean, you know we're trying to serve persons with an advertisism. We're trying to deal with persons who are throwing teches across the table and schools psychologist are in high demand. They can't get in there what if they could see what was going on. What if they could communicate directly with the teacher. And, and then, you know finally, I'll close with this, Mike, you know I know that you guys have been talking a lot about, the reimbursement issues. The amount of money that third party pairs will pay for some of these services, it all comes down to evidenced based research studies. The more that you have good quality studies with outcome data associated with them, it won't necessarily be that you have to do it better than the existing way, but going, you'll be /TAOEUBL reach that many more people, but you have to show that it is a doable edge any /KAEURBS approach. So again, I'll close with just saying that I was extremely excited with everything I heard, and I think that it raises more questions, and issues for new rounds of research, is certainly exciteded us when we look at what we're doing at our center and seeing whether or not we could could lab /PWRAEUT with you on some of our activity. We think business would be very excited about doing this with, not only the person with disabilitied but other at risk populations that are in there workforce that they may need support for. So I'll close with that, and, and I hope I didn't take too much time. I'm sorry for the delay at the beginning.

Thank Mike.

No, that's great, Paul, really. Some excellent comments. I think very pragmatic information about how we might, we might move forward with this in the future. You know, sort of while maintaining sort of our, sort of engineering guidelines that, that are sort of mandated by our funding source, but also looking at using those technologies that we developed to filter down into more pragmatic every day solutions, not throwing away some of the low tech things, as we put models together, as Suzanne talked about, integrating components of, of a telerehabilitation service delivery sort of into one portal, which is something that our searchers yesterday talked about, our integrated portal, so we could certainly develop an integrated system that has the capability of, of a broad spectrum of support, so and many of those that you talk about are excellent. We also have a project that looked at sort of usability from a consumer speculative, or an employer perspective or a /SROBG rehab counselor perspective. As a resource that they can go in and look at what techologies might be available for what types of activities. Your starting with this client problem, and then what, what technologies might be used for, what applications might be useful for that. So those, I think are excellent suggestions. We thank you very much for your participation.

Thank you, Mike.

You going to stick around for some field some open.

I'm here to the end. Yeah.

Excellent. Thank you, Paul. Very good. Okay. Now. We're going to call on Barb do /PHAOPBLG. She is a nurse. Who is the director of the telehealth program at sur /PHAOUS a. And we try to get Barb on-line here. Barb.

Yeah my computer, everything took down. I'm still on-line but your not going to see me because I'm not sure what happened. I think I got the screen of death.

Okay. Well we can hear you.

Okay. As long as you can hear me. That's a good start.

Excellent. Okay.

So Barb is with the director of the telehealth program at certify /PHAOUS a, which is the center of excellence for remote and medically under served areas. And that is at St. Frances university and Barb and I crossed paths frequently at the [ INAUDIBLE ] G Andrews center at Johnstown a state operated vocational rehabilitation center. Barb direct the development and I police departmentation of Alltel /H*ELT and teleresearch activities am under other guidance, the telehealth department of certify /PHAOUS a because of its community involvement, research orientation and public exposure has become a respected entity on a state, regional, national and international level for efforts and ability to I am prove healthcare delivery and educational services through the implementation of the technology. Her supervision of a proof of concept /H*EL health study done in John Johnstown. Resulted in musty million dollar funding to establish the national telerehabilitation service system or N T SS. The development of the N T SS resulted in a robust information technology research test bed to investigate emerging technology for improving accessibility, to quality comprehensive rehab services for people with disability and I want to through a plug in here because we use the N T SS on a routine basis. We have several faculty up in Johnstown running a clinical program in Johnstown and we use the N T SS as our base cliff our communication mechanism between our faculty, staff, students, and patients up in Johnstown. So Barb, thank you for joining us.

I apologize my computer just went nuts. But such is live when you work in the telecommunications industry. A couple of thing first of all, I want to applaud you and your co-workers on doing an excellent job on this paper. I started with my with staff we've all kind of reacted and had some thoughts about it, and think you did a great be Jo. I want to hit some high points when I'm talking about the issues and one the big issues as you mentioned early agree on is reimbursement. I agree with Suzanne you need to do some evidence based outcome research that's the way to get people to pay for services. If you can find a political champion to help give you some money to do a funding for a, a project that's would be great too. So that's one of the things that I think you really need to be working on. And then secondly one thing that nobody seems to address still, it was mentioned in the presentation, was the issue of licenseture across state lines, and I would suggest that you take a look at what the nursing profession has done. Is developed a nursing /KPHAT Lanceture which means state sign on to it and they recognize [ INAUDIBLE ] From the other states. That if, somebody is licensed in one state and it's a compact state agreement they can go into another state and practice on that staple state's, so when you're looking across, the telerehab part of it that a us /HRO you to do something across the lines. Again it's called a nursing licenseture compact. Limitation of telerehabilitation you mentioned them while the band width technology, ten years ago I would tently said it was band width it's getting better. The technology has definitely improved we're no longer use a lot of ISDN now but looking at using Internet protocol. IP based programs so it's less expensive that type of thing will but one of the biggest stumbling blocks I see is happening is the human factors. Users acceptance, patients are willing to accept it, but getting somebody in the rehab side of the house to use it. You need to have a champion. You need to have somebody that's to say hey I realliy want to come use this. People are kind of tech owe taro. My generation. I'm getting old there. Looks at computers as something [ INAUDIBLE ] A job. But these young kids. The 18 to 25-year old, the 30-year old, see it as part ever of their lives and they are comfortable with it, so they need to be able to get the technology and utilizing the technology into that type of thing. You need to work on clinical competencies for the students, and because it's part of the education process, it should also be clinical competenceries for the provider in the long run. When you look at the issues of security, I agree with Suzanne. Why re-invent the wheel there's a lot of stuff out there. You've got HIPAA Privacy compliance. You can do information technologies, all type of things to do that. What I would also suggest is at that you look at the security end of when you have the patient on the other end. What all is happening with that, because patients, you know, in open environment will say things that they don't realize is being transmitted to somebody else, and that type of thing, so the physical location of where you're doing your interactions is important thing to consider, consideration too.

Barb you're phone is fading a little bit.

I'm sorry.

That's better. Much better.

Sorry. So I would go back and, I will not stop rambling since I still upset with my computer here because all my notes are on the computer. Thank you, guys have done a great job, would continue, like to continue working with you, Mike and any other projects you have going on, and congratulate you on a great, job well done.

Thank you Barb. And again, thanks for your support over the past several years. Funding, few of the studies, many of the few studies that exist out there looking at some of these vocational aspects, so we appreciate that. Your going to stay with us for a while Barb.

Yeah I'll be on until 4:00.

Great. Okay. Our next panelist is Steven Dahling. Steven, are you on camera. Are you there Steven?

Yes, I am. If.

Welcome. I'm going to introduce you. Steven has over 15 years of experience. At the Rusk Institute of Rehabilitation Medicine in New York. As senior rehab technician and assisty technology coordinator. He's responsible for all assistive technology equipment foreign patients and out patients, in both the adult and pediatric service. He's a current vice chair of the rehab engineers and technologies within the pro special specialty group and current vice chair of the telerehab special interest group both within the, the rehab engineering and assistive technology society of north we were. Welcome, Steven.

Thanks. Nice to be here. I want to add my voice to the others that for a wonderful presentation that you gentlemen have made. It's something for us here, over here at the Rusk institute we're all pretty much novices of this. We've been kind of reading the /PAEUPDZ phase and all that kind of stuff but to hear it put together with some practical application with research studies is really encouraging, it shows us we're on the right track. I've noted that many of the commentators have pointed out the need for the owl come study, and I'm a firm believer in that one because you're not going to convince any funding source that this is worthwhile unless you can show them the numbers as it were. Actually we're having a little bit of problem here with our administration because all they want know is how much money is this going to cost to get it started and how much is it going to save us in the long run. And even among the therapist some of them if I have to spend all this time in front of a camera, talking to people why can't they come in and get it done herement they like that hands on approach. I think part of it ises this multiprong approach to this, is we have to convince people that this is a worthwhile type of approach to taking care of medical needs of folks, and that we have to show them that, yes, we can make some money on this as well, and save some money. But one of the things that, that I want to just throw out there and see if anybody can pick up the ball on this, I've been to some conferences on telemedicine, telerehab type of thing, the American telemedicine association just recently had one and I noticed that when it comes to things like monitoring, telemonitoring, home healthcare they have some specific equipment that's been designed just for that purpose and hear I'm listening and basically weapon /W*EF to kind kind of a hodgepodge putting together different systems depending on our own personal knowledge of what's out there and then trying to make it work. Just even something like this conference. I have to admit that between pushing buttons and muteing phones and going back and forth, it kind of was maybe a little bit more complicated than I like it to be, but now we're translating that to folks at home, we need some sort of set up where basically they can just push a button to turn the whole thing on and get it going they don't even have to think about it other than that. So I think that the equipment end of it is one thing we really need to address. Selling it to the people who are going to use it, the therapists, I think the end users from what I've seen just in talking to people here are enthusiastic about trying such a thing. I don't know how enthusiastic they will be you know actually using this equipment, but they seem to think it's a great idea then they don't have to come out of the house and come down to the hospital. It's like and all day project to come down for a few they were I have session they can do it at home and save some time that way. That's one thing we really need to do. The other thing too is, I'm sensing a need for cooperation here between all the various organizations that are doing this sort of thing. Like the A T A, restaurant that's as an example, and I notice that some of the board members there, I think are, at least members or an affiliated with many of the these organizations, and wouldn't it be nice to start getting everybody on the same page with this, in order to promote all the things like state licensure issues and reimbursement issues and things of that sort. It's like so many things that have to be done. I'm personally I'm looking at this from like the technical aspect I'm not a therapist or anything of that nature, but I'm the guy who they call onto make set it up and make it work, so that's really my field of focus right there, so this has been a very interesting conference that way to demonstrate what we need to do, and I think that if we can all just kind of banned together and stay in touch through blogs or websites or E-Mails or whatever we can start addressing all these issues as soon as we possibly can.

Thank you, Steve. I appreciate your input. Again from a pragmatic perspective, I think a lot of the issues relate to the whole concern about usability. That that we struggle with. So you're point is very well taken, and, and we shall incorporate your thoughts. Our final panelist is Christine woo, Christine are you here?

Yes, I am.

I see you on the list, good. Do you have a camera, Christine, will you be joining us by camera.

No, just by audio phone.

Okay. Great. Christine work for Cleveland spinal cord injury disorder center. In 2,004 she was hired by the Cleveland VA spinal cord service to set up a clinic to clinic telehealth program in Ohio. Since then she's been an active participant on several national telehealth groups including the VHV telerehabilitation field group and the general telehealth [ INAUDIBLE ] Advisory committee. She was involved in involving the teletool kiss. The and more recently the SCI telehealth curriculum course. Locally she co-lab /PWRAEUTS with primary care service to conduct training sessions on setting up developing home telephone health programs she has expensive work experience with the set up, development and administration of clinical programs in research studies, and manages both roles in her current position. She was recently asked to coordinate the development of a national clinic and home based spinal cord injury telehealth program in the Veterans Health Administration. Welcome Christine.

Thank you. I want to comment first ever of all I'm /PROPBLy one of the new ones in this field. I've been in this field for about five years and I come from a mostly a practical program development and implementation perspective not a clinician in, by training. I want to make some comments about some, first of all, I want to thank, for the invitation to speak at this convention. And I also enjoyed the presentations that were given today. I want to comment on some of the polls that I saw. One was the relative low percentage of medical and clinicians and therapists who are attending this conference. I think this is reflective of small number of telerehab clinical programs that are out there, and then the second poll that struck out at me, was the percentage of participants that had less than five years experience in telerehab, and I'm wondering if this is reflective, an actual experience or interest in this field. The one thing that I want to comment on with my experience and I was asked to comment specifically on, from a VA, veterans affairs perspective. I have been involved with the telerehab group there for about five years, and when I became involved, telerehab was defined as six different areas. Pollee trauma, multiple sclerosis, spinal cord injury and other areas, stroke. Speech. /AUDology and research and while it was helpful to see the diversity and interest, I also think it poses a challenge in terms of program development, in the area of clinical telerehabilitation. And perhaps we need to look at specifically defining the clinical specialty areas in rehab. For example, my area of course, is spinal cord injury un spinal cord injury and pressure ultra management or, you know, the stroke population rather than sort of grouping into larger chronic illnesses and then also define the specific telerehab application areas for example, you know specialty clinic to clinic consultations or home telehealth applications using home telemonitoring devices versus home tele, DMS. And storm forward /PHREUBGs related to clinic to clinic encounters, and you know store in and normal applications related to home telehealth types of encounters. I think some of the challenge with working directly withcally in this cases in terms of becoming involved with telerehab is really understanding what it is, and sometimes when the plan is too grand /KWROES, there's already a fear among many clinicians about regarding change and use of technology. To have a grandiose plan or to have all these options can be really overwhelming in terms of starting, in terms of program development and growing programs. Obviously I think the bigger picture of this is that the large goal would be to have all these different clinical specialty and sub clinical specialty areas involved with all of these tele, telerehab application areas and that would be the larger network but I think that we need to start small and clinical groups need to, to start small. There were a lot of good example presented today on medical uses of telerehabilitation and the applications, but I think some of the, the /PHREUBGs were also very sophisticated and for, un, a large percentage of people or a ten he's who are new comers to this field, some, some very practical examples that, that I can present, that, you know we implemented were just, un, some specialty consultations, your urology issues or wheelchair issues or skin issues between clinical facilities. And they may seem very basic, but for a clinicians or, you know, or people who not done this at the practical level, you know, it's simple. It's something that can be done. It's something that's did doable. And, for example, for a home telehealth application it could be a situation where a patient needs assistance with establishing a new routine or a new, there's a new role for a family or caregiver of that patient. It could be psychosocial issues. Couples issues. It could be, you know, supportive a caregiver or a /KHAEUFRB in physical home setting, patient has new adaptive equipment that they could use more education. Those are all very practical home telehealth application very simple non-sophisticated and when clinicians can get involved with those very simple applications, and this is not, this is not even considering some of the fear of technology that they have, then maybe there's a bigger chance like clinicians will become more involved or, or see the potential to apply some of the more sophisticated applications and technologies that are available. So that, that's my comment in terms of program development for telerehab. Now, the other, the comment, one of the panel members made a comment about, a challenges about program development is needing a champion. I have to agree with that. That there needs to be, someone who is willing to and able to coordinate program development and also the recognition that program development needs to be focused on the technical infrastructure that's in place and available. Not sort of, because what is or should I say more accessible and not necessarily available. There's many technologies available, but is may not be accessible, in terms of trying to set up a program, and I'm looking at some of our experiences here at veterans affairs of the home telehealth program is very well established, and more in the, about the primary care chronic diseases, rather than rehab, but the technical infrastructure in place currently only supports plain old telephone based [ INAUDIBLE ] Technology and that mace /EUBGZ very complicated for telerehab program development and, for example, just wound care is, it's difficult to assess it for a nurse assess over positive technology. And the other issue that, practical issue that we faced is, from the patient's standpoint for home telehealth for example, many of the devices that are available for a patients, are, are not adapted for the functionally impaired, and /UPS you know, while we can work with our occupational therapists to make those adaptations, a lot of clinicians are not aware that that's an option. If the vendor doesn't sell the de /SRAOEUGS or have a device with them adaptations, then they don't see a way to proceed with this program. I guess those are, my main comments in terms of, you know what was presented to, and the follow-up.

Well thank you Christine, thinky that that it's very helpful to hear your perspective from somebody who admits for only being around for five years for telerehabilitation but has developed quite a resume of experience in that field. Certainly want you under underscore the fact of what's going on in the Veterans Health Administration in term of telerehabilitation. Clearly one of the leaders or if not the leader in terms of, in terms of the development and use of those technologies. I guess, you know, what's unfortunate about that is that's a fairly closed system, and if we can somehow, as a field benefit from the vast experience that you have in the Veterans Health Administration in terms of crossing over into, sort of public sector, I think that would be a tremendous advantage and gain for, for rehabilitation overall in telerehabilitation. So thanks very much for your comments. I also think that we have a sample here that's, you mentioned the percentage of folks who are five years or less, we've probably captured a sample here that's probably much more likely to have had exposure to telerehabilitation as well by virtue of this conference, by virtue of this virtual conference. So thank you very much for your comments. We're on our last leg here. Sort of winding, winding down we have about 20 minutes or so for, for questions, and there are a few questions. Most of the comments that came through, are complaining about their heads hurt because of the audio feed. So again we apologize for that. But there are a few questions here that relate to content and I'm going to select them and throw them out. But I would encourage you to use your chat room to submit tip any of your comments or questions for the, for the authors as well as our expert panelists, so please take the opportunity now to, to participant with us, and interact with us. And I'm going to see if I can come up with some of the questions that you've already submitted. In terms of many of these questions, is it possible to get the presentation downloaded? Where will that be?

On our public --

It will be on the RERC. Www.RERC it. .PI it. .EDU website. So we will post that shortly.

[ INAUDIBLE ]

Okay. there's, I saw some of these. Andrea Wilson asked it appears no state VR offices are utilizing it. R on a trial basis. None that I know of, but again that's not likely something that's going to be disseminated. In the professional literature so if anybody is aware of that, I will certainly like to hear about that. And awn /TKRAOE an also asked, or commented is it because CRC doesn't recognize that telerehab yet.

I think CRC does recognize telecounseling and the use of technology for the delivery of services, so I think their efforts should be lotted in terms of impacting professional practice to assist in addressing potential delivery source that, I mean, even if we're just talking about telephones and fax and E-Mail attachments and so forth, that's just sort of tip of the iceberg and certainly all of us in rehabilitation are using those telerehab technologies. There's a question from Marissa about what data collection program was used to collect and /TKPHRAEU movements.

Well this is basically something that we wrote. I didn't write it. I'm not a software engineer, but our software engineers at, at car neglecty Mel on developed their own program to extract data from video an also from Accelerometers. We used statistical programs like case neighbor and add a boost to basically interpret that information. HRSA question I'll throw out. Do you see demand for telerehab services coming from clients, is there a way to foster expectations for remote delivery of telepractice in the patient's home? Mark, is rich, panelists?

I, I can't say that I've seen it directly coming from the consumers, I think it's been more and more out of the clinician, but just the feedback that we've been getting from clients that we've provided service to, services to through telerehab have been pretty positive. I mean, just anecdotally un some, one family person did tell me that there was, there was no way that his, one, this is somebody we saw through, through one of the clinics up north, that there's no way that his mother would have been able to tolerate driving the four hours into Pittsburgh. They had been struggling with her wheelchair and her comfort, she was an older woman that was kind of provided with a wheelchair that didn't fit her very well and she was sitting in it all day and you know comfortable and /SHROUFPed and through the telerehab not only did we get her a good, a better wheelchair with better postural supports working closely with the clinicians there but also got it funded through her insurance, which was what the local clinicians had been struggling with, so I think the, from a client perspective. Yeah they, they do embrace it, most of it has been coming, most of the demand for telerehab is initiated in the clinical setting. I think as it becomes more mainstream and clients are aware of it, they'll be asking for it.

I'd like to add to that, that the, you know, I see it at a very broad level, eHealth and telehealth service demand in the last 24 months be driven very aggressively by pairs and by employers as part of payer contracts. As [ INAUDIBLE ] Mentioned in the case of very complex patients, pairs are actively looking for ways to deliver quality service to their members and/or their employer members through contracts, while saving money, but also being responsible for services so when you look at these patients for instance, I don't think that many of these patients can be looked at just in the isolation chamber of, you know I'm in a wheelchair or I have this disability. Many of these folks are very complex or at least some of them, I would say are very complex consumers, and so I see payers getting very, very aggressive about mining claims information to look for populations of people for whom eHealth telehealth kinds of services can be effective, and then coming to providers, whether it's through clinician networks, physician contract,s you know, however, coming to a provider, help us manage this population of patients. Again sort of old thinking, five years ago was, help us manage diabetes or help us manage, you know, pick a condition, but today, what I see, is as I sit at the table from a business perspective and when I'm in that role, I see employers and payers looking at persons, and saying, these are populations of people for whom we are responsible for covering their health, and at the end of the day many of them have disabilities and lots of other issues going on, so so that I think is an opportunity to hook into pay for performance programs and other areas where that's really driving large skill demand. I think that it's just a matter of time before telerehab is, is, you know, put into that train. But I wouldn't just think of it in terms of patients or clinicians. I think there's also those two other steak holder groups.

Mike, can I comment on that, this is Barb.

Sure.

A lot of patients are also used to being home monitored for telehealth applications. And so now they're beginning to ask, why can't I have my telerehab, why can'ty my rehab at home through a distance also.

Good point.

So there's a little catalyst out there that begins, begins with, with the health information, and then broad even and expands. So Rachel has asked several questions here relating to sort of, is this really counseling? Will counseling be lost? Specifically are you afraid of losing the personal touch factor with all this telerehabilitation? Anybody want to respond to that?

That's, that's certainly a valid concern with telerehabilitation just my experience as a clinician. I don't really, I don't see that as an issue because I'm, I'm providing consultation to another clinician, and I still have the, the sense that I'm interacting an have an impact on how that treatment is going or being able to monitor the effectiveness of the treatment.

I think there's also a spectrum of involvement that, that occurs potentially in tell prerehabilitation you know one even of the spectrum could be sort of on-line counseling where you don't even know who the therapist is, and they don't know you for sure, an and there's certainly some clear professional and ethical issues with response to that type of a counseling. On the other end of the spectrum, it may be just that there are these technologies that serve as an adjunct to, to a relationship that you've already developed with a client or that you continue with a client performing some elements of face to face, but also being more accessible to your client over time in remote situations. For example, you're rehab counselor or you're job coach may be a component component of your first 2 week on a job face to face, but then realistically may be able to provide support from a distance. Once you've already established that, that relationship or perhaps supporting on an as needed basis, face to face and then following up. So I don't really see it as and all or none things and I certainly don't see it as a down fall of counseling, because from a sound clinical perspective, you're going going to want to build in those aspects of a relationship that are so important to success in rehabilitation. And I think, you know, we, I think you're point is well taken from the standpoint that we have to guard against these approaches being somehow so removed from the client that, that a relationship isn't possible other than of totally distance relationship.

And the telepsychology certainly has topped [ INAUDIBLE ]

[ MULTIPLE SPEAKERS ] Yeah I'm glad you brought that up. The whom notion of telepsychology has addressed that from a, from a professional and from an ethiccy standpoint. I've heard mark speak about the few. I feel as it is an excellent functional tool that can be helpful with various telerehab clinics. Is the tool available for the public to use? Any CEU on how to [ INAUDIBLE ]

I'm not connected.

It's from Chris young is she on the payroll?

The tool itself you can actually go to the website. [ INAUDIBLE ] .PI it. /TK*D EDU. And yes there's a self pace learning component, continuing education component to it, and if anybody goes there, and looks at it, has any questions, I, they can reach me through that website.

Thanks, Mark. Whether there those among you with experience in using telerehab with support groups of stroke survivesors? Families and caregivers, would that be considered counseling? ?

I say there's a whole telestroke program that actually just gained reimbursement about four months ago through UPMC. I, I, I'm not a clinician so I can't speak to whether clinicians would consider that counseling, but I can say that it's more of a clinical intervention focus, I think to say you have a specialist who can make recommendations about acute stroke care, but there are some follow-up /KPHOEPBTS as mark compensationed very similar to clinicians in a tube airy setting, training or counseling orcally in this cases who are reaching out to patients in the community, so again I, I know there's a program running through UPMC specifically to telestroke.

And, and I think, although I'm not, I can't cite one specifically, I would be very, very surprised if there was several stroke family and caregiver support groups that exist. There's a lot of virtual kind of support activities that, that, that do exist using technologies like second live, so there's, there's exist much of that out. Again, it relates to what is counseling and that whole spectrum of, of contacts with clients and patients. I would not consider a life, you know, face to face support group counseling much that's sort of a different nature and I think there's probably less rigid guidelines on sort of virtual support or Internet based support activities, but that, that doesn't diminish the value and the need for those kinds of resources for people. Any comments from our panelists? There's a question here. Who does workplace assessments? Do O T's or /SROBG counselor's do them in the US?

Primarily, I think they would be vocational counselors, job coaches? We have rehab engineers as well as to some degree O it. who are doing the workplace assessments, so I think it's broad.

Pretty much an inner disciplinary approach we just bring our own, you know, capacities, the skills to the assessment process. And again it depends on what resources you have in your area.

Okay. So perhaps we failed at one of our objectives. Arthur going Ellman suggests I'm still not clear if there's a universal definition of telerehabilitation since so many disciplines are involved. Mark?

It's a good point. I think we're getting there, but that's, I think it's like one of our panelists say we could have a two-day workshop just oncoming up terminology that everybody is happy with, but I think overall we've got, observe dens ought there they Saul seem to say a very similar, a very similar thing.

Okay. .

Okay.

Could this telerehabilitation be used in a rural wheelchair clinic setting? ?

Yeah, I mean, that's, essentially what we're, one of the, well the key aim of our research study is to set up wheelchair clinics in distance or facilities located at a distance from the, from us here in Pittsburgh and it's worked like I said, it's worked well revty well. I think some of the key things as far as setting things up, anything can be set up pretty much anywhere as long as you work closely with your information technology people understand their I T infrastructure, understand their needs and work closely with them and I think that's true across all organizations large and small that we've encountered, whether it be a small hospital with their own I T system or own UPMC health system is which is probably one of the most wired in the country. The veterans administration, and actually, you know, even in discussing the infrastructure yesterday, these are all things that needs to be look into, but yes, we're, the results are showing that this is a feasible option for supporting wheelchair clinics in remote areas.

Okay. We have a few more here. Just 1 second. Sue, Dr. Sue, asks in Oregon we are starting to review the evident based, basis for identifying procedures and providers and provider sites which are appropriate candidates for Medicaid reimbursement. Currently there is no activity by the state therapy professional associations in telerehab. If we were to pick one pilot telerehab application, which would you recommend? That's an excellent question.

That is an excellent question.

I'll tell you which one we shouldn't recommend, and that's not to indict anyway our wonderful work here at the University of Pittsburgh, but I think you need to pick a, some application that that has a large, a large number of people with a need for that particular service. You can't, I think it's very challenging to pick a specialty service that effects only a small percentage of people, and I think we've done a tremendous job with our wheelchair seating research in telerehabilitation in terms of efficacy but it is very hard to convince payers to buy into something that has such a low incidence, and such a small affected population, so you know, this is where we have to look to groups like telepsychology and telemedicine with very high incidents disorders with, with a great deal of known problems in access to services, so can anybody else contribute to that.

I'd say not only it has a population that needs it, but has a pretty well defined clinical practice guideline or procedure for meeting the needs, because, right, wheelchairs was something that was easy for us to do because we had those compassties, but even in wheelchairs there's still not an identified gold standard, so again I think something like telepsychology. I know they're talking about therapy applications here, but what are, what are some common needs out there that people typically need related to P T or O T, and what have established clinical guidelines that could be monitored more system matically.

One of the approaches that I think has sort of confronted us or a period with us was the fact that some /( providers. Some payers have actual actively involved proposed us to say that look we're getting hammered in rural areas to come up with clinicians to provide services for autism, for example, we don't have the level of specialty of services in rural areas for autisms and frankly ourcally in this cases aren't willing to travel so we're having a hard time meeting the needs of our patients in these rural areas. Can you please help us find a telerehab application that would enable us to provide this. So Medicare or Mead /KAEUD may not be a good source for that information you may want to look to other payers to find out really where they're gaps are and if they might be willing to look at different ways to, to meet the needs that they're confronted with on a daily basis.

Okay. I'm getting the hook here, so Dave'sing me it's time to wrap up. So with that I would like to thank all of you for participating and listening. Thank our expert panelists you've done an excellent job and we really appreciate the work you've put into this as well as the output on this. I'd also like to introduce tomorrow's paper, and that paper is authored by Dr. Michael Pramuka and Dr. Linda van Roosmalen.

Paul Wehman. Left.

The title is telerehabilitationologies accessibility and usability, and this is going to be an excellent paper on some real pragmatic aspects of how programs can initiate. How clinical /PRABGs it initiate telerehabilitation as one mechanism in their tool book box expert panel will be Phil Girard. The defense manage brain center Patty Campbell of private practice. Jack Winters at Marquette /KAOUFRT. One of the sort of founders of telerehabilitation. Greg Traynor out rehab counsel in pry the a. Onny shatter gee with data lust research specialist so please join us tomorrow at one clock for day three of our program. Thanks everyone.

Thank you.

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