Event ID: 1167662
Event Started: 11/19/2008 12:48:12 PM ET
Please standby for realtime caption text.
Think unto all of you who are online -- thanks to all of you who are online. We will star in a few minutes. Bear with us.
Okay.
:ladies and gentlemen of around the world. Welcome to this third
session of the historic telerehabilitation state of science, Prince
provided by the -- provided by the Research Center here at the
University of Pittsburgh. And I am Kate Seelman. I am delighted and
happy to be able to introduce the two directors. On my right is David
Brienza and on my left is Michael McCue. Do you want to kick off for
us?
I would like to.
Let me add my welcome to
everyone. This is our third day of the conference. I assume that you
read and hear one of the last two days and as a mug you are new. So
welcome to the new folks and will come -- and some of you are new so
welcome to the new folks. I just want to say that this is a great
opportunity that we have here today and this week in running this
conference. We have more than 250 people registered from around the
country and around the world if we have 37 states represented in the
people were registered and 50 countries. We have a spot extremely
diverse audience to work with here.
As you all know,
professionals and consumers recognize the need for accessible and
affordable rehabilitation services. Because the percentage of the
population that is disabled increases with age the number of persons
needing health care services projected to increase dramatically off. In
turn, and the society adopts innovated strategies that curb costs, it
threatens to have health care spending at unsustainable levels.
This is what brings us together today. It calls three fundamental
questions that we would like to address. Does telerehabilitation
provide a cost-effective alternative to a face-to-face Services?
Second, what are the research problems and training needs? And finally,
how can we will fully integrate it for participation of consumers. We
have several objectives for our of an.
To present state of
the are in telerehabilitation. We want to explore issues with user
usability and the acceptance and public policy. This is where we need
your participation. We also want to identify deficiencies in the use of
telerehabilitation product and service delivery approaches. And finally
to identify and prioritize future research if entry needs and
dissemination strategies. This can only work if we can participate
together. We will be presenting what we view as the state of art. We
have gone through a process and started about a year ago and developing
papers that needs to be did to you. We chose others from it in our own
group approximately a year ago and then quickly added people from
outside of our center to get as many perspectives as possible and as
many contributions as possible. The papers have gone through to
revisions in the second one is one that we put codes into e-mail and on
our website. Today we are going to present those papers and further
refine them for discussion among the panelists here in Pittsburgh were
and the careless who are remote and with you. All of the inputs -- and
the participants who are remote with you. We will continue a block site
that will have continuation with the papers. We will keep that site
active and we will pose the questions the come up today on talk blog
site wow. We will take all of this input, the original papers in the
discussion a conference, the input from the blog site and produce a
final version of the paper. Those final versions of the paper will be
published in the premiere issue of our journal, the International
Journal of telerehabilitation. It's an on-line journal that will be
publishing it first issued in April 2009. I would also like to tell you
that the conference cash sessions will be archived and be made
available after the conference. I also need to tell those of you who
were here yesterday that we have a bit of a snap, and we did not retain
the recording from Mr. Did. However, we have the transcript from the
closed captioning -- we did not reach into recording from yesterday, so
we have the audio portion. If we can if we've resynch the audio with
the powerpoint, which we'll do that. And the entire beach from this
session is being recorded and will be available after the session is
concluded.
I want to bring you through an orientation of the
layout on the screen. We have two or three layouts that we will be
using but they all contain these the same basic control components. In
the upper left you see a video feed. And we will put the images up of
presenters up in this window in a live video prepared to the right you
see a PowerPoint slide. This is where the PowerPoint participation will
be displayed. Underneath the PowerPoint of the right is a list window
showing filenames. If you click on those filenames and select download
to my computer, you can transfer those files to your computer to use
them as you see fit to be offline or what have you. To the left of the
bottle window is the chat window. Through this -- to the left of the
bottle window is the chat window where you can communicate with as big
we can't have you come into this portion of the feed here. But we can't
take your comments through bat were -- they're the chat window did you
will does your own comments. On the screen on does I copied them to the
main display window.
In the bottom left of the screen is the
closed captioning window. All of the text from the audio portion of the
broadcast will be displayed there. I was like to think caption Colorado
who is captioning this for us. Doing a fantastic job. Thank you again.
As long as I am thinking people, there are a bunch of people that have
contributed to this and made is the success it is so far. First of all,
the sponsor, the National Institute on disability research. Thank you
for your funding and allowing this to happen and this exchange to take
place. I would also like to mention that our center has a very
dedicated group of the Pfizer's research on our scientific advisory
panel -- of did Pfizer's who serve on our scientific advisor panel.
Here locally we have a group of people who really pioneered or have led
the technical development of this program. And they are Kit, Joe and
Eric. They're the people behind the scenes here and they are making
this happen from a technical perspective I would also like to think the
students to produce a bit with us in our center. They have done all of
the menial jobs with a smile on their face and again I thank you for
that. Also in terms of technical support we had Dave from Adobe Systems
who is providing behind-the-scenes support for us and has taught us to
use the software that we're using to produce this. And he has showed us
the way with Adobe connect and he continues to support us, thank you,
Dave.
Most of all, I would like to think these two. They have
led the efforts for the development of this. They have been involved in
every detail of it and they have forged many hours putting this
together and it's turning out to great, thank you, Kate Seelman and
Ashley -- We will been over to prove that she really exists.
Thanks.
At this point I would like to turn back over to use.
Thank you and thank you for coming today and enjoying us from the
comfort of your office or your living room or wherever you might be
located. I am pleased to introduce the authors of today's paper which
is entitled, telerehabilitation Technology comics as ability and
usability. They include Mike Pramuka, he is an assistant director here
at the School of Health and rehabilitation scientists at the University
of Pittsburgh. He was the University investigator of the Global Project
on self management and epilepsy and a skirt the one of our
investigators. He is also involved in a number of projects on the
telerehabilitation. He has that experience with rehabilitation and
psychology and House also worked in addition of to the university
setting and the Veterans Administration as well as in the Department.
He is teaching here, he teaches courses in our masters program and
rehabilitation counseling. He practiced as a psychologist and a pencil
in it and is a certified rehabilitation counselor.
Linda is a
an assistant professor here at the University of Pittsburgh. She is one
of the investigators on telerehabilitation as well as the RERC on
wheelchair safety. She told a background in design engineering from the
Netherlands and features designed courses to graduate students. She is
active in technology transfer and collaborates with various industry
partners. So I would like to welcome our authors and kick off today's
paper. You will experience a short delay until we get our authors
seated and ready to go. And then we will carry on the.
Thank you very much.
In join the conference -- enjoy the conference.
Hello. A and Mike. And I think the GATT is on. they think the camera is
on. Welcome everybody and thank you for attending to did. It's a little
bit different than those on the previous two days. We are focusing
primarily on technology issues. And in doing so we need to talk about
some other issues that to affect the choice of technology. We would
like to start off today with myself and wind up until about 2:00 or so.
And then we will move onto our expert panelists. We are very lucky
today to have five expert panelists joining us in two of them are you
with us today and three of them are joining remotely. Remotely we have
Dr. Jack Winters who is here talking about research and
telerehabilitation did we also have Mr Philip Gerard. He has a lot of
experience with implementing telerehabilitation technology. Here with
us today we have Betty Campbell who is like myself a telerehabilitation
counselor and has a lot of experience in terms rural and remote of
services. Also we have great trainer who is a counselor and a user of
technology as well Lucan bring a different perspective to us. And
joining us in person is [ Indiscernible ], a usability experts here in
Pittsburgh. We have a variety of perspectives to sure that we would
like to integrate as we consider how best to consider accessibility and
usability issues and technology choice when finding remote's
rehabilitation services.
In terms of overview, I would like
to talk about telerehabilitation, and it differs in some way from
telemedicine did I know in the previous two days, but if you're able to
attend we talked about definitions of telerehabilitation of bonds and
telemedicine. This will not go over that. This is a perspective that
are special to rehabilitation, is separating us from telemedicine.
I would like to spend a few minutes of doing an overview of
telerehabilitation Technologies although the scope of that is beyond
the time limits to did. I want to acknowledge these main categories of
technology that are being used and identifies some issues that we face
with does technologies. And then Linda will talk about usability issues
and design issues as related to the technology and moved on to talk
about some important conceptual issues of of the taxonomy of the
technology and we can talk about matching rehabilitation needs to
technology and then move onto the expert Peres in terms of the next ups
and future directions and topics and activities that we're hoping to
get feedback from our experts can lids and from you, our participants.
Linda and I have talked a lot about the technology and Vicks disability
issues. We both recognize that we need to hear from our audience
participant above the barriers to technology used and other
telerehabilitation issues that you may also be expressing yourself. We
really do hope for your participation in short observation.
Linda comments you want to say hello?
Sure. Hello. In addition to what Mike mentioned, we will also ask you
some questions to outbid we would like to have your response to those
questions. I will turn it over to use.
I should mention my
background is in rehabilitation counseling and psychology and you heard
that Linda is in design. And early on we recognized we need the both
critical side in design for engineering side when we work with
technology. Because there are complexities that are easily addressed
with the more than one perspective. This has been a good partnership.
And we try to consider that as though we put our expert panel together
to bring in people who have a critical perspective and other people who
are much more oriented to engineering or technology.
Let me
talk a little bit about telerehabilitation versus telemedicine. And I
said that telemedicine is moving for rapidly and progressing in terms
of technology used and funding and reimbursement. When I think there
are some differences between the world of medicine and the world of
rehabilitation in general to keep in mind as remove the word -- as we
move forward. One is that much rehabilitation services to occur in
community-based settings as opposed to acute medical settings. So the
staff involved and debarment in the access to the technology may be
very different than it is in a medical setting because of the emphasis
on community based rehabilitation some services are provided outside of
the funding extremes that medical services use such as Blue Cross Blue
shield or other medical pace system. So services may be developed
through States or county funds or through non-governmental
organizations. And so while there are considerations about how to
obtain funding in purchase technologies and how to provide services in
terms of how to pay for this, they may be somewhat different than what
we face in trying to cover services under a health plan and maybe more
generally to take a step back, remember that all of us who work for a
long time in rehabilitation have struggled with the relatively poor
reimbursement and relatively poor access to funding that ourselves as
providers and consumers face in trying to access services and
rehabilitation in terms of acute rehabilitation, it's not very easy to
front.
In community-based rehabilitation settings, we have
sometimes have professionals who are not allied with specific
disciplines such as occupational therapy, however, not all people who
work in community rehabilitation are not going to come from a specific
session. A number of people across the country may not be aligned with
a specific profession there for their funding streams are outside the
typical system.
Another thing clinically in rehabilitation is
that we work with people in personal and private matters about their
lives. So we need a close working environment. We need to develop a
very good report and it eighth therapeutic relationship that stands
across many years. Saw the technologies that we need are going to be
required to maintain that report and it bought from somebody and
maintain that over months and years were as medical interventions may
also be much much more brief.
We also involve killing members
and friends -- We also involve family members and friends and our
technology needs to integrate other people, of friends, spouses,
employers into our interventions as well. Many of those people are not
in the same setting or are not in the medical setting so they require a
different perspective on how to integrate the technology.
Moving on to the next slide I think what we might want to do is get a
sense of what we're talking about and it is here. Linda mentioned that
we have some polling question. And I think question Number one
actually, if we can bring that up, you can see a little box that lets
us choose it, please, tell us about the background pick a gives a
choice of different disciplines. Please click on the button that best
represents your background.
All I am glad to see that we have
a lot of people from rehabilitation counseling and vocational
rehabilitation in the audience were.
We have some people from
occupational therapy, a good number of engineers, and people from other
directions that are not clinicians.
I realize that some of
them overlap. Okay. I think that we can close that down. It great to
see that we have a about a people from the world of a vocational
rehabilitation. As I know and as what Patty will speak to,
rehabilitation counseling is one of the disciplines that works with
people in community settings and jobs settings.
Do any to start my camera again?
Okay.
Okay. So we have a second polling question before we move on. Question
Number two is what type of the rehabilitation setting do you primarily
work in? Said -- okay. We see a good number of people are in
community-based rehabilitation. A smaller set are also in the world of
the Q -- rehabilitation or an acute medical setting. And we have
benefited all lot from the initial allegations of rehabilitation remote
the to our friends who are closer to the world of the medical model.
Okay.
Wheezy that people are from acute rehabilitation and from a vocational rehabilitation.
Okay.
So at a simple level, telerehabilitation can involve the use of tax.
Almost all of us use it through e-mail. Text messaging has been used
more and more for rehabilitation services. Keep in mind that text can
also be like acceleration data from a wheelchair, collected from a
wheelchair, a device attached to the wheel, an encoder.
Okay.
Sorry about that.
So there is a variety of data that is three simple such as text.
Okay.
So we have some simple data such as e-mails and text messaging that we
used frequently in everyday life and can be applied to
telerehabilitation. There is also simple data like that that can be
collected such as acceleration data from a wheelchair that can be saved
on a wheelchair --
We can't hear you -- can you turn that on? That is fine.
Is the are -- the audio back ? We're going to wait a minute until the audio comes back.
Can you hear me?
Yes, it is.
Thank you.
So we have some opportunities for simple data collection, such as on a
wheelchair, that can be saved to the clinician or engineer.
We have an echo.
Okay.
One moment please...
I keep turning it off.
It should be on.
Five One moment please, audio difficulties.
Our apologies for the delay.
Okay. We have audio. Okay. Thank you.
Perfect timing. I wanted to talk about cutting a technology.
We need it is.
We need audios.
Obviously we can use phones, a speaker phones, sold bonds, boys over
Internet protocol -- voice over internet protocol. Commonly we attempt
to use visual technologies. We may use real-time such as we're doing
today with a web, or more confident it seemed equipment over Internet
protocol -- or more videoconferencing over Internet protocol for lines
that are installed and provide access it echoes.
Okay.
Can I keep going?
Keep going.
When the sound goes off, remember that you can look at the captioning
window and that will allow you to follow along with what we are talking
about here.
In terms of these technologies, we have ISPN,
which is more complicated because the lines need to be installed and a
process needs to be installed. And there is also the use of video and
visual images that we can store and download and e-mail to each other.
Why don't we go on to Number six.
Actually can we just -- That is a polling question.
I am curious if you use text messaging or instant messaging for rehabilitation services.
It basically says 90% says no.
Okay. Why don't we close that it looks like a lot of people don't use
text messaging for rehabilitation services. One of the highlights is
that they are inexpensive and available to almost everybody at least in
the United States. So it's a quick and simple way to connect to people
remotely. Of course, there are some limitations to that technology as
well.
On to the second slide here. If we can just move away from the polling question and back to the slides.
I want to make knowledge that virtual reality is more and more used and
that really sounds really complex and it can be but we also have things
like secondlife.com and games five that can be used -- and Wii Games
that can be used. So it is relatively simple things that you can't
access over the Internet or at home or at an office setting. Or a more
complicated system, and of two technologies that use a tactic analysis
and real touch and virtual reality. A lot of technologies our web based
on the Internet. We have a website that allow us to learn and respond
and fill out questionnaires. We have integrated Systems, I am sorry, we
also have wireless technologies, as -- cell phones, PDAs, blue tooth
technologies that allow us to connect nearby. And usually they are not
one or the other, they are integrated. We have systems that use
multiple assistant technologies. There is one technology on the users'
side and a separate technology on the client for consumer side. And we
also have robotics which is a complex integrated system which is a
level of the intelligence that has been built into the system as well.
So why don't we ask polling question number eight. I am curious if
people are using virtual reality. So tell us about your use of virtual
reality. So I've used Internet board game based virtual reality, I have
used for most virtual reality systems. I am accused complex virtual
reality systems. Or I have not used virtual reality at all.
We don't have many respondents to this. I guess that we have a few people who are familiar with virtual reality.
Okay. Why do we close that down. Thank you.
They are coming in out?
Okay. I will wait a minute.
Okay. So we do have people who read used some Internet based virtual
reality or a game based virtual reality. But I still think the majority
of people have not used it at all.
I think that we should move on.
Okay.
So I think we would like to move on and talk above usability and design issues with the technology. So, Linda?
Yes, when we talk about usability and design, before we start I would
like to bring up polling question number three on how many of use
rehabilitation. Mike just mentioned all of the different types of
technologies that are existing. We would like to see who would you
things that they're using technology -- who thinks that they're using
technology. I am seeing it about 50/50 that are using
telerehabilitation. So that is a good sign. We do have a large number
that utilizes technology. Another question that I would like to ask his
question Number five -- is question Number five. What would be your
main reason for using telerehabilitation over a face to face service.
Or why would you utilize an telerehabilitation service. That is
question Number five . Okay. We can close question three.
Yes.
So what is your main reason for using telerehab over a face to face
service? We noticed that 50% of you use some type of technology. We see
a large number with access to consumers at a distance. That is the main
use of the technology. That makes sense. Convenience, cost savings,
increased efficiency for people who travel. That is somehow what we in
addition, too on our end.
Okay. We can close this what ever we have everybody.
So then I like to come to my next point is technology designed for
people? If we looked at the will stage of receiving technology on the
remote end by consumers as well as providing a service remotely by
inclination, there may also be a middleman between those two partners.
And some technology may be My first point, knowledge and education,
what is the knowledge level of your potential consumer? What is their
level of education? Are they able to use a specific type of technology?
What is the prior experience they may have with certain technology? I
have heard of the use of self funds by younger population so that they
could -- a self loans by younger population so they could take pictures
of areas in their homes and send it to a condition to see if their
homes are accessible could be a very viable solution. However, if we
could have a elderly couple having to manipulate paid cellphone and
taking images and sending this through a condition, it could be more
difficult for this user group. So it could be a factor when we talk
about adoption and experience of technology.
Another aspect that has an effect is the accessibility of technology.
We talked a lot about people with disabilities not being able to use
our environment and not being able to get into buildings, but the same
counts for use user technology. You could think the visually impaired
individuals on the remote end, and the clinician trying to get a
connection with this person, and you may not think that
videoconferencing with be the best solution to communicate with a
person with a visual impairment. Another technology may be more
desirable. So when we are taking technology, and providing remote
services, we would like technology to be adjustable and customizable so
we know the potential end user or customer is able to utilize and
[indiscernible]. It had difficulty installing it or setting it up, it
may run into issues of, I don't want to use this technology or use this
remote service because I don't like it or I am not comfortable doing
it. There may be certain issues.
What I would like to bring up, and I also wrote a little bit about that
in the white paper is, the thought process of universal design I think
could bring us some help here. Universal design was initiated at North
Carolina and University, where they came up with specific principles of
designing products and technologies that are easy to use for a broader
range of people with and without disabilities. And I believe that this
thinking approach would be. Casting if you select a technology and try
to provide remote services for people with a variety of disabilities.
When Mike mentioned that the technology taxonomy, how can we somehow
organized the technology? How can make it more clear for clinicians' or
perhaps most of you how two select a certain technology for how to use
a technology where a specific application, where the application is a
follow up or evaluation or assessment, so, you may require different
technologies to perform these different services. Also, you may need to
for technologies for different types of people that have different
types of abilities. a n other thing, I will go to this next slide where
have and other table. I tried to present this level of complexity
technology. What we're trying to prevent is to not have to use an
extremely complex technology for a fairly simple data collection. You
could think for example, that a person -- there is a face-to-face
communication, and this could easily be done by phone. You don't
necessarily need a video to have a face to face for conversation with
someone. However, it depends again on the type of service if this is
viable way of communicating. And Michael talk a little bit more about
this when he talks about matching technology to user needs.
One other thing I would like to mention is that, I talked about the
receiving end and providing -- the providing service and. It is
important to realize that even this session, but we're doing today and
the past two days, it is very easy from where I am sitting and from
where you are sitting. He may not realize that there are people running
around here to make sure that there things going smoothly and voices
are coming in and out, so it may seem easy pour for this service
provider and the receiving end, but you also need to realize what is
needed is between regarding installation, software updates, technology,
bandwidth, connections -- these are all types of things to consider
when you select a specific type of technology.
Another way could have been that we had you all on a conference call,
but it may be less attractive. It is always good to see a face on the
other side of who you are talking to.
I'd like to throw in another polling question, number 11, and this
question talks about which technologies may have the most potential for
widespread use of telerehabilitation. We see increasingly complex
technologies coming two the market and you may have experience with a
lot of them. There are also trends, we see more robotic types and more
virtual reality types coming up on the market such as the Wii and
Second Light and things like that, and they may not be used allot today
but they do have potential. So we are just trying to get were opinion
on what technologies have the most potential for widespread use. And
Tuesday on my screen that a lot of you think that with cameras and the
Internet has great potential. I think so too, but I am not going to
vote right now.
I like to see this, because I think the Internet is, for a lot of us,
it. Low-cost way to still communicate with each other, and you may not
need a very expensive video conferencing system with different types of
remote-control and a lot of chance for error if you can just click on a
link and join in Chatham like this. -- chat rooms like this.
Two close out this section on some of the user's issues and flexibility
issues, and also, the success of using technology, I would like to pull
out question number 12, which ask you, as it actually happens in your
experience, how would you typically choose for a certain technology? Is
it cost based? Are you thinking about the least amount of cost? Is it
that you want technology that is easiest to use or is less complex with
installation, etc.
To use more technologies that are
currently available in your settings, or option E, do you best match to
the client and we rehab activity?
I see that E, to look at the best match between client and rehab
activity has a lot of votes. That is good to see. I would not advise
you to choose, a technology on because of the cost.
Mike, are you going to tell people -- we are in the process of having a question.
Okay, that is great. We can close down this question. And I will give
the floor to Mike who will talk more on matching technologies.
Okay, we have some questions on-line. I am sorry, I should be looking
more closely. Peter asks, I'm not sure and instead what virtualitwhy is
in terms of -- it went away. Whoever is shrinking that bar, I will be
able to read the question. Can you see the question?
He was
asking, I am not sure and instead what virtual reality is in terms of a
patient [indiscernible] [speaker/audio faint and unclear].
Do you want to cover that? Virtual reality in vocational rehabilitation?
For example, we may use second like Doc, which allows us to create
avatars of ourselves, a symbol [indiscernible] that has buildings or in
their midst and we could have a meeting there with individuals so we
can invite and employer, a client, a rehabilitation counselor into a
room and talk about or basically two a career counseling session, or if
the person is already employed, had a conversation about workplace
issues that need to be resolved without being physically present in the
same place. So it gets rid of the problem of having to transport
ourselves physically all into the same building at the same time, yet
be able to talk and communicate and share information also.
[speaker/audio faint and unclear] study of how beneficial the soulful would be two counselors?
The question is, how do we use cell phones in our employers did not provide as with cell phones, and the second part was that?
Has there been or could there be a study on beneficial impacts of cell phones?
The second question is, our people studying the issue of the use of
cell phones? The first question I think kind of gets it accessible the
question as to what is available in our work environment and what have
to do institutionally to change practices and change rules so that
technology, especially something like a cell phone that is inexpensive
and used by many people any way would be available to as
professionally. That is really an institutional issue for a policy
issue that Doctor Sealman will touch on. Tomorrow we have an entire day
set aside for policy issues, but I think sometimes we recognize that
those issues are touched on by policy or institutional practice, so
there is nothing wrong with the technology, it is getting rid of the
stomach stomach --
Both in terms of boys but also in terms of
sending images, sending photographs via phone and text messaging as a
way to support people on the job as well as a variety of other
applications.
I might jump back and it just finished in about five minutes and then we can move on.
I wanted to just talk about for a few minutes matching technology to
individuals' needs. What I am proposing really is that to all of us as
we approach it, we have to think about it from a task analysis
perspective. What is the task at hand? What are the components of it
that are really critical and which can we let go of before we matched
Technology?
Sorry about that. Do I need to change the --
No, you are good.
Okay. So what we probably did not want to do is two try to replicate
our face-to-face interaction is using technology. That is, on the
surface, the most logical or easiest approach. If I normally meet with
a person in a room where I can see them and see their movements, and
the initially Tuesday is a complex videoconference system which in many
ways replicates what I do face-to-face, but in fact, that may not
really be the court characteristics of of the task -- core
characteristics of task. So I think in terms of a task analysis, I
think the first choice would be the real goals of the clinical task at
hand. So the world of education I think has already moved far ahead.
All of us probably in our own settings now participate in some version
of Education remotely. So we may already understand that we don't need
to get ourselves two the same classroom, we don't need a person to set
up in front of us in real time, but instead, we can click onto a web
site via a link and watch at our own discretion and on our own time a
training session. We can respond to it, take tests and quizzes on it
and pass or fail it. So education has already moved on to separate out
the real component task of what we need to separate versus the
face-to-face aspects of what we normally think of it. So for a clinical
test to involve a spouse or a counseling session in some kind of
rehabilitation training, the clinical task, the goal may differ, so if
we really want to educate the spouse and maybe understand where we're
headed, we may simply need them to listen to us for us to be able to
hear us and respond for example over a phone.
If on the other hand what we really want to know is how our spouse and
our client really interact with each other since onset of disability,
and we probably need to see them together and they both may need to be
in the same room somewhere on video where we can see them. So we have
to think about the goals of our clinical test and what kind of
technology we need to have supported.
Time frames for interactions are very important and it differs
significantly. Some types typing is short, brief, and more often in
rehabilitation, are tied fans are extended over months and years, and
therefore we need to consider the dependability to access a different
technologies.
I think Linda brought up a good point about Communication and response
modalities and the technology in between what we need to -- for people
to respond and communicate and what do we need to respond to them? The
technology in may be simple or complex, but the need to think carefully
about what we're trying to measure or observe, we may need a close-up
of the face, see their hands or eyes as well, so we need to think about
what kind of to vacation we need them to provide and how we respond to
them as well.
When we think about Internet based activities, many times people are
listening or reading to audios that has been restored, and the only its
response we need from them is two move a mouse or click on the mouse.
The response is fairly restricted and in many of the Internet self
management systems. The kind of data that we want to be stored and
Exchange, and that data may be very simple or sophisticated and complex
and add up over time, so if we are reaching somebody's ability in terms
of strength and we are doing it numerous times over, there is a lot of
data to be stored and either send forward or exchanged in real time.
But we have to think, what do I really need? Maybe I don't need any
data is stored, and we can keep it fairly simple. Probably the most
important batching issue is the usability of the technology by the
consumer, and Linda certainly got some important points as well.
Let me talk to the next slide, just a few other comments about the
technology. A reminder to all of us, technology itself does not need to
be innovative. The application [indiscernible] needs to be innovative
for technology innovation. So we often find common technologies that
are available to us that we can use now that allow us to provide a
service remotely that in the past record face-to-face services. So many
of the technologies are already familiar to the consumers and the
professionals. And in somewhat of a summary statement, adopted that
technology specifications need to exceed the clinical capacity
required. Sometimes we do need complicated technology because the
clinical activity is very complicated itself. Other times we can do it
with a very strict for simple application. So think about a counseling
intervention prisses holding stepping about the clash remotely. In a
counseling intervention, we may need high official security to see
people's facial expressions, read at the emotions on their face. If we
may want to see if not just their face but their hand movements.
Whether or not their leg is jumping up and down, whether their hands
are clenching or not. So we need to have some control over with the
visual image is showing us as well. Many people [indiscernible] reduced
the volume of their voice, and the people coming to us may have speech
communication issues, so we may have fairly high demands for audio as
well in a counseling in private. We know we want to develop a repoire
with people, and when someone is coming on campus, will want to be able
to respond at the moment, so we may have someone who wants to come and
show us a photograph of something or a report card or something so we
may need some opportunities for flexibility on the moment in our
technology to meet their needs.
I like to address a question.
One other thing. On the opposite side, if we are having a client
staffing, when we talk about a client's progress for a variety of
professionals that are at different in various and different sites, we
probably need to verbalize the auditory component, it is nice to see
who is speaking, but because we have a lot of control over those
individuals and we can plant with them, which can allow them to
announce themselves when they are speaking, we can ask them to e-mail
or post information two a shared website before the meeting so we can
all access it, so that pre planning, that intense that we have had time
allows us to be much more possible with the level of technology we are
using.
I would just like to -- there are two questions that
are kind of similar that came from the audience. One of them asks, by
Evelyn, a cost comes into play when we are addressing developing
countries needs. Can you address this with the technology in this
context, and then, there was another one regarding addressing a band
with issues, Alexandra [indiscernible]. Band with issues in areas that
do not have reliable or any it sell wireless coverage. The same as what
we're doing now, they're basically using a voice connection on a land
line with our panel members because we want to make sure that we get
the voice loud and clear over two to all of you. So I think sometimes
we could combine a combination of reliable technologies, and then it
will become more advanced, but it is still be reliable. I don't know if
you want to address some of the bed with issues with world areas. Even
here in the United States, we have seen a rapid escalation of access to
broadband over the last several years, dramatically, so in our
Engineering of the rehabilitation center here, we basically banked on
the Internet accessibility and reliability as our medium. And what
could have argued that we were going to be in trouble with that. In
fact, at least in the United States, it has come along very quickly.
And I think it is promising to see that once people begin to install
broadband and have it available, it is feasible in some settings for it
to come up very quickly in terms of availability. But certainly, I
think there is another side to this that you're raising, which,
sometimes we take the opposite approach and say, what we currently have
available, and what ways can we make use of it to provide services
remotely.
Well, keeping a separate agenda of pushing and
acknowledging saying, people are available and interested in remote
rehabilitation services. Telerehabilitation, basically there is a push
for it on the people that we are trying to serve. Right now we are only
trying to use simple technology, but there are others that are not far
from us if we continue to advocate. So I think just the demand and the
engagement that any of us provide in telerehabilitation or remote
services, even if it is with a simple technology and not adequate for
what we really want, it still brings the issue forward to our
government or institutions.
We have, as I mentioned earlier, five expert panelists here. An avid
like to move on and start hearing from some of them, because I know
each of them has some useful contributions to share with us.
So as I mentioned, we will start with Doctor Jack Winters, who has a
very long history and research and applications in the world of
telerehabilitation. And Dr. Winters is a professor of biomedical
engineering at Marquette University. He was principal investigator and
co-director of prior rehabilitation Engineering Center on
telerehabilitation, and also, more recently, at the rehab engineering,
[indiscernible] accessible medical engineering. 2002 through 2008. His
interest include applied Research in rehabilitation engineering, and
that developing more effective tools for 20 percent 33 had there'd be
as well as neuromuscular systems, musculoskeletal bottling and muscle
tissue remodeling. He has extensive publications on the topic including
his book on the rich emerging Telecommunications Technologies. DR
winter, I no you are here on the line and I believe you also have the
power point presentation that we are bringing up momentarily. I see it
loading.
There it is. Okay, Doctor Winters.
Thank you very much for the time the that kind introduction.
Can you hear me?
Okay. I am delighted to be here and I think this is an impressive
example of telerehabilitation, or at least the technologies associated
with it right here. And I just had a couple of comments that really are
intended to augment what you talked about in one or two aspects. This
light you see now, and I know it is busy, but there are three aspects
to it. All the talk talks about -- well, I was tasked to talk about
research, but my focus is going to be thinking of who the human
subjects could be for the telerehabilitation studies in the future.
Right now, hope is alive and we aren't able to dream again because of
changes in our country, and I just wanted to share some thoughts
related to ways of doing science and telerehabilitation in the future.
Based on frustrations and challenges and things that interests me that
hopefully will interest you.
Also on this slide is talking about the science behind -- the top one
was looking at the science behind optimizing we have strategies and the
intervention plants. The how and where and why. That takes a lot of
time and money. The other is looking at strategies for a lifestyle
Peter --
We have lost the audio, please hold on a second.
Testing?
David Pitcher and Kip both say it is back, so Doctor Winters, please continue.
The lower level is talking about optimizing the human technology interface. And that is really all I'm going to focus on here.
I am adding something to what [indiscernible] said, this is
complementary to what she said that I want to focus on accessibility.
Accessibility in my eyes, there are many definitions. The ability to
access a product or service for which there is potential benefit. And
there are a number of access barriers, and one of the things that is of
the about telerehabilitation, is it is helping hopefully minimize the
barrier of distance. There appears appears that are associated with
interface which we all know about and barriers associated with costs.
And every single challenges to have a different solution, so I will say
some general words about these.
In selecting the technology, universal design is great. One of the
things about telerehabilitation is, it is fundamentally flexibly modal.
And [indiscernible] [speaker/audio faint and unclear]. -- national
standard body for many years which involved many meetings which was
related to the Human factors panel the seceded with medical device
usability standards. And one of the things that became very clear was
that, most of those in usability Engineering had never heard of Section
508. And usability Engineering is a purely mature field. In the process
of maximizing usability for the masses, and document initially
[indiscernible] a population of eight or 10 or 12 or 15, you can't
diminish the [speaker/audio faint and unclear]. It is a challenge. Self
I want to just drop this idea in my comments, and maybe go on two the
next slide.
Telerehabilitation, we want to focus in the future a lot on
accessibility. We have a [indiscernible] encounter with a high
likelihood that we will have users with disabilities who are part of
the process. It is also highly likely that -- the biggest treat in.
From a usability perspective, the process telerehabilitation can be
included in both the name and [indiscernible] of the users but a lot of
these users have the versatility. And and not just talking about the
clans that have disabilities who may be in homes or other settings, but
the idea is when we think about the deployment of the future and when
we did about jobs and the like, and the provider may also have
disability.
If we go to the next one, I just want to raise the idea that in human
subject studies of the future, we might want to do have virtually all
of our participants on both sides of the telecommunication line have
disabilities. This is similar to what we have done or had done for
about 10 studies RERC and accessible medical [indiscernible]. Can't we
use these tools in collaboration with University of California
Berkeley, between them at Marquette University that we can't called the
[indiscernible] accessibly lead. What we did different was, of our
participants had disabilities. And I think the process, we not only
learned about how they would use medical products, but we were actually
doing very good disability pipes studying primary accessibility. And I
wanted to throw that out, because if RERCs are not having populations
in their studies with individuals with disabilities, the one is,
because the usability Committee will not be doing it. That is one of
the main points I wanted to make. And I wanted to distinguish between
visibility and accessibility.
Just to give you an example of that, and this is where I think I could
probably stop, because I notice that in yesterday's presentation, a
little bit of my work in the past was cited, and you were looking at
and partitioning studies into essentially these four studies that were
listed here teleconsultation, teleHealth, telecounseling and telehealth
care. And I want to design some studies in this area of the future. In
the area of teleconsultation, one of our [indiscernible] with the RERC
on two teleconsultation was because a number the staff had
disabilities, as they often had to adjust how we communicated in our
meetings. For instance, we had video conferencing available but it
continues it because it would have put one of the members of our core
team at a disadvantage because of poor visual site. I also had meetings
with someone who was deaf, and we ended up using text messaging for
most of our meetings because simply, neither of us was at a
disadvantage. So in teleconsultation, when have a lot of months that
are available, one thing I want to point out is, if you use them all,
he will find that one of the participants may be at a disadvantage. On
the other hand, having all of these modes can't really enhance the
potential for accessibility and you think about how to design a
teeseven consultation session. Forty-seven home care, I want to suggest
that, we have a shortage of nurses. Bills to have an intimate talent
and we also had a loss of as it turns out, retired nurses whose
eyesight and hearing isn't quite what it used to be. They're not quite
as strong as he or she used to be, but they may be very interested in
employment. And so on the telehome care aside, I am suggesting that not
only may be clients have disabilities, but the providers may also, in
the research studies that target that would be very useful and me help
extract some of the technical features and their strengths and
weaknesses for such applications.
For telemonitoring, there is no reason I can think of why a diversity
of individuals with disabilities could not be the monetarists. Most of
that is done Offline -- among the trees. Most of that is done Offline
and all of you are doing is extracting information and understanding
it. There is no reason that can't be done remotely.
I also wanted to take this opportunity two-point out that I noticed the
Web and Internet based and Really Computer based telerehabilitation was
far more popular in our survey. But I wanted to point out another
reason why that is so important for the future, and that is, underlying
the Internet is a lot of accessibility capability. You can use
different input devices, Deacon have many different products work with
a computer enhanced accessibility. When you tube videoconferencing, you
could be using a small remote that could be very hard for a lot of
individuals to use. Video conferencing technologies off of the shelf
are not very accessible. While what based have much more potential for
finding accessible solutions, because of that, and that is related to
telemonitoring.
The last thing I had to say was about teletherapy. And they don't have
too much to say about that. Other than one comment. This one on the
left there, that is the user. And this relates today activity we did
with Craig bender Hayden and his RERC and also Georgia Tech wireless.
And we reusing this remote Consul standard. And I would suggest that
the communities would want to think about that. One of the things you
see to the left there of the user and right above that, is being aware
of their abilities and preferences when you design your interface. That
can help personalize the interface, and I think that that could be
really helpful in terms of setting up interfaces telerehabilitation. So
really my take-home message is, relate to a desire on my part to say to
you, it could consider doing your research studies and have in a lot of
the participants have disabilities and have that be true on both sides
of the line. Those are my quick comments.
Thank you very
much, Jack. We just received a question here. He mentioned that the Web
and Internet is brought technology that can be used for a lot of
people. Can you address any privacy issues related to the use of that
technology versus the use of video conferencing?
That is a
great question and some of the a medieval to address that better than
me, because I could have address that very well Corps or five years
ago, but probably more of your staff are more directed to that now that
I would speak at this stage, so I wouldn't want to get a four or five
year old story. Is there someone there that would like to talk about
that?
Do you want to talk about privacy issues and the use of the Internet?
That may be addressed somewhat more with policy issues, because in fact
-- and I know that Mark suggested somewhat yesterday. It is a potential
issue, you are right, that we have not completely resolved yet.
Especially in light ups hippa Regulations and other governmental
regulation institutions that are here to protect us as consumers. On
the other hand, I know that a lot of transmissions occur, through a
variety of media, and I rarely hear people tell stories about privacy
violation. Now they of course be occurring and people not be aware of
it and therefore they're not be any impact. But I know on the Internet
in particular there is the issue of packing and access to systems
remotely.
Just mentioned using text messages between two
people, that could contain confidential information, so if you were to
do messaging on MSM or maybe Skype, that could be intercepted by
someone else. But Dr. Stillman may cover some of that tomorrow. And
Mark covered some of that yesterday.
Again, to take a
nontechnical perspective on this, all of us in our current
rehabilitation activities, whatever they are, currently are at risk for
some privacy violations anyway. Having a conversation between the two
of us with a door closed still presents some privacy issues. So it is
in some ways, some of the same issues we face when we move to
technology. It is not as if there were no pot, privacy issues before we
started to meet Corporate Internet or using webcams. Technology both
escalates them but also offers some [indiscernible] as well.
Jack, thank you so much. It declared Gore emphasis on what we need need
to think upon -- the accusal much into two clear Cure and kisses on
what we need to think about when we declare a evidence based set of
studies to document how it best works and who it works for best and
what technologies serve as well. That is very important to consider.
And I'd definitely agree with you. To design well and provide
technology well, you should look at a broad population of potential
users that has a broad library of abilities and disabilities, so you
are aware of some of the issues related to usability and accessibility.
I think we are going to a short break. By kayfour or five minute break, so we will be back at around --
We will be back at 2:32 p.m. and we will be right back with you with our next panel member who will be Philip Gerard.
(RERC on Telerehab is taking a 5 minute break at this time.)
Okay, I think we can resume. We turn next to our expert panelists Mr.
Gerard. And he is the manager of the Office of telemedicine with that
veterans and brain injuries Center, also known as DDBIC. His response
will for the operation and and and management of National telemedicine
services which the to assess and treat traumatic brain injury in active
service members and veterans. Mr.Girard has written and lectured on the
technological and advances that affect the people with those injuries
and his background includes 12 years of program development in Health
and rehabilitation and significant work with adults with brain injury,
medically fragile children and their families using telemedicine.
Thank you very much for being here today.
Thank you, Mike.
Your slides are up.
You can start a camera if you have it.
I don't have a camera. But I am hoping that slide presentation will add
additional support folks as we go. -- visual poor folks as we go.
This is a disclaimer, and to work for the Department of Defense and these are my opinions. They like me to mention that.
What I want to talk about today is, the continuum of care for service
members and veterans with dramatic brain injury, and for those that are
injured in battles these days, and they benefit from teleMadison
[indiscernible] often without even without them knowing. I am giving
specific examples [indiscernible] three absenting to support patients,
specifically those with dramatic brain injury.
Next slide.
The defensive veteran brain injury setting is concerned with the a
[speaker/audio faint and unclear] includes mild TBI and concussion all
the way up through severe TBI that resulted cognizant and physical
injury. We're interested every ^ level in setting from the battlefield
to military treatment facilities through two the SBA and community
retreat and return to civilian life or return to duty for those that
can. This is just a quick slide to show that the DDBIC works and
military sites and be a sites and we also part of Muslim community
civilian reactor programs. Our initial site was launched in Germany but
we have a number of military partners throughout the country. This
shows the continuum of care which Just [speaker/audio faint and
unclear] medical evacuation and Germany and back two the continental
United States, where they may have, depending on the nature of the
injury, or if they are a Pauley trauma patient that has sustained a
brain injury or something else, they may go to the Pauley, level of
care they makos to Walter Reed or at [indiscernible]. So there is not a
strict path for anyone patient that may be altered depending on the
patient, but this is generally the course that they follow.
What do we do as far as telemedicine? We use the term philosophy. All
of our telemedicine should provide the greatest benefit to the number
of people. A level of existing infrastructure and Resources if
possible, become self sustaining it support a holistic support from
health care.
We will talk about several TBI applications. Just talking on briefly
the ones in acute care setting and hopefully spending in the apartheid
talking about telerehabilitation.
The first thing that we offered was an electronic version of what we
called the nays scans for concussion. Often the service members in
theater will be exposed to blast or of vaulted accidents or involved in
the may have sustained a concussion, and we need to provide a means for
medics to assess concussion within minutes and then record that
information. In the past, they have always used these pocket cards and
attached it to the patient as they moved up the medical team.
What we have begun to do now is computerized information so they can go
through a checklist and do that concussion assessment. That information
is recorded and imploded onto an electronic dog tag that the service
member wares and in the information, a fact that the patient had a
concussion assessment that was done with them as they move up the chain
or go back to duty and realize, maybe they have had a three potential
concussions and given the mace on the number of times, separate
occasions, they were able to see that.
Next slide, the other thing that they do is, we provide in the
consultation through e-mail. And this is done and allows Upper deployed
providers to connect to traumatic brain injury specialist, will take
disciplinary teams of [indiscernible] experts, including neurologist
and Merrill psychologists and after this and others. Questions the
coming from theater typically involve assessment assessment assessment,
said the mismanagement or the IT recommendation to return a soldier to
2D or send them back for for their evaluation.
These consultations generally are done within five hours of the email.
It is female, so we are subject to limitations of transmission speeds
and people having full in boxes, but generally a response time is 24
hours and in general it is five hours.
This is more for this two the injured, but for those with severe TBI
that went to Walter Reed as a trauma patient, we will begin from the
moment they arrive at Walter Reed to Courtney with [indiscernible]
Pauline, the work of care, establishing what we call a clinical
transition reading. And that is a meeting for the trauma team at Walter
Reed to connect to the Pauly, a team at the VA site, and often as
possible we have a patient involved in the beating as low as family
members said they can get to know the team that they're about to be
working with as their chairman said that that work. This is also an
important aspect for follow-up, so the folks at Walter Reed can
understand what the outcomes were of patients moving out into the VA
system. And also as patients sometimes moved back for whatever services
at Walter Reed, they can have that coordination.
And at the VA level, you can have levels one, two and three of care and
as [indiscernible] closer to home, the same concept of creating one
team that works over distances using videoconferencing is extended. So
the Pauley trauma centers throughout the country are then connected to
the global to VA centers that could be in any state.
Next slide? One thing we are doing to more directly serve patients with
traumatic brain injury, and this is specific to military sites that may
have a burying assets stomach stomach burying assets equipped to manage
traumatic brain injury, piled [indiscernible] or concussion or those
that have moderate campaign stomach complaints, and disturbances and
persistent headaches and continuing systems. We are developing what we
call it a virtual traumatic brain injury Clinic and that is going to
feature interdisciplinary teams that can work remotely. The two of
course primary responders will be that TBI assistant and interest
practitioner and they will be supported by barrel psychologist to do
assessments and a neurologist and in the future we hope to bring on the
rehab component. This idea of extended TBI clinical services more
directly two the patient has already been done with success in the
peaty as the world through Walter Reed [speaker/audio faint and
unclear] teleBerra surgery where we had in local offices and public
physician work with a patient in connecting a neurosurgeon at Walter
Reed and trying to do conservative there is first before sending away
for surgical care.
So our virtual TBI clinic will be the one serving the northeast. You
can see in this picture, the different Army Medal commands and Walter
Reed is the medical command for that northeast section, but there are
other medical commands, and each one will also have similar teleTBI
clinics serving rural and underserved military sites or sites where
they do have the resources to handle TBI, but when patients and service
members return in such large numbers, the volume increases beyond what
they can handle. So the ability to overflow and try to connect to
patients will be served through the same type of program.
This is just depicting the clinical operations, and we need to go into this next slide.
Some of the clinical activities for the virtual TBI clinic include this
green papaya -- the basic screening for TBI, a review of record and
history imaging, a physical exam, which needs to be done in
consultation with a local provider, revealing stomach reviewing the
symptom complex and [indiscernible] treatment management and
evaluation. Cognitive and psychological evaluation, of course important
but not always essential two the care. Only 20 percent of the TBI
positive patients require bureau psychological follow up. It is a point
of some debate and then of course follow-up care is essential for the
program as well.
A couple of the key considerations in developing our virtual TBI clinic
is that TBI may have vestibular or sensory or cognitive problems which
will necessitate physical assistance by local provider. So these are
just soldiers and service members coming in the psychological
distresses, the actual ethical problems and -- actually had physical
problems and need to protest the in video interaction. Also, the
physical interaction of cranial nerves and the neurological exam itself
it really requires a hands-on approach. So for some types of what we're
intending through the virtual TBI clinic will provide help on the other
end, and our hope is, if the provider works with specialist, will be
able to increase their knowledge and we will know how to treat specific
symptoms.
This just breaks down some of the aspects of physical exams.
And ultimately, which would provide recommendations to the patients and
family and the unit. Return to duty and restrictions that should be
followed, the medication plan, symptom management strategies, depending
on what issues the patient may be having, education of course is vital,
and physical and occupational therapies, and ERA psychological and
cognitive assessment.
Phill, can I ask you a brief question about the previous line? Even to
that sometimes you need hands on assessments. Busey in the future baby
the use of robotics or other types of systems that could help with this
hands on assessment?
I think when you are talking about
examining someone's pupils and looking into their mouth to see a bit
midline shift, you could do those things in doing close-up views of the
patient. But when you're talking about the deep tendon reason reflexes
and testing a nervous response two a touch, that is a more interesting
area. It is always necessary to have a skilled physician assistant on
the end, you may be able to have a lesser trained person, but there is
some physical attraction in the physical exam at that is very helpful.
I wouldn't rule out robotics. They are doing surgical robotics and
other fancy works, so those things can be made to work but I just don't
think we're there yet.
Okay, thank you.
Okay, let's
move into telerehabilitation. And where of like to take this is, talks
starting with those things that a patient can do independently and work
up to increasing the level of support and more interaction with care
providers.
If we think about service members returning from duty, one thing that
we're providing to them is on line support. More than just a website
they can look at for information. We have designed what we call self
help web sites that is known as afterdeployment.org and they can go in
and look at the psychological effects that have happened to them after
deployment and what issues they need to face after they get home. Focus
on whatever topic is of concern to them, and they could have a E
library there to help them understand the characteristics of what
they're feeling and also be given the ability to read what they're
doing and how they're feeling in each area. One thing we are doing,
this after deployments I was actually developed by the dissent Center
of excellence health and technology directed, and a different component
center which deals specifically with TBI is developing a TBI module for
this site, and so we're in the beginning stages of that. So you could
go to the site already and see how helping service members with
post-traumatic stress disorder. And ultimately what happens is, you can
make yourself over time and see where you are at. Of course, the site
also provides large numbers of resources in places to go and things to
watch. If you are reading up in the red, and you can't see the need to
see a health professional. It doesn't leave you on your own but does
give you some ability to help yourself.
What we're doing with the TBI module is trying to help people
understand the relationship between TBI and PTSD. Many come back with
symptoms that could be related to either. Some maybe want to just sleep
or may not be able to sleep and we're trying to set up ways you can
deal with those specific symptoms but also caustically.
And then to understand the interaction of these symptoms, so if you
improve the sleep, you are actually improving or headache and in our
memory problems, and the converse is true, if you drink alcohol or do
things that may aggravate our mood or your car ignition, your
aggravating the other problems and reducing the amount of sleep as a
possibility for other symptoms.
And perhaps it is important to note that TBIs very widely in severity.
There are affected by your personal places, by your age and past
history of TBI, Cure resilience and in Norplant and goals and
everything kind of works into that, so we're trying to illustrate that
there.
And before I go through this slide, I just want to imagine, I think
that most people understand traumatic brain injury realize that TBI
patients may be isolated by many different things. They may be isolated
geographically, economically, by physical disability or even socially.
They may say or do auditing this or any combination of those things. So
what can we try to do is create opportunities for people to interact
with one another in create ability to interact with one another.
So two that and we're trying to develop more guided social networking
opportunities at a community portal where service members, specifically
those with TBI can get help to share with others who may have the same
challenges out in the community. Certainly, have opportunities for
social networking and they are already out there. They already talked
about this today, connecting with user groups and sharing experiences.
But the military and those who are then deployed have certain
understanding of their deployment experience and what it means to not
be a service member if they are now a veteran. So they're trying to
pull together groups that understand those things.
Then we talked about cell phone, the use of cell phone rehabilitation,
and this is something we are getting into also. They're trying to take
this two the next level of providing remote monitoring and care and
connecting in this case, what we're doing is connecting National Guard
and reservists who have sustained a mild or moderate TBI but are still
in the Guard and able to function but may have continuing symptoms,
memory problems or other issues of concentration or Cure irritability
problems associated with TBI. And may need reminders for care managers,
platoon sergeants or even a centralized TBI expert to follow what is
happening to these patients over the short or long term, depending on
what is needed. And this is something we are rolling out with
telemedicine Advanced Technology Research Center, also known as
Patrick.
And this shows the interface between the patient and the platoon
sergeant and the care manager, plus, less formal providers that we hope
to connect.
I wanted to put this in. This is not part of my current work with the
DOT and the VA, but before I was with the DOD, I was with a
rehabilitation center where we did videoconferencing our specialist out
into the community to help serve patients. And what we found was that,
when we hooked up our site and provided the wiry and network resources
to the brain injury Clinic is that, if we just put in a video camera
two the families out in distant parts of the country, we were able to
involve patients not only in the nightly kind of good night calls but
the family members, also involve the family members in that their peace
themselves. So we found we had a couple of key findings. Now this is
not a study, this is anecdotal, but on at least two occasions we have
noticed improved therapy outcomes, and had a couple of breaks through
moments were those with minimal movement ability were able to move
their Lake for the first time -- there Lake for the first time. It is
just general interest I guess in seeing your family member improving --
and proving to than that you can actually achieve. Quite frankly, the
folks we reserving or in long-term rehabilitation, and sometimes were
getting sick of the therapists that were working them and challenging
them on a daily basis and develop almost a brother and sister
relationship with these people, so we've put the family member in the
next, it can add something special to the therapy session.
Even more importantly than that, we were serving a group of medically
fragile children many of whom were nonverbal. And to communicate with
them, it involved a phone call with it. It all the talking and the
child did all of the listing. There is no to we communication except
the real expression by the care manager of the purples that are
happening on the side of the child. But when you happen to add video
conferencing into the mix, we were able to have the parent or the
family, depending on who they were, speak with the child and then get
all of the nonverbal from the child back to them and that was very
special. And of course, any time you had video in those non burbles
between the care providers and families, you are increasing the level
of care as well.
So I want to share all of those things with you folks. There is in a
lot I could say about the planet, I was on the Technology deployment
level in all of these programs. I am less involved in the actual
payment of services, so there may be others that can speak more
knowledge of the stomach knowledgeably about how those services are
paid for especially in civilian cases, but I would be happy to take any
questions. Thank you very much. I think those are some very good
examples of technology that has been applied in the moment in response
to our service members coming back from Iraq and Afghanistan. And
clearly you are using a variety of technologies that are a best fit,
and also I think pushing the envelope and developing new ones because I
am recognizing you're have some very complicated clinical needs and
your developing a very complex set of technologies and applications.
Thank you very much for sharing that.
We did have one more polling question. It is question number four,
Ashley. What is the most frequent application that you use
telerehabilitation for? And that is coming up.
Is almost 3:00, and we have one more hour, or less than an hour, so we
have three more expert panelists, and we also know that they will have
some additional questions come in.
We need some more in
answers there. Staffing the beatings and follow up seems to be used
quite often -- [speaker/audio faint and unclear].
As we are
waiting for that, our next expert panelists is Patty Campbell, and we
should probably I think move Patti over. If you want to set that up.
Patti Campbell is a certified rehabilitation counselor, licensed
professional counselor and instructor at she has worked in the field of
neuroscience and behavioral health since 1981. Petty has served both as
a practitioner and administrator in Pennsylvania and New York well
received efforts in world communities throughout the United States.
Since establishing a private practice in 2001, [indiscernible]
Strategic team the ball and and long-term support has successfully
impacted more than 300 individuals and families living in rural
intermix. Mrs.Campbell is the primary matter of the Patricia Campbell
and Associates and an adjunct lecturer for the Pittsburgh School of
rehabilitation Health and sciences. I really wanted Patty's input today
because she does provide some hands-on practical services in the
community, often in rural communities, and I know that Patty has
started two, on her own, reintegrate [indiscernible] to make things
easier for herself and her consumers.
Before you go on, I think we got a good number of answers in the last
polling question best, and we see that people are spread out a lot on
follow-up activities in terms of applications, which is good to know.
Because politics often really tough to do.
Patti?
Thank you so much Mike and Linda, I am thrilled to be here today to
talk with all of you and also to see that so many rehabilitation
counselors are joining us at the conference. I am [indiscernible] that
I am able to it actually answer some of the questions that you have
already asked.
First of all, I do believe as I am talking, he may find some answers to
the usability of cell phones. And maybe able to provide you some
information concerning confidentiality, and your consideration with the
code of ethics as well as HIPPA, and also the vocational and her
stomach implication in using telerehabilitation. I noted that in the
question that you were providing to us, and hopefully I can touch base
with them.
I thought it would be helpful for all of you if I were to give give a
bit of information on exactly what I do, because although I am a CRC
and a LPC, my work is slightly different from others in my field. I am
in my own private practice, which came about after approximately 20 or
25 years in hospitals where I had served in the rule of an
administrator and practitioner. And I went into my own practice because
[indiscernible] were underserved. So my involvement in the area of
technology has really been very simple, it has been that necessity is
the mother of invention and that is how I have become familiar with a
number of the different notes that I will talk about today.
Perhaps a battalion of about the types of cases that I work with, they
are all complex. All of the cases. But nature is that they have a
tremendous constellation of needs and access to individual services is
very poor. When a person involved with the case, and they are
challenged by many complications. It can be the consumer is location,
and the location of the specialist that the consumer needs in that
case.
Also, my job is two build the appropriate team and create a network
through which the consumer will Optima the benefit. I am actually seen
by many of my colleagues as a broker of services, if you will. Many of
the consumer is that I work with R living in a world communities, and
that creates a tremendous challenging. Many of these are incredibly
isolated in addition, to their disability and other medical
complications. An example of this is in the area of pediatrics, which
is still an area which is both understudied -- bariatrics, which is
under study and underserved. Some of these clans which I have served,
some 400 or 500 pounds, they are unable to leave it from where they
live. Transportation is not available. Many of the consumer is which I
serve also need the support of specialist which may be located not only
hundreds of miles away but also perhaps across the country. I also find
many of the consumerist I work with have dealing with the issues they
are dealing with, if not for most of their lives, at least an average
of 10 years. Many are on the caseloads of MHMR staff that are out there
doing the best they can with multiple diagnoses and little support to
not only understand what that leaves are about two help them to treat
and supports the individuals. Now that he give you an example of
perhaps a few of these cases. Now and do happen to have some
information on the dramatic and often dramatic. And that perhaps could
be a primary interest of mine. One of the areas that became very strong
in my area of concern years ago is the fact that no one is immune. By
that, let me give you some examples. Age 42, juvenile diabetes. Status
Post, cancer, treated with radiation and chemotherapy. Leave the edema
is present. -- flip the demon is present. Retinopathy [speaker/audio
faint and unclear] one pancreatic transplant. They then suffered a CDA,
a stroke. Three years after the last CDA is involved. That person lives
approximately 12 miles from last metropolitan area.
Another case, at age 32, a woman has Down's syndrome, cardiac complications and traumatic brain injury.
Another individual, each 41, Advanced show grands syndrome and has
survived 19 surgeries and sustained a traumatic brain injury in an auto
crash. And my fourth client, which is someone I explained here, which
is very typical in out there and underserved as well, age 22. At an
early age, they sustained several sequential traumatic brain injuries
as a result of sexual and physical violence. She is also dealing with
substance abuse and presented to the medical system after a crash in
which she suffered both traumatic brain injury in the third degree
burns over at least 54 percent upper body.
These are people that are out there and they're the begin world
communities and they need a lot of specialized help. The question has
been, how does this help them to these individuals? Because as you know
and I know, these specialists are not able to be there and they're not
able to travel to the metropolitan area. Technology is literally
bridging the gap and it is a very significant gap between these
individuals and the support they need. And though I and oftentimes are
able to locate very good OT, PT, and speech pathologist in the world
community, ty, that has not been the tallish army. These are providers
who have very traditional skills and really are meeting advanced skills
in the areas of medicine and therapy that the consumer needs. And so it
is very important that they are also connected with other therapists
that have those skills that they're looking for. It is also very
important that there are other specialists in medicine such as
dendrochronology, oncology, rheumatology, neuro psychiatry, anesthesia,
Internal -- neural psychology, and not just a neuropsychologist, but a
narrow psychologist who specializes in stroke or traumatic brain
injury, learning disabilities, forensics, Downs syndrome, but so
retardation. These people are out there and the task is two find them
and bring them to the person who needs their help.
Psychology and counseling. Also-- substance abuse, bipolar disorder,
mental-health, traumatic brain injury, and abuse and marriage, and also
to bring rehab engineers and they're wonderful creativity two the front
line where people need it.
So this is the task and my job is two build the team around these
individuals [indiscernible] individuals and that is that they must be
open-minded, they must be enthusiastic, and the consumer. And not only
to act with initiative but to look for ways to make new ideas work and
not for reasons why they want. If you are not going to be part of the
team, then your basically out. We are here to build a team.
Let me give you an example of some of the things I use and they are not
complicated to build these teams. And we're talking about very
complicated cases where specialists, education and support are brought
into their homes through technology. A virtual conference room, which
is very very easy to set up. They're not only companies out there
providing this service, but it can be set up the Interior owns cell
phone. The use of cell phone. The speaker system in the cell phone,
text messaging, and the e mailing, the ability to take pictures on
yourself on, and for the individual that was out there that was asking
the question about usability of cell phones, I offer my support to talk
any time, E-mail me, and we can definitely talk about that. That worked
in areas of the planet rissole funds have been offered as part of
Employment and alsonot -- opportunity to use the cell phone that is out
there and that would be more than happy to help talk to you about that.
The
Internet and e kneeling, it is absolutely wonderful and it is extremely
wonderful for people with cognitive disabilities. And the message off
and that is for a whole host of cognitive issues.
Whenever you are also using a different forms of audio and visual
recording, that is excellent for the use of both immediate feedback two
the consumer, being able to carry that over two their nests in remote
areas, and Porsche family education, and it is also excellent to show
progress to individuals down the road for follow-up. We use a lot of
PDA is, we have the practitioners that use PDA as as two the consumers.
I do have to caution that as wonderful as a PDA candy, it is only as
good as the user's ability to use it. That is the huge costs in there.
Assistive technology is wonderful and it does work, and it is possible
to have we had Engineers that have been open to come to individual
homes and do the initial set up, and all you have to do is get the word
out there, you'd be amazed at the tremendous providers out there that
are willing to offer their skills and talents, and once it is sapping
up -- set up, text messaging and emails and phone calls can all make it
work. The bottom line is, you can do just about anything you need to do
with the opportunity of telerehabilitation. And I want to be very brief
on my comments here because I would like to leave more room for
discussion. So my final comment here are really for all of you to
understand and to know that it is extremely important that, as if a
field in rehab counseling, and for all of us dealing in rehabilitation,
it is critical that we increased the promised -- in masse two the
underserved.
Thank you very much, and he made some very good points, 1I would like
to highlight because I am not sure it came out today, but many times,
telerehabilitation offers additional opportunities that face to face
does not, and your example was, individuals with coveted disabilities
who often process information more slowly than others after of that
delay is natural, especially in Ealing or even in instant message Chat
allows an opportunity to present what they have experience and what
they want to present back without the pressures up face-to-face
interaction that we normally have, so it often offers advantages
sometimes.
That is a good point and it is important and almost a powering for the
individual to learn and be able to use the Internet, text messaging,
appealing. That is. Powering and very important for the consumer to be
able to use these two terms and not just the provider.
Thank you very much for your observations.
You are going to move on next to our expert panelist great trainer.
Greg is joining us remotely. But Italian a little bit about Greg. Greg
was in a diving accident in 1999 resulting in a spinal cord injury. He
completed his rehabilitation at set of stomach to pretend in Atlantic
Georgia and received his bachelor's degree from Penn State and
president and his master's degree in rehabilitation counseling from the
inner-city of Pittsburgh in 2007 along with a rehabilitation
Technologies certificate. Greg is a member of the National
rehabilitation association. He is the owner and operator of it rehab
counselor.com and vice-chairman of the Consumer Advisory Council, the
opposite of vocational rehabilitation for Washington, green and Fayette
counties in Pennsylvania. Greg was awarded the 2008 Department happens
award from the Pennsylvania Association of rehabilitation facilities.
And break, we're very thankful that you could join us today and we are
eager to hear your comments.
And we can see you.
Okay, great. I don't have any slides but everyone can see my bright and
shining face. Protected think the authors for inviting me to
participate today. Telerehabilitation has the potential to affect the
lives of many individuals with disabilities and name of led to be a
part of this discussion today. A reading of the paper of today's
discussion, I thought the authors did a great job explaining the many
options available in telerehabilitation and the need to standardize the
practice for clinical practices.
As a user of assistive technology and a person with a spinal cord
injury, I had the opportunity to use the computer for my own rehab, but
also with others have done for the disability community. For example,
the wheelchair [indiscernible] or the disability Carnival or other
resources being used every day. It would be great if resources were in
place so that individuals could receive professional services
[indiscernible] directly of inpatient care or treat it. And this paper
[indiscernible] which is very important. The offer is kept in mind that
if the --
Greg, I believe that we have an audio problem.
Could you hit the hands free button because we have an echo with some
of the audience.
Okay, detect.
I think it did.
I apologize for that.
Let's see. Stressing usability and universal design, the authors kept
that in mind. The Klan or in abuser may not be the only -- the client
or in the user may not be the only person with technology. This
morning, I did not realize I would use a landslide to participate, I
thought I would do everything over my laptop. I had it set up with a
complete different room. And I and by myself all day that I have an
attendant come in and pick me to lunch. So I had to have my attendant
break down my laptop and move it into a different room that is closer
to a telephone. Even though I have a fairly proficient computer user
and self-proclaimed tech group, I people to participate today if I
could explain to someone how to break down my laptop and plug in my
trackball, so we may be relying on attendant care or other individuals
to help set up the telerehabilitation conference for who we are trying
to serve.
Another thing that was pointed out by Dr. [indiscernible] today was, we
don't have to reinvent the wheel when it comes to using technology.
Individuals were comfortable with technology such as the internet or
cell phones or instant messaging or would cancel or PDA can make an
easy transition to telerehabilitation. Chances are they are already
using this for social networking or disability advocacy. I myself use
myself on just to remind me when two take medication in the afternoon
so I don't worry about it, and I take it every day at the same time so
it is more effective.
And I have thought about that wasn't a rigid today was, using
telerehabilitation, individuals as a group, People with disabilities
are the least likely to use the Internet compared to any other group in
America. The only research that I could see was from [indiscernible]
with a disability with [indiscernible] access to computers at home, and
when you're talking about use of computers with Internet, the gap is
even greater and present have access at home compared to 38% without
disabilities. A lot of the technology doesn't cost a lot of money but
when you're talking about people with disabilities, we're usually on
fixed-income said have got a lot of discretionary funds to pay for
itself funds or pay for an Internet connection, so that they be an
issue of concern.
That being said, if this technology can be made available to
individuals, I believe it has any immediate impact. Telerehabilitation
has the ability to bring a licensed professional into any home
throughout the world, and that says a lot. There's a lot of information
available on the intranet, but it may be from less reputable sources or
just from and users of, try this or tried that, but I'd like to see
licensed professionals putting that out directly out of rehab work
directly out of treatment so the individual with the disability does
not have to search on their own and make it less than quality
information.
I believe telerehabilitation provides an invaluable service and of like
to see these services implemented and standardized as soon as possible.
That is all I really have to stay and I appreciate the opportunity that
everyone has given me to speak today.
Those are all great
poets, especially the point being made that only 10 percent of people
with disabilities have the Internet at home. Would you suggest another
type of technology that is more widespread use to be better to start
off with? Or what could be a potential solution for that, or even reach
the time until all people have Internet at their homes?
I
think so phones are more readily available, and cheaper to start off
and maybe purchasing the computer or purchasing a monthly contract for
the Internet. Bonds services such as cricket that are pretty
all-inclusive for not a lot of money may be a good solution. I don't
get a kick back from cricket, but it may be a solution or service or
something like that.
Greg, thank you very much for your
comments and especially your comments about this Digital divide, so to
speak. And another came up with some of the comments the other day
also, and certainly, people have [indiscernible] always need to involve
people with disabilities in our research activities as well as our
clinical, and I know that many involved in that building in the cost of
technology two the research project because I know that many people may
not have computers for broadband connections and so we have to provide
that as part of the research project to make sure we can kind of level
the playing field, but that's still [indiscernible] advocacy here for
changing people's access to technology, because ultimately, it is much
cheaper for people to not receive services and not be a part of the
community.
Absolutely, and just getting the finding and the
people to the computer and broadband, that should be a major concern.
Accessibility is getting better at being built into systems. If we look
at distant, they come out with distant voice, and delete it will
eventually take over strike and naturally speaking -- Dragon naturally
speaking, it works quite well and it is already loaded with
accessibility features.
Again, thank you very much for your comments. Those were right on target.
That we can basically ask you to enter the next question. It kind of
goes forward on what you are entering. Question number 10, it is, what
is the biggest barrier to using telerehabilitation for consumers? We
have two questions, and next we will ask it for the clinicians. So this
is the biggest barrier to using telerehabilitation and technology for
consumers? Is that the lack of adoption? Is it a problem using the
technology? Is it the client's aid to that is an issue, the lack of
access to technology or a fear?
We see a lot of people entering lack of access.
I would assume it is a cost issue. The technology is readily available,
if you know what to get. But there are a lot of high-priced adaptations
that may not be necessary, or may not even work until we get some money
to evaluate the client and find out exactly what he or she needs. Cost
is major barrier to many, in my opinion.
So if cost is an
issue, do you have suggestions on some ways to deal with that? Are
there special resources that [indiscernible] can look for when you have
a disability and are in use for technology besides, probably the
biggest one is the vocational rehab.
The lending library is a
good source. Pennsylvania. Individual consumers can try accessible
technology before they purchase it, so I would recommend the lending
library as a good resource.
Interesting.
And then,
one other polling question before we continue to our next panel member,
the number nine, but is the most important barrier to using
telerehabilitation for clinician's.
Is insufficient knowledge
about telerehabilitation? Discomfort with the use of remote Services?
That you are not sure that you will get the right output from your
technology? Is it low interest by the clinician or lack of funding
perhaps? Legal concerns? So, the lack of funding again, we're looking
at cost year.
On both sides.
On both sides, so I
think there is definitely a need for more outcomes studies that we will
be saving a lot of money by implementing technology, even if you think
about this conference, we have hundreds of people calling in and it
would be very interesting, as Mike mentioned Offline, What kind of
funds that we're sitting here.
So we will go to the next --
we will move you back over here so they are the user at [ Indiscernible
] Laxalt a project of firm in Pittsburgh.He has been involved in
research and human factors work for hospitals and home use as well as
for consumer safety end products. He has cut user techniques and he is
the co-president of the Pittsburgh Association, and he has a
concentration in product design from Stanford University.
I
am very honored to be on this panel. I thought that I would try to make
my comments brief given that we are running into the discussion time
out. What I it is usability research -- what I'd do is use ability
research. I have none studied these groups but I have done this for a
wide variety of projects. So listening to the discussion here reminded
me of some projects that I have done it and some of the things that
were brought up by other speakers that I wanted to hire late. You
mentioned page informs and I am doing a project on dialysis and we
encountered a lot of these patients forums. The most successful seem to
be moderated by clinicians. In this seems like a aspect of the
telerehabilitation that should not be missed. And that is the community
and support network that builds up by patients talking to other
patients especially in a context in which clinicians are able and
understanding and to create a foster an environment of care and
communications. So those types of communities should be -- those kind
of community should not be missed. And I want to second Dr. Winter's
point unpicking user groups carefully. I don't want to reiterate that
point but I think it's fundamental that the correct user groups are
selected otherwise you will end up deciding something that does not
work very well for the people better it is intended to help. There was
one thing in Phil's presentation. He showed an image of the electronic
to base. And I notice that the original mix was was just a paper base
survey period were as the electronic version have an image of the party
on it. of the body on it. This is an important aspect of usability that
should not be missed. Internet technologies can integrate video, sound,
images and annotation to create Communications that go beyond simply
taxed. And this is by no when we are asking patients to solve report
issues -- this is vital when you're asking patients to self report
prepared and things like complex medical terms can be confusing for
people. And these sorts of technology that integrate video and pictures
can go a long way to increasing the usability of those sorts of tools
with. Let me see year. I have several notes.
So Mike talked
about looking at task analysis. When that studying the problems we're
trying to solve, instead of throwing up a video screen and trying to
recreate the face to face interaction, he talked about looking at the
task at hand and tried to understand what sort of communication is
needed I want to build upon that. It may be useful to take a service
designed approach opposed to a product design approach for these types
of problems of. And for those are not in the field, I noticed that
there are one or zero designers here on this conference. The product
design approach is looking strictly at technology to solve these
problems. And the surface design approach can be more holistic.
Originally, it is there to work on the design of the services which
involves human contact and that is often supplemented by technological
are -- Art of wax. If you think about banks, you have human tellers,
ATM machines and online baking services that creates one integrated
services. Sometimes they are not free will integrated. And that gets to
the importance of looking at this whole mystically and designing it
holistic Lee. So taking a service design approach that understands the
face-to-face contact that clinicians have. And integrating data with
products and integrating that with technologies. That may provide a
better frame for approaching the design of these types of
telerehabilitation s ervices. The last point that I want to make is
taking a step back and looking at the overall structure of how these
technologies are implemented. And maybe it could be thought of as a Mac
vs. PC approach.
If you're watching on the screen you will
see a lot of Macs here and I don't mean that one is better than the
other. I think there is an interesting approach that both of them take.
And the PC approach may be more helpful to the issues at hand with
telerehabilitation. Let me define what I mean by the Mac approach. That
has one company that has an integrated few of the entire process. But
because they are one company they designed things that work for 80 or
90% of users. Doing 80 or 90% of their tasks. It is a very easy to do
something that most people want to do. But when you run into exceptions
often times they can be very difficult. They like having one button for
the next step. But if your next step is not the next step that the
invasion, you have to dig through the menus and figure out where you
are going to go. The PC approach is to create an ecosystem in which the
various components can be added or taken away. So you have a wide great
deal of hard work Tauruses, like you can get a small laptop -- you have
a great variety of trees is such as a "toughbook" and those are not
served by the Mac approach. I have this in my notes. Dr. Winter was
talking about using these different communication tools for different
means based on the level of -- based on the various disabilities that
he was encountering. He talked about having a meeting with someone who
was deaf and moving from a phone conference to instant messaging. And
also talked about people who are visually impaired that they decided to
move to the teleconference as opposed to a videophone. And those issues
of acceptability are important. You don't want one person to feel left
out within the ideal case be one in which everyone could use these
accessibility technologies or the level of communication technology
that suited them perfectly. And there was a system that enabled
translation, which speech to text, speech to text into Braille that was
working in the background to make sure that each person could use the
parole or the mode of communication that was best saluted oh suited for
them. So maybe instead of thinking about these products or technologies
as integrated, you know, Mac it like objects, maybe we should think
about creating ecosystems like the PC. And there are standards for
integrating these technologies to gathered to create the best possible
world for those users that we are trying to serve with. So I think
those are my comments. We should probably move to the questions now.
There are probably several of them.
We would like to take time to ask questions and at the same time, Onmy,
I would like to thank you. It was a great fish and from where you came
from. Are you going to design a system -- it was a great addition.
I would love to do that.
Okay, great.
I think we have about ten minutes before we turn this back to Dr.
McCue, although some of us have some comments and questions to pose.
Do we have anything from the audience.
We have several questions that came in with.
Alexandra Anders has a comment, while there is definite lead a
disability Digital divide, there is more current data. There is a
website that she sent us to, rtc.ruralinstitute.edu we. And all of
these will be posted on the web at some point.
And then we see some other --
I have some comments, I know that they have done some research on
Internet use prod the and part of that research has been on individuals
with disabilities are access to Broadbent.
Greg, are you still on the phone? My guess Mike.
What types of technologies does the lending library offer?
The lending library went out all types of the system of technology.
They have hundreds of devices. They lend out all types of assisted
technology. It is due out Pennsylvania. I am unsure exactly who fun
tidbits through the assisted technology foundation of the Internet. And
if you contact your local independent living center, they would be able
to get you some more information in your area.
I hope you heard that, Evelyn.
Let's see. There is another question from Harriet James. The issue of
costs is the main it main issue. Most people are balancing the cost of
a vacation -- off medicine and food. And what we say is that
technologies to not have to expensive to provide a promote services.
You could save money on travel and instead use the fund to send a text
message on the phone or have a remote phone call. So there are
different ways to solve that. But there still needs to be more research
there.
Onmy?
Can I add something to that? Is
interesting to look at Third World countries like India which is the
example that I know the best. There are other parts of the other
examples in other Third World countries. They have taken a completely
different approach to developing these technologies because cost is
such a extreme constraint for them. They face the same
telerehabilitation challenges were much of their population it is rural
and the doctors are in the cities. I cannot provide examples but I know
that there are some out there. Maybe we can look to those countries to
see what they are developing there to help address the cost issues that
people are finding here as well.
Yeah, I support that. I was
at a conference and this is related to telemedicine. They were
providing medical and by is in the rural areas. So we can learn from
telemedicine and see how we can adopt those technologies and how we can
apply that to telerehab.
That is a good point.
I
know a subset of people who abuse social networking sides and self
management programs -- who use social networking sites or other self
management programs. So there is a disconnect. If you read carefully
how people were questioned about their access to the Internet, because
many people do not own a computer or have an Internet connection and
their home. So if you ask it that way, the answer. But many of those
people do find access to the Internet in settings like libraries and
many of them will open the firewall to use some of the programs that
are available on the Web.
There is a similar question -- this
is a difficult name [ Indiscernible ] from the Philippines for on
living in Asia and how does telerehab, how can it reached us when it
comes to the availability of technology? And that is a technology that
we see that we use in telemedicine and me that we could form a solution
there.
This issue has come up earlier today and in our other
sessions also. I don't think that this is a telerehabilitation issue, I
think that this is a rehabilitation issue in general. We have always
been behind are federally funded counterpart or behind some areas -- we
have been behind buildings are have more services. And the only way
people have gotten services despite advocacy pinpointing of the fact
there is a need. Many things that Patty Campbell talked about,
identifying a need and the willingness for someone to bridge that. And
in this case with technology and demanding that we bring the technology
poleward or find some ways to bridge was financed gaps. That is not a
telerehab problem, that is a rehabilitation problem in the U.S.. It's
an issue in the United States as well, I don't think the rehabilitation
approach is that we can do it because they don't have the money. We
say, we have people who are sitting at home but could be employed, one,
too, and three. So that is the independent living movement in
rehabilitation. Some people stop a step in the status quo and literally
took to the streets -- people stop accepting the status quo and said,
we have to change the institutional settings and policies. And that is
issue applies to that aspect as will appear it is not an easy answer
but it is our history of rehabilitation.
I have to agree with
you, completely, Mike because one of these services that I provide are
funded through insurance. They are funded through various
non-traditional forces. And although there is an assumption that many
of my services are three state CR, that is a minor source of funding.
There are trusts and foundations initiatives. There is grant money,
there are all types of structures -- different structured types of
moneys that are of there. I think that first, unfortunately or
fortunately, you have to approve and then negotiate and mediate with
the papers that are out there. That the funding is needed. But
somewhere people do need to provide the proof. And in order to do that,
you have to be willing to search out nontraditional funding. And it's
not easy, but it can be done. It can be done.
Another way
could be to provide more evidence that telerehab will save money. And
with that -- That is another way to educate policymakers on the
advantages.
All right and browsing through some more
questions. Again, we will bring these questions on the Web. There were
some resources that were highlighted off. Speakers have mentioned the
need for research and publications, can you suggest anything for us to
publish small scare case studies that are not sufficient for. You
journal's? Mike yes, we can.
-- that are not sufficient for peer review journals? My guess not, that is exactly what we need.
If you perform telerehab and you're using your cell phone, we would
like to hear from you and for your experiences and what applications
and you're using your technology with so that we can't use all of that
and provide evidence to the policy makers -- and we can use all of that
to provide evidence to the policy makers.
And with
telerehabilitation, one of the challenges that we face is we know that
people are they shooting some remote service activity usually out of
necessity of as Patty describes. But they are not in the role of a
primary researcher or did they have the time or the orientation to
publish. So I think it's a good amount of work being done and lessons
being learned by some of us somewhere but it's not consolidated into
anyone setting. So we do in this field the more opportunities to share.
And yes, case studies, and in some ways they will add up to a research
base as well. So we hope that our new journal, eJournal, the
International Journal of telerehabilitation will provide a general of
that will.
And finally, before we need to head back to the
directors, we are also working on a web based tool for clinicians to
collect so many case studies and to provide a knowledge base so that
you can select a certain technology and select a certain publication.
And see how you can make that work for a user population. So any case
studies that he might have, I would be very appreciative if you could
e-mail that to Mike or myself. And all our information is on our
website.
So do we want to invite any of the panel members Tuesday closing remarks -- to say some closing remarks?
Thank you for all of you and everyone who helped organize this.
Thanks to all of the panel members. We appreciate or and input.
We have a good set of comments in this made this a much richer
experience for all of us could we will turn the spot over enough to are
assistant directors -- we will turn this back over now.
Okay.
Is it coming up?
Hello everybody. This is Kate. And I am going to tell you about
tomorrow's session. Will it is directed to areas of policy issues and
research tools. There has been so much discretion about Third World and
International today. Tomorrow is a panelist including myself have been
very involved with the U.N. Convention on the rights of peoples with
disabilities and the international classification and the rural report
and who will report on disability and the International
Telecommunications Union and then down to the various country levels.
Our panelists have great expertise in international and national
policy. We have Alexander who is really an expert on rural
telecommunication and has great depth in other areas. And we have Dina
from US HHS, and we also have Dr. Larry Wexler who works at the
Institute here in the University of the Pittsburgh Medical Center and
has the telemedicine unit. And we also have Cynthia, who among other
contributions have served as a consultant to the National
Telecommunications Union and fall Thomas who is a lawyer and one of our
premier of lawyers on reimbursement matters. So we hope to hear of a
very interactive and inclusive day tomorrow. You look forward to seeing
you then.
Thank you and are there any other additional reminders from my colleagues here?
Don't forget the evaluations, please. If you want to get your credit. Are there any other reminders?
Okay. We will send off to day and look forward to seeing you tomorrow.
Bye.
[ event concluded ]