Development of a Service Delivery Protocol Used for Remote ...

ORIGINAL RESEARCH

Development of a Service Delivery Protocol Used for Remote Wheelchair Consultation via Telerehabilitation Richard M. Schein, M.S.,1 Mark R. Schmeler, Ph.D., O.T.R./L., A.T.P.,1 David Brienza, Ph.D.,1 Andi Saptono, M.S.,2 and Bambang Parmanto, Ph.D.2 Departments of 1Rehabilitation Science and Technology, 2 Health Information Management, University of Pittsburgh, Pittsburgh, Pennsylvania.

is a new field that can only be measured by its long-term impact; however, its success can be looked at by its development and implementation into everyday clinical service delivery. Key words: remote wheelchair prescriptions, service delivery protocol, outcome measure tool

Introduction Abstract The purpose of this paper is to explain the development, methodology, and implementation of an assistive technology (AT) service delivery protocol using a telerehabilitation consultation model for evaluation of remote wheelchair prescriptions. The provision of wheeled mobility and seating interventions can be complex when considering people with intricate seating and positioning needs, environmental factors, and wide array of product interventions. The availability of qualified practitioners with specialty expertise in this area is limited, especially outside of urban areas. Therefore, people are potentially isolated from rehabilitation services due to geography or physical limitations. A repeated measure study design is used to evaluate the service delivery protocol measured by the effectiveness of wheeled mobility and seating interventions provided in a remote location by a generalist occupational and/or physical therapy practitioner with consultation from an expert therapist via interactive teleconferencing. Effectiveness is measured by magnitude of change and scored by pre and post scores of the Functioning Everyday with a Wheelchair (FEW) outcome measure tool. Two model programs have been specified and are currently implementing the service delivery protocol. The live interaction has enabled remote therapists the ability to exchange personal and health information to experts in the field from an urban facility. The impact of this service delivery protocol will be augmented as it is to be launched and replicated in three additional sites. Telerehabilitation

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oving into the 21st century is a time of innovation for not only telecommunications technology but also the assistive technology (AT) field. This is brought about by partnerships between rehabilitation specialists, manufacturers, engineers, and most importantly the consumers. It is estimated that AT devices have doubled over the past 20 years.1 One of the most productive areas of new development is seen in wheelchair mobility, where choices for style, features, and controls continue to evolve.2 The wheelchair industry itself has grown into a competitive halfbillion dollar industry serving a growing market of nearly 2 million wheelchair users in the United States alone.3 Demography studies of disability show that there are 12.5 million rural Americans who have disabilities in nonmetropolitan areas who are in need of rehabilitation services.4 The Department of Veterans Affairs predicts that this number will increase by 22% over the next 10 years.5 Worldwide, an estimated 100–130 million people with disabilities need wheelchairs.6 Remarkably, less than 10% of those who need a wheelchair own or have access to one.6 Wheelchairs are used to enhance function, improve independence, and enable a person to live at home and within the community productively.7 The assessment of the user’s needs, matching the user with an appropriate wheeled mobility and seating intervention, and fitting and training are essential for successful outcomes.8

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SERVICE DELIVERY PROTOCOL FOR REMOTE WHEELCHAIR CONSULTATION

Selection of an appropriate wheelchair is commonly viewed as complex, a byproduct of different theories of seating and mobility as well as abundant options to address users’ needs, skills, and resources. Decision-making is difficult because of adjustment to change, the unknown or inexperienced reality of new impairments, and an array of personal and social issues. Selection is inevitably constrained by costs and access to resources. Few training opportunities to educate clinicians who prescribe wheelchairs are available. Prescription strategies should pertain to priorities of the individual and take into account physical needs, functional environment, funding, and other related issues.9,10 Rural providers are often isolated from advancements and technologies used in larger metropolitan centers. As a result, when an individual in a rural area needs an assessment, a specific treatment, or both, he or she must travel long distances to receive the specialized healthcare necessary to address their needs. Studies have reported that 50% of veterans travel more than 25 miles for healthcare.11,12 Remote areas often experience shortages of professionals and technical resources crucial to the delivery of services related to specialized medical fields.13 This impacts both the healthcare providers and the patients. Recently, there is a growing amount of literature on the use of technology for remote assessment and intervention in medicine14 and rehabilitation.15–17 However, most descriptions and projects are limited to one or two types of technology and one population. Over the last 30 years, technologists and clinicians have investigated the use of advanced telecommunications and information technologies as a way of bridging the gap between individuals with specialized medical needs living in remote areas and the source of specialty care.18 Telerehabilitation (TR), a subcomponent of the broader area of telemedicine, is the application of telecommunication technology that provides distant support, assessment, and intervention to individuals with disabilities.19 More people are in need of assistive technology specialty services than there are regional clinics to serve them. The challenge becomes to find feasible and effective methods to deliver the same level of service and intervention to remote populations as those with access to experts in more urban areas. One way to conceptualize TR is via a secure point-to-point Internet-based videoconferencing transmitting data, video, and voice. Security and privacy is essential in the development of TR protocols, given the sensitivity of protected personal health information. In this manner, an expert practitioner (EP) from a large urban clinical setting can be made accessible to places where such care is not available. This concept has led to the development of remote clinical locations modeled after the Center for Assistive Technology at the University of

Pittsburgh Medical Center (CAT-UPMC). Cooper et al.8 have discussed the potential of rapid improvement in telecommunications technology to improve access to AT services for people with disabilities in rural areas.

Methods PROTOCOL A multicenter prospective controlled nonrandomized study was used to measure the effectiveness of wheeled mobility and seating interventions provided in a remote location by a generalist occupational and/or physical therapy practitioner with consultation from an EP via interactive teleconferencing. An EP is an occupational therapist or physical therapist with an assistive technology practitioner certification and 10 or more years of experience in the area of seating and wheeled mobility. Effectiveness is measured by magnitude of change scored by the pre and post scores of the Functioning Everyday with a Wheelchair (FEW) outcome tool. A total of 50 participants with mobility impairments who use a mobility device (i.e., manual wheelchair, power wheelchair, or scooter) as their primary means of mobility were recruited and assessed. The TR group is seen face-to-face by a generalist practitioner (GP) with consultation from the EP via TR at the remote clinic. For the TR group, a high-speed secure Internet-based videoconferencing link was established between the EP and the remote GP. To support this link, a set of equipment was needed, including a 2.4-GB Pentium IV personal computer with 1-GB memory (Intel, Santa Clara, CA), Logitech QuickCam Orbit MP USB Web camera with built-in microphone (Logitech, Fremont, CA), the Rehabilitation Engineering Research Center on Telerehabilitation’s secure custom videoconferencing system, at least a high-speed digital subscriber line connection (512 Kbps to >1 Mbps) to a T1 (5 Mbps) Internet connection, and an Internet Protocol–based Panasonic BB-HCM381A network camera (Matsushita Electric Industrial Co., Osaka, Japan). The Logitech web camera was used to initiate the teleconsultation. The Panasonic network camera added flexibility to the session as it gives the EP access to a camera that can be remotely controlled. Controlling the camera allowed the EP to see the client up close with features such as optical zoom, pan, and tilt. The protocol is explained in three distinct phases and tabulated in Table 1. Phase 1. The first visit for either the TR group seen at the remote sites or in-person (IP) group seen at the CAT-UPMC takes up to 2 hours (typical of an initial assessment). This involves a comprehensive interview regarding their needs, preferences, and goals. This session also includes a physical examination of muscle strength, joint

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range of motion, posture, mobility, and observation of their ability to perform activities of daily living. All individuals in either the TR or IP group received the same face-to-face physician assessment. For all participants, the practitioners at either site were asked to fill out a Demographic Data Form-Pre. These sessions further involved a trial of various mobility assistive equipment (MAE) to determine appropriateness for the improvement of function. For the control group, a baseline administration of the FEW was performed. For the experimental group, both the FEW and Functioning Everyday with a Wheelchair-Capacity (FEW-C) provision of a device is performed; however, the GP receives consultation from the EP observing via TR. The tele-assessments were conducted with a multi-interdisci-

Table 1. Phases of the Clinical Service Delivery Protocol IN-PERSON AT CAT-UPMC Phase I

Phase II

Phase III

Initial evaluation by EP

TELEREHABILITATION Initial evaluation by GP with consultation from EP

Demographic Data Form-Pre

Demographic Data Form-Pre

Administration of FEW

Administration of both FEW and FEW-C with consultation from an EP

Trial of various MAE with RTS

Trial of various MAE with RTS and EP

LMN generated

LMN generated asynchronously via secure online portal

Home assessment by RTS

Home assessment by RTS

RTS sends report and specifications via e-mail to EP

RTS sends report and specifications via e-mail to GP

LMN sent to attending physician for review and signature

LMN sent to attending physician for review and signature

LMN submitted to funding agency

LMN submitted to funding agency

Once approved, fitting and delivery of MAE scheduled with EP

Once approved, fitting and delivery of MAE scheduled with GP with consultation from EP

Demographic Data Form-Post

Demographic Data Form-Post and TR Questionnaire

FEW via telephone no less than 2 weeks following delivery

FEW via telephone no less than 2 weeks following delivery

CAT-UPMC, Center for Assistive Technology at the University of Pittsburgh Medical Center; EP, expert practitioner; GP, generalist practitioner; FEW, Functioning Everyday with a Wheelchair; FEW-C, Functioning Everyday with a WheelchairCapacity; MAE, mobility assistive equipment; RTS, rehabilitative technology suppliers; LMN, letter of medical necessity; TR, telerehabilitation.


plinary team that includes the client, the client’s family member(s)/ caregiver(s), GP, rehabilitative technology suppliers (RTS), manufacturer representatives, and remote EP. The EP observes the individuals’ demonstration of the various activities of daily living identified in the FEW-C. Figure 1 shows a flow chart of a TR assessment. Phase II. Following the initial assessment for both the control and experimental groups, phase II involved a visit to the individual’s home performed by a RTS to determine the appropriateness and feasibility of a specified MAE that was identified in the initial visit. Home assessments were performed on individuals in both groups as a component of CAT-UPMC service delivery protocol. This included determining whether the wheeled mobility and seating intervention was compatible in the natural environment. Following the visit to the home, the RTS reported back to the practitioner(s) via secured e-mail regarding the feasibility of using a MAE in the natural environment as well as specifications for the MAE intervention. For the TR group, the EP reviewed and discussed the findings of the home assessment as well as the appropriateness of the MAE specifications with the GP to prepare a final report and a letter of medical necessity (LMN). For the control group the same applied; however, there was no remote GP involvement. The LMN template has been shared with Charles Cole Memorial Hospital (CCMH) and DuBois Regional Medical Center (DRMC), our two collaborating wheelchair clinic sites. For both the experimental and control groups, the completed LMN was sent to the attending physician or primary care physician for review and signature. This document was then sent to the RTS, who took responsibility for submitting it to the participant’s medical insurance or other third-party paying source. Once the MAE device was approved, an appointment was scheduled for the participant to be seen in the clinic for fitting and delivery of the equipment. For the experimental group, the EP participated via TR to observe the fit and appropriateness of the intervention and provide any assistance as needed. After delivery, administration of the Demographic Data Form-Post was administered to both groups and the Telerehabilitation Questionnaire was filled out only to the experimental group. Phase III. The third phase was a follow-up to administer the FEW via telephone for either groups or if possible via TR for the experimental group conducted no less than 2 weeks following delivery. This time home allowed participants’ to familiarize themselves with their new wheeled mobility and seating intervention. Table 1 shows the breakdown of the specific phases related to the service delivery protocol.


OUTCOME MEASURES Outcome measurement tools must be valid, reliable, and practical for implementation within the context of clinical environments as well as capable of being Synchronous Communication: administered within a reasonable amount Remote Teleconferencing of time.20 Expert Therapist The FEW was designed as a self-report questionnaire to be administered over time to consumers of wheeled mobility and seating technology regarding perceived user Multidisciplinary Assessment Team function related to wheelchair/scooter use. and Client at the Rural Clinic The FEW consists of 10 consumer-generatServer Site ed, self-report items, which are scored using Asynchronous Communication: a 6-point scale of 6 = completely agree to Online Portal 1 = completely disagree, and a score of 0 = does not apply. The 10 items are: stability, durability, and dependability; comfort; Fig. 1. Flow chart of a telerehabilitation assessment. health needs; operate wheelchair/scooter; reach and carry out tasks at different sursonal care tasks; indoor mobility; and outdoor mobility are strictly face heights; transfers; personal care tasks; indoor mobility; outdoor performance-based; three tasks: comfort needs; health needs; and mobility; and personal/public transportation.21 The tool was systempersonal/public transportation have both performance-based and atically developed by a team of clinical researchers at the University self-report components because of the complexity (i.e., subjectivity, of Pittsburgh due to the lack of available outcome measures related feasibility) associated with task measurement; and stability, durabilto function with the use a wheelchair. The self-report task items were ity, and dependability is a self-report item, which is subsequently developed and validated based on structured interviews with wheelmeasured during performance of all other tasks. The scoring method chair users and analysis of goals and items documented by consumers for the items with self-report components includes indicating conand clinicians in other sources including additional research studies sumers’ responses with a mark or circle, and writing responses in related to wheeled mobility and seating. The FEW has demonstrated provided spaces. The performance-based items yield three distinct good test–retest reliability and takes about 20 minutes to complete.22,23 category scores: independence, safety, and quality, which then equate The FEW can be self-administered, administered as an interview, or to a summary score based on a predefined 4-point ordinal scale. The by phone. There is no specific setting required to administer the tool FEW-C has demonstrated good-to-excellent internal consistency, and no examiner training is required; however, it is recommended moderate-to-strong convergent and discriminant validity, as well as that the examiner have some background experience and/or knowlexcellent inter-rater reliability with a sample of adult manual and edge base of seating-mobility technology and evaluation. power wheelchair users administered in-person. The FEW-C is a criterion-referenced, performance-based observation tool used by practitioners and researchers to measure functional outcomes of seating-mobility technology interventions. Based on Results Dr. Schmeler’s unpublished dissertation data, the FEW–C focuses Project team leaders have assisted both CCMH located in on consumers’ capacity to perform tasks or activities (e.g., mobility, Coudersport, PA (180 miles from Pittsburgh) and DRMC located in reach, and transfer) in a controlled clinical or laboratory environDubois, PA (120 miles from Pittsburgh) in setting up wheelchair ment that takes around 45 minutes to 1 hour to administer. The clinics modeled after the CAT-UPMC. Clinicians at both sites have FEW-C consists of 10 criterion-referenced, performance-based tasks, been trained in documentation and outcome measures and informawhich are identical to the 10 FEW items. Of the 10 tasks, operate; tion technologists have downloaded and trialed our secure custom reach and carry out tasks at different surface heights; transfers; pervideoconferencing system. Data collection is in progress as the


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first-ever TR clinic day was held on November 22, 2006 with DRMC and is scheduled once a month. The first TR clinic with CCMH was held on May 24, 2007 and occurs once a month. There have been no adverse effects as confidentiality and privacy have been established, because these are two of the main concerns when performing live assessments and exchanging data via the Internet. Figure 2 shows the complete service delivery model for both control and experimental groups.

Discussion As with any technological advancement, there are barriers and/ or limitations. Proving the efficacy of TR is a daunting task due to limitations encountered such as scientific evidence, legal and ethical issues, cost, and reimbursement. This is not new rehabilitation or even care management, but rather new technology being incorporated into rehabilitation services. The TR service delivery protocol

uses health information technology and is based on the CAT-UPMC model of evaluating an individual IP. The TR protocol provides a quality system that utilizes current standards of practice. The protocol assists service providers in meeting the challenges of wheelchair prescription as it demonstrates the capacity to effect change and influence outcomes by addressing factors thought to contribute to poor assessment and by generating important outcome data that has not been reported in TR applications. The protocol assists in improving prescription practices by reducing variations in clinical practice and provides opportunities for professional development and education. One of the main limitations encountered in developing a TR protocol for wheelchair prescription was the lack of scientific evidence in the area of assistive technology. It became apparent that the clinicians at the remote hospitals needed assistance because training opportunities for rehabilitation professionals in seating and mobility at the profes-

Current Service Delivery Model

Telerehabilitation Service Delivery Model

C.A.T.

Data Storage and Transfer

Telerehab Information Management System

Direct In-Person & On Computer

Interview & Data Entry Form


Direct In-Person & On Computer

Pre-FEW & Pre-FEW C


Direct In-Person & On Computer Center for Assistive Technology

Remote Clinic Locations

In-take & Data Entry Form

Dubois Regional Medical Center

Client Shown Equipment

Review & Discussion of Options

Telerehab and Remote Wheelchair Selection-Advisor

Technology Supplier Report

Device Trial & Home Assessment

Technology Supplier Report & Telerehab Information Management System

On Computer

Direct In-Person

Direct Observation

Fig. 2. Clinical Service Delivery Protocol.


Letter of Medical Necessity


Device set-up, Fitting, Telerehab Information Management System and Training Follow-up & Post FEW


Charles Cole Memorial Hospital


sional level are less than ideal.24,25 Despite this limitation, the TR protocol actively provides a useful way to share our knowledge and provides the GPs with the skills, training, and mentoring whereby one day they will become experts in the field of seating and wheeled mobility. One of the most important results is that the individuals in rural areas have access to expertise in rehabilitative technology and offer a quality service, and that the assessment is cost-effective whereby they did not have the associated travel expenses to an urban medical facility. Researchers have not encountered any difficulty in directing the therapists at DRMC and CCMH. The system’s point-and-click interface is relatively intuitive for the therapist to understand without a training session. The remote therapists at DRMC and the EP reviewed the system thoroughly by checking off a requirements list before conducting the first wheelchair assessment. Researchers did encounter snowy weather in the months of December through February, limiting our TR clinic days and, more importantly, limiting the mobility and travel of our participants where tele-homecare could be a viable solution; however, this has not been tested within our research center. The system has been deployed at CCMH, where researchers refined their audio compression rate because of a bandwidth limitation imposed by the site’s wireless Internet connection. However, this has not proven to be a limiting factor based upon multiple tests with the GP and information technology support. Researchers also have found that talking clearly and slowly increase the clarity of the communication. The EP agreed that our implementation of the conferencing system has delivered ideal video and audio quality for the tele-assessments. The EP had been able to monitor the therapy session in real time, ask necessary questions, and receive responses in a timely manner. TR is a new field that can only be measured by its long-term impact; however, its success can be determined by its development and implementation into everyday clinical service delivery. The influence of this service delivery protocol will be augmented as it is to be launched and replicated in three additional sites. Overall, this paper provides a comprehensive overview of the service delivery protocol that has been put into practice at two remote clinics using TR consultation model for the evaluation of remote wheelchair prescription.

This research was supported by the National Institute on Disability and Rehabilitation Research, United States Department of Education (grant H133E040012) at the University of Pittsburgh, Rehabilitation Engineering Research Center (RERC) on Telerehabilitation.

No competing financial interests exist.

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Acknowledgments

Disclosure Statement

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Address reprint requests to: Richard M. Schein, M.S. Department of Rehabilitation Science and Technology University of Pittsburgh 2310 Jane Street, Suite 1300 Pittsburgh, PA 15203 E-mail: [email protected] Received: January 1, 2008 Accepted: March 5, 2008