Hardware/Software Solutions

IBM's Person to Person (P2P) video conferencing system, running under OS/2 Warp 3.0, was used for this study. P2P provided an interactive chalkboard, chat mode communication, window mirroring, and file transfer capabilities as part of the OS/2 Warp Bonus pack (i.e., software bundled with the operating system). With the addition of a video capture card, P2P could send video and high resolution still images between sites (Appendix D). The OS/2 Bonus Pack also provided a word processor/spreadsheet/database program and Internet related software.

Figure 1 : Computer communication system.

System Setup

IBM hardware was used for this project, although any IBM compatible system could have been implemented. A Pentium 90 (host site) and two Pentium 75 (remote sites) based systems were used for the majority of this study. An Intel 80486DX-66 system was employed for initial system and communication tests. All systems were equipped with 16Mb RAM and a 17 inch monitor. The 17 inch monitor was essential since the additional screen space permitted many windows to be open and visible at the same time (i.e., video window, chalk board, database, etc.). System setup and configuration were performed by the research team.

Setting up a P2P session that incorporated live video took much longer than initially planned. The majority of the problems were related to faulty device drivers and hardware conflicts. A summary of system setup problems are listed in Table 1. The setup process took approximately three months.

Table 1: Setup considerations for OS/2 Warp 3.0 and P2P.

The lengthy time required to setup the system would be a major problem for a small health care centre with little computer experience or unavailable computer research personnel. Having the system completely pre-installed and configured for the specific application is essential to build consumer confidence, reduce frustrations, and reduce expensive remote servicing costs.

Database

The orthotic database program was initially setup using the IBM Works Datafiler application; however, program problems lead to rewriting the database in Microsoft (MS) Access for Windows 3.1 (Appendix E). When IBM corrects the programming errors, Datafiler should be adequate for maintaining an on-line database for distance communication.

Figure 2 : Orthotic database - patient information.

A runtime version of the MS Access program ran in a MS Windows session under OS/2. Intermittent problems occurred when loading MS Access; however, these problems were resolved by installing the blue-spine version of OS/2 Warp (with MS Windows better integrated with the OS/2 system). To share database records between sites, the following protocol was developed:

1. Copy the desired database records in MS Access,
2. Open the Clipboard Viewer application in MS Windows,
3. Save the clipboard contents to disk,
4. Use the P2P File Transfer program to send the clipboard file to the other site,
5. Receive the file and load it into the Clipboard Viewer,
6. Paste the record into the database.

Figure 3 : AFO database - design section.

This procedure is efficient if links to the Clipboard Viewer program are made readily available to the user (i.e., an icon is used to start the Clipboard Viewer without having to open a complete MS Windows session). In cases where the data does not have to be transferred to the other site, the database windows can be mirrored into the Chalkboard for discussion.

Reference Images

A series of reference images were scanned and saved as bitmap graphic files. These images were grouped in Light Table folders for easy access (an OS/2 feature for organizing multimedia files by displaying the information as a series of small slides). Since a Light Table was used for image organization, the user can easily share pictures by clicking on the image's slide to display a full size picture and mirroring the enlarged picture into the chalkboard. The reference images were very useful for the training sessions and during on-line discussions regarding client characteristics.

Direct Modem Connection / Internet

For the majority of this study direct modem connections were used for communication. While the Internet is an effective means for remote communication, communications can slow down during high traffic periods on the Internet. A direct 28.8 Kbps modem connection between two sites was found to be the best medium for communications over a telephone line.

While the telephone line data connection was satisfactory, the connection between sites was not always reliable. The main connection problems were based on running the system through hospital switch boards. In particular, the Rehabilitation Centre's PBX based telephone system created data communication problems during the initial stages of this project. Switching to a direct, outside telephone line solved most of these problems. Hawkesbury had more reliable data communications than Arnprior. This could be due to better telecommunication links between Ottawa and Hawkesbury or interference from the Arnprior District and Memorial Hospital switchboard system (the telephone line was routed through the main switchboard).

As small communities with inferior telecommunication links are connected to a clinical consultation system, data line failures can be expected. Generally, this is not a problem since it is a simple task to reconnect and resume the assessment. Frequent connection problems; however, are detrimental to the efficiency of remote clinical communication and user confidence. It is recommended that pre-tests of the telephone system be performed before installing a computer distance communication system to ensure a reliable data flow between sites.

Internet connections were easy to initiate and the connections were reliable. For site-to-site communication the Chalkboard and video functions could worked; however, the video frame rate was slower than with a direct 28.8 Kbps modem and there was a longer time lag between the live action and remote video display. Even with these limitations, an Internet connection was considered a viable medium for cost effective site-to-site communication.

Multi-site Internet communications involved Ottawa, Arnprior, and Hawkesbury simultaneously sharing the same Chalkboard and Talk window. This feature performed very well when each location took turns accessing the shared resources; however, if all sites continuously used the pointer function for more than a few minutes the system would lock up (i.e., a continuous data stream from all participants using the Chalkboard). If short to medium burst of activity were performed no errors occurred. Live-video was not reliable for multi-site Internet connections. Higher bandwidth TCP-IP connections would be required before the video function could be used between more than two sites. A recommended multi-site setup would involve:

1. using the Talk window to keep minutes of a meeting, display/paste text for the group to read, or write hard to spell words,
2. using the Chalkboard window to share captured images, pre-prepared graphics, or as a sketchpad to illustrate an idea,
3. using the Stills Capture program to grab video images and share them with the group (these images can take between one and two minutes to be displayed at all sites, depending on the amount of Internet traffic),
4. using the File Transfer program to send video files, database records, word processed files, or reports between sites.

System Validation

To compensate for the additional time required to configure the communication system, the first Mobile Clinic visit was used as a test session and was not included in the validation results. At the start of the project, clinicians in Arnprior and Hawkesbury had minimal, or no, computer experience and no previous exposure to OS/2. The combination of clinician training on the system, system trouble shooting, and database errors made data from the first clinic visit unreliable.

A total of twelve subjects were assessed during two Mobile Clinic visits: six assessments in Arnprior and six in Hawkesbury. Assessment sheets were completed by the on-site and Rehabilitation Centre orthotists for each assessment. Computer system data questionnaires were completed by the Rehabilitation Centre orthotist. All subjects were informed of the project protocol and completed a consent form. One additional patient was evaluated during the data collection period as a clinical consultation. This contact will be described as an example of how a clinical consultation could work.

The following sections will describe the questionnaire results, debriefing results, and the additional clinical consultation. Assessment results were compared between the on-site orthotist and the on-line orthotist/therapist team.

Assessment Questionnaire Results

The assessment data sheet was divided into three areas: client data, physical data, and gait data.

Client Data

The client data section provided information on the client's medical status, social factors, and environmental factors. Orthotic assessment questionnaires have traditionally provided a space to write a description based on client assessments, discussions, and a medical chart review. To compare these clinical data, the information was coded into three groups: same information (1), same information with some additional details (2), different information (3). Since it is expected that different clinicians will have slight variations in what information they decide is most relevant, group one and group two results were acceptable.

Client data results are summarized in table 2. Different results for data of birth, height, and weight occurred because the fields were not completed on the data form. Three areas with unsatisfactory results were prescription, history, and complications. It was reasonable that difference occurred with prescription since the subjects, while being potential candidates for an ankle foot orthosis (AFO), were not assessed on the basis of a prescription (i.e., they were at the clinic to take part in the pilot project and not for a specific orthotic problem). If a written prescription were available for each subject the prescription results would have been much better.

Differences in medical history and possible complications were attributed to differences between orthotic methods and physiotherapy / occupational therapy methods. The various fields of rehabilitation have different focusses when reviewing the medical history and determining what constitutes a potential complication. These differences became apparent when reviewing the responses from the on-site orthotist and the combination of an orthotist / physiotherapist / occupational therapist team. It is suggested that these areas be replaced by a predefined list of choices to better focus the assessment to the needs of an orthotist.

Since the medical history and complications sections were based on subject feedback, some differences could have been due to different information, or a different focus, being supplied by the subject for the two assessments. Problems with the speaker-phone could have also lead to problems hearing the subject.

Physical Data

The physical data section recorded information concerning muscular function, joint function, vascular problems, and balance. For the strength measurements, individual variations were accommodated by grouping the Oxford Muscle Strength Scale values into three sections: no functional strength (0,1,2), weak functional strength (3), acceptable functional strength (4,5).

Table 2: Physical test results.

The range of motion values were grouped into normal or abnormal sections. These groupings were required since orthotists typically do not perform strength and range of motion assessments with the same emphasis as physiotherapy. This probably occurs since physiotherapists and occupational therapists are concerned with the physical improvement of the client while an orthotists is concerned with production of a device based on the client's functional condition. More precise measurements are required to show how the client is progressing as part of treatment. Broader scales were considered sufficient by the team orthotists and were better aligned with current clinical practices.

Results from the physical tests are listed in table 3. Spearman correlation coefficients are displayed for sensation, spasticity, and strength since these measures are defined on an ordinal scale.

The general physical measures were similar in all cases except spasticity. Upon reviewing the raw data, the spasticity values were found to differ by only one level (i.e., none-mild or mild-moderate). Since the two assessments could be at different times of the day, variations in spasticity of up to one level can be expected. This possibility was supported upon review of the assessment schedule and the client's medical condition.

In terms of range of motion, knee flexion and hip extension measurements showed the largest between-assessment differences. In all cases, the on-site orthotist indicated no range of motion problem but the orthotist/therapist team indicated a range of motion problem. These results could be attributed to differences in client's position during measurement (i.e., whether the subject was measured sitting or lying down), confusion between angular conventions (i.e., is the angle measured clockwise or counter clockwise), and/or what normal values were used (i.e., what is functionally normal).

Table 3: Physical test results.

Strength measures were the most variable assessment results. General trends showed that, of the ankle and knee cases that were different, the on-site orthotist rated strength higher than the orthotist/therapist team (86% of the different knee and ankle cases). The orthotist/therapist team generally rated the hip strength higher than the on-site orthotist (75.0 % of the different hip cases). These trends could be attributed to individual differences in the way strength is measured since an orthotist did the on-site measurements and a physio or occupational therapist performed the on-line strength measurements.

Gait Data

The gait data section described how the person walked. Since the video record from one subject was corrupted, the gait data analysis was performed on 11 subjects (table 4).

Table 4: Gait data results.

All gait parameters, except inversion/eversion, produced acceptable results. In three of four different inversion/eversion assessments the on-site orthotist indicated inversion/eversion while the on-line orthotist did not indicate a problem. This results were consistent with the pre-test sessions where the on-site orthotist consistently indicated inversion/eversion problems while the on-line orthotists did not assess that the degree of inversion/eversion was a problem.

The clarity of the video could also be a factor for picking up fine motion, such as inversion/eversion. Since only a two to three stride sample of the person walking was taken, the inversion/eversion problems may not have been captured in the video clip used for analysis. Often inversion/eversion problems are due to fatigue and take some time to notice. The on-line orthotist must rely on the on-site therapist to choose a representative video clip for analysis.

Computer Assessment Results

A questionnaire was completed by the on-line orthotist for each assessment. These questionnaires described the time requirements for on-line assessments, usage factors, and satisfaction with the system/process. The temporal results are shown in table 5 and the satisfaction results are shown in table 6.

Table 5: Computer and off-line time for orthotic assessments.

Improvement in remote assessment efficiency was shown for each successive trial. In fact, almost 50 percent improvement occurred between the first and third sessions. Results from the third session were comparable with the time required to do an on-site assessment. Possible reasons for the improvement are:

1. more computer experience
2. better at using the communication system software and hardware
3. familiarity with assessment forms
4. better interaction between the remote therapist and the on-line orthotist
5. less system problems (i.e., many of the bugs had been worked out of the system after the first session)

These results indicate the importance of training. A medical distance communication system should not be expected to work at peak efficiency during the first session. Staff training on using the computer, using the distance communication tools, and live practice sessions are essential to optimize the distance communication process.

The qualitative results also showed improvement between the first and last sessions. None of the measures were rated poor and below average ratings were only recorded for the first session. The majority of responses were above average or excellent in all areas except ease of assessment and confidence of assessment. It was not surprising that the on-line orthotist considered the ease of assessment and assessment confidence to be average since the distance communication system should be at least as good as a regular assessment. Cases where the rating was above average or excellent may be related to improved gait analysis tools or obtaining a different perspective from the remote clinician.

Table 6: Responses from computer assessment questionnaire as a percent of the total number of responses.

Debriefing

The debriefing session was held on-line with the objective of obtaining feedback from clinicians at all sites. Using an Internet connection, all three hospitals were able to share a P2P Chalkboard and Talk window. A video still image of the Rehabilitation Centre team was mirrored into the chalkboard to start the session. The Talk feature was used record all the ideas that came up during the session so that all sites could follow, comment on, or add to the written record. A conference call was used for verbal communication. Although the Chalkboard was available, it was not required during the debriefing.

A series of questions related to the distance communication system, system training, clinical factors, project coordination, and future possibilities were answered during the session. The results are listed below:

What are the rehabilitation benefits from distance communication?

1. The patient does not have to travel to a central rehabilitation site. This is especially important in cases where the problem could be easily dealt with on-site, specialized rehabilitation is not required, travel is hazardous (i.e., winter months), or transportation is unavailable. The reduction in patient travel could reduce health care expenses and improve health care service efficiency.
2. If access to rehabilitation services is more convenient, people who have manageable problems will be more likely to access rehabilitation services before the problem becomes severe.
3. A distance communication system provides readily available expertise. Often the remote clinician desires a second opinion to confirm or adjust a treatment regime. This would not merit an on-site visit from a rehabilitation specialist; however, an on-line consultation would either confirm that the best form of treatment is being used or result in improved treatment.
4. Distance communication can supply resources that are not readily available within the community (i.e., orthotics, prosthetics, wheelchair/seating, etc.).
5. Pre-assessments can be done before an on-site visit to confirm that the visit is still required and to ensure that the required resources for the visit are available.
6. Patient follow-up assessments could be done using the communication system.
7. Skills can be taught using the distance communication system; including, new clinical skills, computer skills, theoretical learning, and refresher courses.

What are the problems of using distance communication for rehabilitation?

1. A reliable telephone connection is does not always occur. Disconnection of the modem line in the middle of an assessment directly effects assessment efficiency. These problems could have been due to the telephone line, line connections within the hospital, or having to go through a hospital switchboard system.
2. A low-end speaker-phone was not adequate for high quality verbal communication between the on-line clinician, remote clinician(s), and patient. The clinicians and clients frequently had to repeat themselves and had difficulty hearing during a conference call. These problems are compounded when background noise is taken into effect. Replacement of the speaker-phone with a better quality device should solve this problem; however, the total system cost will increase.
3. The time required to capture a suitable video clip to disk was longer than anticipated. Streamlining this process would free up some clinician time.
4. The computer should be set up in a clinical area with enough space for the patient to lie down, video the person walking, and have easy access to the communication equipment. This area should also be secure so that none of the equipment is stolen or vandalized. The assessment area in Hawkesbury did not conform to these guidelines; hence, the assessment process was more difficult at this site.
5. Background noise could be reduced by reducing the number of people working in the same area.
6. Adequate time must be given to learn how to use the system and develop confidence in the measurements/information.

How would you improve the project?

1. Upgrade the speaker-phone
2. Arrange a face-to-face meeting with the complete project team and computer support staff at all sites before initiating the project. The project protocol could be presented at this session and the first system training session could be done. While the written project protocol was given to each site before starting the project, the size of the document was not conducive to effectively communicate the specific project objectives and framework.
3. Supply feedback on the questionnaire and assessment form results after each session instead of at the end of the project (clinicians and volunteer patients). Since the focus shifted from one site to the other, depending on which was the next test site, communication was not at regular intervals.
4. There was too much time between visits to maintain a high level of proficiency with the system. This comment demonstrates a potential pitfall for continued use of the distance communication system. It is recommended that at least one staff person at the remote site be responsible for maintaining their skills with the distance communication system. This person could act as a resource for other clinicians who would consult on a sporadic basis.
5. The time commitment for the remote clinicians was underestimated. It was difficult to combine clinical and research commitments
6. The media launch would have worked better if separate presentations were given at each site instead of trying to have all sites interacting at the same time. Since each site had to wait to ask questions or show the system functions, people were not able to appreciate the computer system's potential and how it was being used in the study. Future presentations will be done with one site leading the presentation and another site acting as support (i.e., respond to on-line requests, draw on screen, mirror pictures, etc.).

How would you change the clinical procedures?

1. The testing day agenda should be defined at least two weeks before the Mobile Clinic visit to ensure the availability of on-site clinicians and subjects. This was a difficult request since the Mobile Clinic's pre-trip patient list is not determined until two weeks before a visit (the patient list was used to define which people could be part of the project). In addition, it often took up to a week to review the list to see if any patients fit the project criteria and find additional subjects to fill the testing schedule. This limitation could be overcome by recruiting subjects who are not necessarily being seen by the Mobile Clinic during the on-site visit. One advantage of several weeks advance notice is that the remote site could complete much of the assessment form from the patient's chart and pre-send the information to the central site.
2. Testing sessions should not be held on the same day as a Mobile Clinic visit since the combination of regular clinic referrals and research assessments makes scheduling difficult with the current on-site human resources.
3. An on-site inservice on orthotic assessment techniques should be done before starting the project (during the initial fact-to-face meeting). This information can be reinforced by on-line training. Additional training will produce a better understanding of the assessment objectives, coordination of clinical techniques, and would have helped focus the assessments process.
4. More time should be allocated to training with clients before the research trial starts.

How would you change the training procedures?

1. The on-site and on-line computer training procedures used in this study were considered good.
2. A regular practice/training schedule should be set up at the start of the project to ensure that the staff do not have scheduling conflicts and to ensure that computer skills are established and maintained.
3. The practice protocol could be expanded to include practice sessions between Arnprior and Hawkesbury. More structure in the practice sessions would be appreciated.
4. Due to time constraints, the clinical practice sessions (mock patient assessments) could not be performed. These sessions would have been very beneficial for staff training.
5. After each on-line session, both sites had to disconnect and lock up pieces of the communication system for security reasons. If the system was always set up it would encourage more on-line practicing. The clinical staff could experiment on the system during slow periods of their day; such as, times when people cancel or miss their appointments.
6. Recruiting subjects for training would be easier if the recruitment guidelines were broader. For the purpose of this project, subjects were limited to people who potentially required an AFO. The remote sites would have liked to test people with other, more prevalent, conditions. These conditions could include shoulder problems, back problems, carpal tunnel syndrome, neurolocomotor deficiencies, etc.
7. An on-site technical person should be designated to provide hardware and software support.

What patient population would most benefit from rehabilitation distance communication?

1. Inpatients who have problems outside the therapists area of expertise would benefit by the on-site therapist making use of rehabilitation expertise from other sites.
2. Almost any physical rehabilitation problem could be addressed using a video based distance communication system.
3. Seating/positioning, pressure sore treatment, skin conditions and psychosocial problem consultations would be very beneficial to both Arnprior and Hawkesbury groups.

What patient population would not benefit from the current distance communication?

1. The video frame rate and image size would make it difficult to perform communication disorder assessments (stuttering, swallowing, etc.).
2. The data transfer rate would have to be much higher for acute care and/or emergency applications.

What is the best way to utilize the communication system?

1. For a specific problem, the remote clinician would call a Mobile Clinic office to set up a consultation time with the appropriate specialist. The on-line tools would be used to define the problem. Once the problem is defined, the remote therapist can take the appropriate steps on their own or with guidance from the on-line consultant. If necessary, the patient could be asked to travel to the central rehabilitation site for treatment.
2. On-line rounds could be set up to occur on a regular, scheduled basis. The remote and central sites could connect to review any problems and/or have an educational session.
3. Short connections between sites could be used to validate clinical judgments or bounce ideas off each other.

What other fields / disciplines could make use of distance communication technology?

Physicians, nurses, occupational therapy, physiotherapy, palliative care, behavioral rehabilitation (with better video quality).

Discussion

The results and debriefing feedback support the use of distance communication technology for remote orthotic assessment. While it is recognized that a larger sample size is required to ensure that this assessment method is valid, the pilot test results have provided insight regarding system requirements, setup, and clinical considerations.

Remote clinical assessments differ in many aspects from distance education. The teaching process involves one person supplying pre-determined information to a student in an interactive environment. Remote medical assessment requires a coordinated effort between central and remote clinicians to obtain applicable and reliable information. While the assessment process can be pre-defined, each assessment is unique to the patient. Two-way interaction is also important for on-line assessments since all information must be requested from the remote site; interpreted, analyzed, and communicated by the rehabilitation site; and confirmed by the remote site. An educational session will often take the form of a presentation followed by questions. Modified distance communication methods are required to adapt to the differences between remote rehabilitation and remote education.

The computer distance communication system used in this study was an effective tool for remote orthotic assessment. The P2P software and hardware provided some setup difficulties; however, it provided an effective means of sharing images between sites using a variety of communication protocols (i.e., modem, Internet).

Of prime importance was the ability to see the client live. Even with the slow frame rate, the consulting orthotist considered the verbal and visual interactions with the client an essential part of the assessment. By seeing the client, the orthotist could perceive non-verbal feedback that may not be communicated in a verbal exchange. This visual feedback provided insight into the person's current status. The orthotist could also monitor any measurements or interventions that were done at the remote site. Improvements in data compression and data transfer rates will improve the quality of the live-video information. To enhance current system performance, the live-video feature was often deactivated when not required. Since live-video uses much of the available bandwidth, deactivation of live-video mode increases overall system performance.

While video is essential for adding the personal element to the assessment session, the Chalkboard feature was the most beneficial for discussions or system training. The Chalkboard was typically used to discuss captured still images, reference images, or to learn how to use related programs or features. Once a person knows how to turn the system on and use the Chalkboard, most other system functions can be taught on-line.

A low-end speaker-phone proved to be unacceptable for interactive clinical assessments. Since the clinic area may have background noise, more than one person will be involved with the assessment, and the client may not be close to the speaker-phone (i.e., on an assessment table) a good quality audio system is required. The ideal system could detect sound from at least three metres away and play back the sound with a quality comparable to a regular telephone conversation. The system should also function well over a conference call.

Pilot testing of the assessment protocol demonstrated successful application of the communication system; however, improvements could be made in certain areas. These areas included medical history, prescription and complicating factors, spasticity, range of motion, and strength. Discrepancies between the on-site and on-line orthotists could be attributed to:

• the subjects being assessed as part of the study and not necessarily because of a specific problem. If a specific problem existed, the assessment would be more focussed and related reference documents would be present (i.e., prescription, referral, related medical history).
• A variance of measurement, interpretation and clinical techniques between the fields of orthotics, physiotherapy and occupational therapy. These differences can especially affect strength and range of motion measurements and reporting.
• A client giving different interview information to a familiar therapist than an orthotist he is meeting for the first time.
• Gait analysis results being adversely affected by personal differences in interpretation.
• Changes in the person's strength and range of motion due to the fact that the two assessments occurred at different times in the day. The client may also give a different focus to the medical history depending on when he was interviewed.
• Interview responses being adversely affected by poor audio quality.
• Video quality making it difficult to detect small variances in walking gait. The orthotist must also rely on the remote therapist to select an appropriate video clip for analysis.

Inter-assessment discrepancies for range of motion, strength, and gait analysis showed consistent trends. These trends involved one group reporting results slightly higher than the other group (usually within one rating). Since the differences are consistent, the discrepancies are likely protocol or interpretation related as opposed to random error. Further instruction should help coordinate these assessment results.

An on-line database was found to be an effective tool for remote orthotic assessment. The database, or assessment questionnaire, provided a consistent method of approaching an orthotic problem. This consistency should reduce communication errors due to terminology, measurement technique, or data entry methods. To achieving this consistency, staff at the remote and central sites must be adequately trained with the assessment protocol. Without adequate training, inter-discipline differences could effect the test results. This database/training combination is of major importance when providing consulting services to a variety of remote locations. As distance communication technology is adapted to different fields, databases and protocols specific to the discipline are required to accommodate different assessment perspectives.

The need for a good rapport between the central and remote clinicians was frequently mentioned as an important factor. Clinicians will work in a much more efficient and accurate manner when they better understand how each other works, what each others abilities are, and how each likes to use the distance communication tools. Since the consulting clinician must rely on the remote clinician as an extension of their hands and as their clinical eye, confidence in each others skills is essential to prolonged success. The clinical participants suggested that face-to-face meetings/educational sessions would help maintain a confident medical distance communication relationship.

Other initiatives that would benefit a distance communication program include designation of on-site technical expertise, scheduling of regular on-line sessions, and organizing a network of expertise between centres. While the consulting site should assume some leadership regarding the technical aspects of setting up, using, and maintaining the computerized communication system, it is important to develop on-site experience with system use and maintenance. The on-site technical person would help train new people on the system, help troubleshoot problems, and help integrate the system into hospital specific networking initiatives. The technical person would also support communications between other remote sites (i.e., communications that do not involve the central rehabilitation site).

A regular on-line consultation session would be beneficial from a scheduling and skills maintenance perspective. If regular on-line rounds or on-line clinics were scheduled, both sites could be assured that the appropriate clinicians are present for consultation. This time could also be used for educational sessions. Regular on-line communications will also ensure that the remote clinicians are adept at using the computer system. While these interactions would be beneficial to the patient and medical professional, long-term funding and resources for these on-line clinics and consultations must be considered.

In addition to consultations with a specialized rehabilitation centre, the remote hospitals could connect with each other to share local expertise or hold meetings. On-line meetings would work best if limited to two sites with no more than four people around the computer screen.

Conclusion

Based on the test results and the clinician feedback, computerized distance communication can be considered an appropriate technology for consultations in orthotic and many areas of physical rehabilitation. The low-cost solution presented in this report should make remote assessment accessible by most clinics in Canada since existing communication lines can be used, low-end computers are required, and the system is easy to use. Methods for applying this technology could also be exported internationally so that other countries may take advantage of Canadian medical expertise. An evaluation of assessment/follow-up reliability with a larger sample size should be performed; however, more sites must come on-line to provide the subject base to carry out such a project.