Appendices

Appendix A - Information Dissemination

Publications

1. Distance Communication Project Goes On-Line at ADMH. Arnprior and District Memorial Hospital Newsletter, Winter 1995.
2. The Rehabilitation Centre Launches Distance Communication Project. Perspective, February, 1996, 3.
3. Lemaire, E.D., Jeffreys, Y., Morazain, G., and Greene, G. (1995) A Model for Remote Orthotic Assessment using Distance Communication Technology. Can J Rehabil, submitted for publication.

Presentations

1. Lemaire, E.D., Bangs, L., Campbell, A. (1996) Rehabilitation by Telemedicine. Ottawa Carleton Health Information Network Conference, Ottawa, February.
2. Lemaire E.D. and Jeffreys, Y. (1996) Distance Communication and Orthotics. Staff Open House, The Rehabilitation Centre, Ottawa.
3. Lemaire, E.D., McBride, S., Buttle, L., Cameron, S. (1995) Canadian Telemedicine Experiences. Miami Conference on the Caribbean and Latin America, Miami, December.
4. Lemaire, E.D. (1995) Distance Communication and Remote Rehabilitation Services. Ottawa Life Sciences Conference, Ottawa, October.

Media

A multi-site press launch was held on January 25, 1996. This launch was successful for informing the community about the distance communication initiative. A by-product of this event was sensitization of health care staff at each site to the project and potential of distance communication. Coverage related to the media initiative included:

1. Rehab Centre Shares Info: Hospitals Go On-Line. The Ottawa Sun, January 26, 1996, 16.
2. ADMH Implements New Link-Up System for Patient Care. The Arnprior News, February 4, 1996, 3.
3. Arnprior Hospital Leaps Into Future, The Arnprior Chronicle-Guide, January 31, 1996, 1.
4. Long Distance Healing: Hawkesbury Hospital Testing Revolutionary Computer Link. The Review, January 31, 1996.
5. Distance Communication Project Coverage. CJOH News, December, 1995.
6. Distance Communication Project Coverage. CBO Radio, January, February, 1996.
7. Distance Communication for Rehabilitation. Rogers Community Channel, March, 1996.

Appendix B - Participating Organizations

This project is being managed through the Institute for Rehabilitation Research and Development (IRRD) at The Rehabilitation Centre (Ottawa). The IRRD staff are joined by representatives from other Rehabilitation Centre services, community hospitals, and industry (table B-1).

Table B-1: Participating institutions.

Appendix C - Background

The application of computer-assisted communication to medicine is an emerging field. Computer hardware and software are now approaching the level of handling the extensive requirements for video communication at a reasonable price. The opportunity for small clinics and/or hospitals to interactively share voice, image, video, and text data with remote experts should lead to better, and more efficient, health care service delivery.

Since the field of computerized distance communication is in its infancy, the lack of published information on distance communication and rehabilitation services is not unexpected. Models for the application of this technology to rehabilitation are required to provide guidance for future developments and clinical applications. While limited information is available on distance communication and clinical rehabilitation, existing information on distance education provides valuable insights on the organizational and technical requirements for computer distance communication.

Melchor Antuñano (1993) defined distance education as "teaching and learning situations in which the instructor or instructors and the learner or learners are separated in geographical location or in time, and consequently have to rely on communication technology, computer technology, and/or printed materials for instructional delivery." Distance education should be treated as complex, interactive, and dynamic systems made up of multiple components, where each component effects all other components and the whole (Harrison, et al., 1991). This complex model can be broken into four components: instruction, management, telecommuting, and support. These components consist of student-instructor interactions, student-student interactions, logistics (audio/video quality, ability to get person on-line, etc.), delivery system, support staff, technology, planning methods, communications, cost, unique features of distance education, and course content.

Distance education programs should make remote education and training more cost effective while maintaining high quality outcomes. A distance education course is also valuable for teaching specialized topics in areas without educators who are knowledgeable in the subject area (Lemaire, 1993). Cost savings can occur by reducing travel and employment costs, such as lost revenue while an employee is travelling and taking an external course. Computer based education courses have been shown to reduce the overall instructional time by 25% (Kulik et al. 1980) and help to provide programs that accommodate unique conditions in remote regions (Ferguson & Manburg, 1986).

While instructional time is minimized, preparation time for computerized distance education is greater than the time required to prepare a conventional course (Østbye, 1989). Østbye (1992) stated that the costs associated with running a computer conference are mainly related to course development, teaching time, books, software, telecommunications, and the cost to use a computer-conferencing system (hardware at central and remote site, software).

Distance education technology has evolved from written correspondence courses to radio, television, and finally computer communication technology. An educator can make use of a variety of media to present a topic (table C-1).

Inter-site connections are presently made using conventional telephone lines, cable, microwave, satellite, and fibre optic networks (Antuñano, 1993). International computer networks can be used to distribute sophisticated calculations to remote, specialized computers, access directories and databases, transfer computer files, and perform specialized message exchange functions. While telephone lines are available in most parts of the world, a packet-switched data communications network is more cost effective for connecting sites outside of a local calling area (Østbye, 1992).

The choice of media for distance education has been outlined based on four learning domains (Antuñano, 1993). Please refer to table C-1 for media definitions.

1. Intellectual skills such as discrimination, conceptualization, ruling, evaluation, interpretation, and problem solving involve high-level cognitive processing by the learner. Medical choices for this domain included CBT, CAI, IVD, DVI, CDI, Hypermedia, Embedded Training, Expert systems, or Two Way Video and Audio Conferencing.
2. Verbal skills include "the learner's ability to convey the meaning of essential information in a relatively imprecise way, which allows the feedback for the correct performance to be similarly imprecise". Media choices for this domain include Audio tape, Audio Disc, Radio, Transparencies, Slides, Filmstrips, Video Tape, Instructional TV, Training Film, IVD, DVI, CDI, Hypermedia, or Teleconferencing.
3. Attitudinal skills involve the "learner's ability to make choices or decisions to act under specific circumstances". An educator may use Video Tape, Instructional TV, Training Film, Two Way Video and Audio Conferencing, IVD, DVI, CDI, or Hypermedia.
4. Psychomotor skills involve "cognitive processing and physical activity in order to accomplish the expected task". Simulators, Models and Mock-ups, Real Objects, Embedded Training, Video Tape, Instructional TV, Training File, Two Way Video Conferencing, CBT, CAI, IVD, DVI, CDI, or Hypermedia can be used to teach psychomotor skills.

Since rehabilitation interventions can cross all of these learning domains, computer based communication methods would be required to best support clinical rehabilitation interactions.

Table C-1: Media available for distance education (Antuñano, 1993; Ferguson and Manburg, 1986; Lemaire, 1993).

As well as providing a platform for structured educational programs, computers are valuable for simple communications between students or between students and faculty (Ferguson & Manburg, 1986; Østbye, 1989). Using electronic mail (e-mail) facilities, on-line conversations can occur between two or more people at any time. This capability allows for "didactic instruction or simultaneous teleconferencing between the faculty and a group of students". These systems have the advantage of being accessible through any telephone line, providing faster and more efficient question submissions and response mechanisms, and maintaining a written record of all messages. The use of e-mail for distance education also permits people with disabilities, people with variable working schedules (varying hours and/or varying locations), and people from other countries to participate in the course (Ferguson & Manburg, 1986; Østbye, 1989, Percy & Withnall, 1992).

Computerized video conferencing can also be used to share teaching resources between institutions (Clark, 1993). A microwave communication based system has been implemented to link five nursing education sites to a central institution. By sending classroom audio and images from six video cameras between the central and remote sites, the instructor could see the remote classroom in a series of monitors and the students could see the instructor and reference material. Technicians were require to run the system during educational sessions. While this method was reported to be effective, the high installation and maintenance costs make this system inappropriate for most remote clinics.

The use of computers and telecommunications to share voice, still images, and text data (Telewriter) requires modifications to traditional education and interactive methods (Rosenthal et al., 1992). In a study on teleconference based teaching, the participants considered the initial courses inferior to classroom lectures. However, ratings for teleconference instruction increased with each course module. Evaluations of distance education courses seemed to be highly related to the outcome measures (Rosenthal et al., 1992; Hintz, 1993; DeLoughry, 1988). Overall, remote teaching using a Telewriter was considered as effective as classroom teaching for a thinking and decision making course.

Rosenthal et al. (1992) and Hintz (1993) have defined a series of considerations for distance education that should be addressed when implementing a clinical service program. These considerations include the following:

1. competence with the communication system (instructor and student),
2. the need for the instructor to ask more questions to compensate for visual feedback on the student's understanding,
3. the including of pre-developed graphics,
4. the providing of printed notes/outlines prior to the on-line session,
5. the including of student presentations,
6. the encouragement of students to be motivated to use the system,
7. higher ability students tend to have more positive outcomes than low ability students,
8. the hardware and software must be able to support the required level of communication, and
9. current systems are better for small or medium groups (10-15 students).

By considering these factors, satisfactory remote inter-clinician interactions should be attainable with the use of a computer communication system.

Distance Communication Benefits for Rehabilitation

Currently, rehabilitation services are available in most urban centres; however, these specialized programs are less common as you move away from medium-large cities. People in areas without specialized rehabilitation must travel to an urban centre for treatment or, if available, take advantage of a mobile-outreach service. Patient visits to a rehabilitation facility have the benefit of direct clinician-specialist contact; however, these visits can be expensive (transportation, accommodation/inpatient costs), can be limited by travel problems in winter, and are not feasible in the later stages of some illnesses. Mobile-outreach services have been shown to be an effective means of providing rehabilitation to remote communities (Wilson et al., in press) but the sporadic time intervals between site visits makes each encounter critical and client follow-up limited.

A distance communication system could allow a rehabilitation specialist to perform assessments and follow-ups without direct patient contact. By providing on-line assessment and follow-up, in additional to on-site visits, rehabilitation services for people in non-urban areas should greatly improve. The ability to provide certain services using computer techniques would be of additional value to people in northern regions where access during winter months is inconsistent.

Some traditional remote rehabilitation services involved telephone conversations between the rehabilitation specialist, the remote clinician, and/or the client. This verbal interaction may have been augmented by a FAX message, mailing patient information between centres, and/or mailing a video tape which describes the problem. This communication strategy suffers from a lack of immediate visual feedback, relatively long delays for detailed information exchange, and potential lapses in confidentiality (i.e., assess to the FAX machine). The lack of visual feedback and relevant information in this process makes the referral/assessment phase difficult, especially for the field of physical rehabilitation. In addition, follow-up sessions are extremely difficult to perform without visual feedback during the remote appointment.

A computer distance communication system would allow remote and central clinicians to exchange verbal, visual, and technical information about the client. Digital assessment information could positively affect the efficiency and cost effectiveness of remote services by streamlining the required resources; such as, planning for a more cost-effective treatment, ensuring that all required equipment is present during a mobile-outreach clinic visit, and only bringing essential personnel to the remote site (i.e., do not involve an orthotist if the client requires another intervention). The ability to only bring essential personnel is increasingly important when the relatively small disabled population in rural areas is considered.

The current assessment process could be improved since an assessment questionnaire could be completed and technical information provided over the communication link. The questionnaire/technical information could be discussed on-line without having to wait for a FAX or letter to be sent and received. Also, due to the rate of progression of some medical conditions, the information on the referral may change between the time the document is received and the mobile clinic visit. A distance communication system would make the referral revision process more efficient and reduce the chance of on-site problems due to confusion regarding the client's status.

The three to five month time lag between mobile outreach visits could adversely affect the clinical follow-up process and, as such, adversely affect rehabilitation service efficiency. For areas such as orthotics, physiotherapy, and occupational therapy, a telephone conversation may be inadequate for addressing clinical problems since the rehabilitation specialist cannot see the assistive device, how the person moves, or how the person interacts with their environment. It may also be difficult to explain to the remote clinician how to proceed without drawing or demonstrating the desired procedure.

A computer distance communication system should allow remote clinicians to show the problem over a video link, annotate the video or graphic image, send the client file over the computer-telecommunications link, and verbally describe the problem over a telephone line. By interacting with the remote site, the rehabilitation specialist could request additional information, determine the required intervention, and describe how to proceed using graphic annotation tools, verbal instructions, and/or a video image or file describing the procedure. Pre-developed educational aids could also be used by both sites to determine the best way to proceed.

The field of orthotics should benefit from this system since modifications to an orthosis are sometimes required within the first month after device dispensing. In the mobile-outreach scenario, these modifications cannot be made until the next visit. During this time, the benefits of increased mobility through use of the assistive device would be lost. With adequate training of the remote centre staff, minor orthosis modifications could be made by the remote clinician under direction of the orthotist. The video link could be used to make sure that the changes have not altered the function of the orthosis. Upon the next visit the orthotist could reassess the changes and make any final modifications. A more effective assessment would also be of benefit for cases where special measurement and assessment tools are needed for the on-site session. Once the system is in place, there are also potential benefits for the fields of communication disorders, physiotherapy, occupational therapy, and psychology. The orthotic application is especially suited to inter-discipline technology transfer since the system must accommodate physical assessments, gait evaluation, and assistive device adaptation.

For successful orthotic distance communication, a remote clinician should be able to :

1. contact a rehabilitation specialist for a client assessment involving video images, motion analysis, on-line questionnaires, and verbal communication (consultation), contact an orthotist at a rehabilitation centre for specific information on a client's brace,
2. get audio/visual instructions on how to adjust an orthosis or correct a problem,
3. make the adjustments and show the orthotist the result.

An orthotist at the central rehabilitation centre could, along with a physiotherapist at the rehabilitation centre,

1. view a video of the client walking, climbing stairs, etc. as a remote assessment of orthosis function (diagnostic service),
2. compare images of modified and unmodified orthoses to verify the changes,
3. provide expertise to a series of remote sites.

While the benefits of on-line communication are many, little research has been performed concerning the application of this technology to medical service. Until recently, the high cost and inadequate capabilities of computer communication hardware and software made the digital service goal inaccessible; however, recent developments have reduced the cost of distance communication systems to a level compatible with most medical clinics. Also, the proliferation of Internet service providers makes the task of connecting remote sites to rehabilitation centres easier and more cost-effective.

References

1. Antuñano, M.J. (1993). Use of Advanced Technology in Distance Education. Aviation, Space, and Environmental Medicine, 64 pt. 1, 876-877.
2. Clark, C.E. (1993). Beam Me Up Nurse! Educational Technology Supports Distance Education. Nurse Educator, 18(2), 18-22.
3. Ferguson, R., & Abbey, M. (1985). Distance Education, External Degrees and Modern Technology: Delivering Training and Education to Meet the Needs. Journal of Children in Contemporary Society, 17(3), 85-100.
4. Kulik, J.A., Kulik, C.C., & Cohen, P.A. (1980). Effectiveness of Computer-Based College Teaching: A Meta-Analysis of Findings. Review of Educational Research, 50(4), 525-544.
5. Lemaire, E.D. (1993). Distance Education Technology for Prosthetic CAD/CAM Instruction. Journal of Prosthetics and Orthotics, 5(3), 82-87.
6. Lemaire, E.D., & O'Neill. P. (1994). CAD/CAM and Distance Communication Technology in Rehab. Ottawa Life Science Conference. Ottawa, October.
7. Østbye, T. (1992). Computer Communications for International Collaboration in Education in Public Health. Annals New York Academy of Sciences, 670, 43-49.
8. Østbye, T. (1989). An Electronic Extramural Course in Epidemiology and Medical Statistics. International Journal of Epidemiology, 18(1), 275-279.
9. Percy, K.A., & Withnall, A. (1992). An Examination of the Motivation and Experience of British Elderly People When Learning at a Distance. Gerontology and Geriatrics Education, 13(1-2), 57-70.
10. Wilson, K.G., Crupi, C.D., Greene, G., Gaulin-Jones, B., Dehoux, E., & Korol, C.T. (in press). A Descriptive Survey of Consumer Satisfaction with a Rehabilitation Out-Reach Program. Archives of Rehabilitation Medicine.

Appendix D - Communication System

The basis for distance communication will be the Person to Person (P2P) computer-supported collaborative working system (IBM). This software is included with OS2 Warp 3.0 and works through an Internet connection, modem, or network. The software/ActionMedia II card setup provides a shared chalkboard work space, still video capture and display, dual interactive video display, background file transfer, mirroring of any application into the chalkboard (i.e., to show the contents of another program to the on-line participants), and allows a participant to share the contents of their clipboard.

Vocal Standard telephone lines can be used at both sites for verbal communication. A speaker attachment will permit more than one person to talk or allow one person to talk while having both hands free (i.e., to hold an object up in front of the video camera, etc.).

Data

Direct modem and Internet connections will be used as the backbone of the communication link. The direct modem link should give better performance in cases where a direct network attachment is not available since (i.e., normal model link) since the overhead an Internet connection is not present. The Internet link should provide reliable communications, free up a telephone line (if a network card is used instead of a modem), reduce communication costs, and allow some correspondence to be done over e-mail (newsletters, educational material, large file transfers, etc.). Tools available with OS2-V3 should make it easy for the remote staff to connect to the central location or the other pilot site. An Internet link will also allow multiple sites to connect, thereby permitting team meetings to take place on-line.

Visual

Video

Using the Person-to-Person software, a video signal can be sent between sites over standard telephone (19.2 Kbps) lines at approximately 0.7 frames/second, over medium speed connections (64 Kbps) at 2.5 frames/second, and over fast connections (400 Kbps) at 11 frames/second. While the standard and medium frequencies are too slow to assess human motion, it will allow both sites to show an assistive device or show a problem area on a client. Since this project is intended to address problems in remote communities with limited financial/technical resources, the feasibility of standard telephone communications for digital clinical assessment should be addressed, as opposed to high speed ATM networks or satellite links.

Since 30 frames/second video is ideal for analyzing walking, a secondary process will be created to share full speed video data. A means of recording video to disk, compressing the data file, sending the file to the central facility over the Internet connection, and decompressing the file for analysis will be developed by the principal investigator. Both sites will be able to examine the client in motion and, once the information is processed, the results can be shared through the digital conference system.

Drawing

Annotation and drawing tools will allow a clinician to outline problem areas, show where to make a device modification, put up pre-made slides as examples, and type words on the screen (i.e., spelling of a client's name, etc.).

Information Exchange

Since a digital connection exists, an easy way of sharing client records, CAD/CAM data files, or scanned information can be included in the system.

OS/2 Specifics

Internet Access

The Internet tools included with OS/2 will be used for all connections, file transfers, and external site links. The OS/2 Internet software has the advantage of being extremely user friendly and compatible with other object oriented programs.

Chalkboard

P2P's Chalkboard could be considered the most important visual communication feature for remote assessment. By displaying and annotating images of the orthosis, walking characteristics, or educational materials, all people connected to the communication system can discuss a problem while seeing and drawing on related images. Since other programs can be mirrored into the Chalkboard, the common viewing area could be used to solve software problems, look at CAD images, or work on reports and documentation (i.e., mirror a word processor or graphics program into the chalkboard). Pilot work with the Chalkboard method of remote communication have demonstrated the usefulness of this medium, as long as the proper visual material is used^6,7.

Computer Database

Much of the background and assessment information can be entered by a remote therapist into a computer database. Once in this format, the database record can be transmitted between the remote site and the central site using standard Internet mail procedures. A series of macros will be developed to automate the record transfer procedure (i.e., make the transfer process transparent to the user). Since OS/2 will be used as the operating system for this project, the database program can be open at the same time as the communication program. Data record transfers can be performed in the background (multitasking) to allow the therapist and orthotist to investigate other factors while the data file is being sent.

In cases where the database record does not have to be sent between sites but some information needs to be discussed, the database program can be mirrored into P2P's virtual chalkboard so that all conference participants can see the data input screen.

Image Capture

The image capture feature is part of the P2P software. This function will capture a stationary, full screen image from the video camera and display the image in a separate window. This image can be transferred to the chalkboard for discussion. While continuous video display is available in P2P's video window, this image is small. Capturing and displaying a large image will help an orthotist to see limb redness, chaffing, orthosis condition, etc.

Video Motion Analysis

An essential part of an orthotic assessment is the visual evaluation of a person's walking style. This information is used to help define the client's problem, determine the best orthotic intervention, and evaluate orthotic function. Ideally, the central and remote clinics would be able to see a full screen, full motion, real time video image of the client as they perform a qualitative gait assessment. The image data would be saved to disk for quantitative evaluation. Unfortunately, current telecommunication limitations (band width, data transfer rates) do not permit instantaneous, full screen video display between central and rural sites.

Video capture will be done using the software which accompanies the IBM ActionMedia Board Capture accessory. Use of a commercially available system for saving video images to disk will decrease software development time, reduce hardware dependence, and ensure optimal integration between the software and hardware. The video tape will be saved on disk as digital, full screen, 30 fps, compressed images. The amount of image compression will be adjusted during the initial test phase based on the required clarity and file transfer rate.

To provide a means of visually assessing human motion, a clinical motion analysis software package will be written to transfer digitized video data files between sites, display full screen, full motion video, step through the file one frame at time, copy or save individual frames, superimpose a rectangular grid on the video image, measure joint angles, and calculate stride parameters.

Video playback

Using a video cassette recorder (VCR) control metaphor, the video data file will be displayed in a scalable window in screen. The control buttons will allow the user to play, stop, fast-forward, or rewind the digital video as they would a tape player. A button will also be added to step through the data file one frame at a time. This frame-by-frame view will be used to see body position at discrete moments in the gait cycle, allow for on-screen measurement, and allow the user to copy or save an individual frame.

Image Transfer

While a single video frame is displayed on screen, the user may copy the image to the clipboard or save the image as an OS/2 bitmap. The copy option will be useful for transferring single video images between the video analysis software and the P2P chalkboard. By copying a video image to the chalkboard, all on-line participants can discuss and annotate the image to examine specific gait characteristics or elements of orthotic function during a communication session.

Images that are saved to disk can be sent as Internet mail between sites before a communication session to reduce the time spent waiting for graphics files to transfer between sites. The bitmap files can also be used as examples for future on-line discussions.

Appendix E - Computer Database Format

Appendix F - Questionnaires

Orthotic Assessment Form

Computer System Data Form

Description of Fields

Appendix G - Glossary

Computer Terms

Person to Person Communication System

Other