D1 - Information Infrastructure and Architecture

Task Leader(s): David Brienza, Ph.D. and Bambang Parmanto, Ph.D.

Other participant: JongBae Kim, Ph.D.

Project Overview

The introduction of advanced telecommunication technologies into rehabilitation service has opened up new possibilities of delivering the service over distance. The field of telerehabilitation (TR) exists under the assumption that the barrier of distance can be minimized to enhance access that will open new possibilities for delivering intervention strategies across the continuum of care.

Information technology is central to telerehabilitation in minimizing the barrier of distance, both of patients to rehabilitative services and of researchers to subject population. Minimizing the barrier of distance can be accomplished through several modes of telecommunications, including:

In the last decade we have witnessed the growing importance of the Internet as the primary infrastructure for telecommunication that is capable of combining various modes of telecommunication into single channel (multimodal telecommunication). Despite its drawbacks (e.g. lack of guaranteed service), Internet has tremendous potentials as the de-facto standard for future multi-modal telecommunications. Increasingly, even voice telecommunication, that requires high level guaranteed of service, is carried out through the Internet (voice over IP/Vo-IP).

The future of the TR infrastructure points toward delivering multiple service modalities over a single communication channel. For example, an integrated TR service that provides teleconsultation, e-health, and teletherapy can be delivered using an application that provides videoconferencing, personal health record access, and personalized consumer health information over the Internet.


To develop an informatics infrastructure and architecture that:

  1. Supports the RERC's telerehabilitation research and development activities
  2. Meets HIPAA requirements
  3. Provides a test-bed for third party telerehabilitation applications
  4. Can be used as a model for future telerehabilitation infrastructure

Significance of Project:

TR offers opportunities for providing equitable access to underserved areas such as rural communities to advanced rehabilitation services that are otherwise only available in metropolitan areas. TR also has the potential of allowing rural community clinics to expand their services to include specialized service, such as speech-language pathology and wheelchair assessment services. Utilizing Internet as a platform also has the potential of bringing an efficient and cost-effective solution to the growing demands of interconnectivity and scalability in modern healthcare service.

The platform developed to achieve the project objectives is in the form of a system that integrates videoconferencing and internet portal technologies. The videoconferencing technologies allow a real-time, synchronous collaboration between TR participants (therapists and clients). On the other hand, the portal will provide researchers a common asynchronous collaboration platform to deliver consumer health information to participants, to discuss and exchange documents with other researchers, to conduct survey and other research activities online, and for educational activities.

Research and Development

In order to develop a common model IT infrastructure for telerehabilitation that is generalizable across various TR applications, as well as providing a model for an IT infrastructure for RERC in general, we design the infrastructure using the following guiding principles:

  1. User-centered design: the design for infrastructure should be inclusive, with all potential users involved in the design process to ensure the compliance of the system with the real needs of TR.
  2. Focus in usability: the infrastructure should be evaluated and refined to remove problems that hinders users from using the system efficiently and effectively to accomplish their tasks. The system should also be intuitive and easy to use to minimize the need of individual training.
  3. Technology: the infrastructure and its components should be based on the Internet protocol (TCP/IP), including its derived technologies (IM, HTTP/HTML/XML, video-conferencing, Internet-2, etc) to absorb the natural advantage of the Internet network, including access from anywhere-anytime, extensible, scalable, and open.
  4. Cost management: the infrastructure will be developed on top of popular off-the-shelf technology readily available in market or proprietary technology only if no other alternatives are found. Any components used in the infrastructure should be cost-effective, with preference to open-source technology or products that are based on open-source initiatives.
  5. Secure and confidential: the infrastructure should comply with common security policies. The infrastructure should also allow for newer security improvement to be placed when available.

Using these principles, we ruled out alternative technologies such as ISDN or videophones over the standard phone line as the backbone of the multimodal telecommunication. This principle also eliminates proprietary videoconferencing technology which most of current high-end technologies are.

Design and development of an information system usually follow certain methodology to systematically evaluate all components and design an architecture that blends the components into an optimally working system. The development of the infrastructure in this project follows these systematic steps:

  1. Identification and Verification of TR needs, which includes:
    1. Identify IT infrastructure components/application across the telerehabilitation project tasks
    2. Identify special requirements from any task that requires specific applications
    3. Identify common components/applications that will be shared across different projects
    4. Build a matrix that describes which components/application is used in what project, and how the component/application will be used
  2. Design and Development of Core IT Infrastructure for TR, which includes:
    1. Design basic infrastructure for supporting common components/applications
    2. Develop and weave the common infrastructure into a cohesive system
    3. Develop task-specific interface layer (skin) in top of the common layer
  3. Validation and Evaluation of IT Infrastructure for TR, which includes:
    1. Deploy the infrastructure to support TR projects
    2. Conduct usability study to evaluate the IT infrastructure

Identification and Verification of TR Needs

The first result of this method is a matrix of components and application for each task within the RERC Telerehabilitation:

D1 chart 1

As shown in the table, four types of infrastructure will serve as the backbone of the RERC Telerehab:

  1. Webconferencing and document sharing
    1. Webconferencing includes video, voice, and textual conversation using Instant Messaging (IM)
    2. Document sharing is used to refer to any interactive sharing of any documents including Office documents (Powerpoint, Word, spreadsheet, etc), as well as sharing of patient record
  2. Database and archiving
    1. Form the backbone for back-office technology for supporting all other infrastructure components
    2. All interactions in multimodal telecommunication, portal, and client-server data transmission will be supported by a database technology for storage and archiving
  3. Portal technology: used to support survey (for researchers to reach patient) and for supporting portal-like web for consumer information
  4. Client-server data transmission

Design and Development of Core IT Infrastructure for TR

In RERC-TR, we designed and developed several core components that are used in the IT infrastructure to support TR:

  1. Real-time webconferencing and document sharing
  2. Online portal
  3. Database and archiving
  4. Client-server data transmission

Webconferencing and Document Sharing

One of the first major tasks in the infrastructure development is evaluating and testing several multimodal telecommunication platforms. We evaluated and tested five platforms:

  1. e/pop from WiredRed
  2. WebDemo from Linktivity from DataConnection
  3. Meeting Server
  4. PolyCom
  5. ConferenceXP from Microsoft

The results of the evaluation are presented in the following table:

D1 chart 2

We are looking for a webconferencing system that can support all the required activities (archiving, document sharing, etc), is platform independent, and cost-effective. We decided to use ConferenceXP because it has all features that we need, and is free. ConferenceXP is based on AccessGrid, an open source webconferencing system grown out of the Internet2 project.

To ensure the best visual communication quality of the system, we evaluated several web cameras, including: Creative Labs Webcam Live!, Logitech Quickcam for Notebook, and Logitech Orbits MX. We also evaluated several types of microphone (including USB microphone, and noise cancellation microphones) for capturing the audio in addition to the camera's built-in microphone. All of these cameras have a price range below $200, in line with our goal for incurring minimal costs on all participants. The complete system specification to support the conferencing system is presented in Table 3.

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The teleconferencing system allows for a synchronous communication between the therapists at the rural hospital and experts at the University of Pittsburgh Medical Center (UPMC). This video communication is enriched with a multimodal information sharing capability of the system, including sharing of documents, web browser, and of presentation. The system is supported by a database system capable of recording the teleassessment session. The recording can be retrieved later to assist the therapist to review the session. Deploying the system requires a minimal amount of effort to set up compared with high-end video conferencing solutions. The system employs a point-and-click interface to access most of its functions. Figure 1 shows a snapshot of the system.

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Online Portal

Online portal is a technology that emerges from the advancement of Web 2.0. Online portals are commonly used as an access point to information over the Internet. It serves as a platform to centralize applications and information from diverse sources. Online portal concept has been used in many areas, including corporations, online commerce, and online services. Popular websites, such as Yahoo and Amazon, are online portals that provide multiple sources of information, integrated in one application.

Adopting online portal concept in TR allows integration of information from different sources. The information sources can potentially range from electronic health record database, web-based health information resources, to expert opinions from related TR sites. The system can be enriched by deploying multiple advanced applications on top of the online portal, such as videoconferencing and decision support systems. Table 4 displays the result of a technology exploration that was conducted to compare the existing popular online portal technologies. The final decision was to utilize Microsoft Windows Sharepoint Service (WSS) due to the ease of use, ease of development, availability of built-in information management modules (document folders, reports, etc), is scalable, and incurs minimal cost impact to users (WSS is provided for free).

Table 4. Comparison of Online Portal Technologies

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Another attractive feature of online portal is customization. Customization provides flexible interface to meet specific TR requirements. For example, a videoconferencing system can be linked to support the need of real-time communication. Conference sessions can be managed online and archived through the portal. Documentation modules and online forms can be deployed to streamline documentation process. Task management modules and problem tracker can be installed to track the progress of the rehabilitation. Online forums, digital messaging systems, and other asynchronous communication tools can also be deployed to encourage active participation of caregivers and client in the rehabilitation process

Figure 3 displays four screenshots of the online portal prototype: login/authentication page, workflow and document folder page, calendar page, and online form page. The login page is connected to the LDAP user management system. The workflow is used to provide access to document and online forms, and also to track the progress of rehabilitation service. The calendar page can be used to track clinician schedules.

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Figure 3. Online Portal deployed using Sharepoint Technology

Database and Archiving

The next important platform to select is the database system for storage and archiving. We evaluated several systems, including:

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We have experienced in all of these platforms. FileMakerPro and Microsoft Access were eliminated from the consideration because they don't have features that we need (capability of handling large and multimodal data sets).

Microsoft SQL Server was selected because it can be tightly integrated with the Portal (Sharepoint) and the web conferencing system (ConferencXP), it is economical (not free like OpenSQL, but relatively inexpensive for a big databases system) and provides a good support.

The database technology allows us to bridge the information between the synchronous collaboration (videoconference) and asynchronous collaboration (online portal) platforms. Figure 5 depicts the position of the database as the information bridge that serves information gathered through asynchronous collaboration efforts into a real-time, synchronous collaboration session.

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Figure 5. Database as Information Bridge Between Collaboration Platforms

Client-Server Data Transmission

The purpose of this component is to seamlessly send data from the clients to the centralized database system and also functions as a bridge between multiple applications used in the project with the database. The data transfer is based on the XML protocol, allowing us to expand the content of the information transferred without modifying the data transmission component itself.

The goal of the data transfer component is to provide automatic and secure data transmission between a stand-alone system with the integrated system. The data transfer component generates an eXtensible Markup Language (XML) file from the data stored within the stand-alone system's database and sends the file to the online portal via the Internet. The system ca selectively sends necessary information which is useful and relevant for therapists and limits itself from sending information that has already been sent. To ensure that the transmission is secure, the data transfer component requires an XML schema for the transmission. The XML files generated are then transferred on top of secure HyperText Transfer Protocol (HTTP). Figure 4 displays the use of the data transmission component for a store-and-forward TR service.

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Figure 4. Data Transfer Component for store-and-forward service

Validation and Evaluation of IT Infrastructure for TR:

The RERCTR is currently conducting usability evaluation study to analyze the impact of the technology to bring 'tele' aspect into rehabilitation service. Preliminary results to the study has shown that Telerehabilitation is a feasible solution to mitigate the problem of limited expertise in rural areas as long as the technology can be used easily (without hassle to both clinicians and the healthcare organization), is cost-effective (create minimal cost-impact, especially in maintaining the system), and is secure.

Technology Implementation

The IT infrastructure has been deployed to support several activities in RERCTR, including:

Supporting Internal RERC-Telerehabilitation Collaboration: RERC Telerehabilitation Portal

Due to the needs to collaborate from the onset of the project, we extended the online portal into the RERC Telerehabilitation Portal. The online portal provides a way to share textual information, such as documents and survey results, and non-textual information, such as multimedia files. Figures 3 shows a snapshot of the Telerehabilitation Portal

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We also deployed web parts -small modules that focus on a specific task within the project. We utilize the web parts to provide extension to the portal, allowing users to fill in monthly reports online, get latest news on TR field, etc. (Figure 4).

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Remote Wheelchair Prescription Project

The adoption of Telerehabilitation (TR) technology into rehabilitation service depends on whether the service's goals can be accomplished through the use of the technology. Remote wheelchair prescription (RWP) is a TR effort to deliver wheelchair prescription service over the distance, particularly to rural areas. To achieve this goal, we developed a system called the Versatile and Integrated System for Telerehabilitation (VISYTER).

Several rural area clinics were invited to test-run VISYTER and became the pilot sites for RWP. After VISYTER's prototype was completed, the system was deployed and used to support actual RWP assessment between rural area clinic and metropolitan area center through teleconsultation session. A typical teleconsultation session was generally conducted by a multidisciplinary team consisting of a generalist therapist and a rehabilitation technology suppliers with the support of an expert therapist. The teleconsultation session was conducted over one hour time, covering RWP client's comfort needs, health needs, mobility assistive equipment (MAE) operation capabilities, reaching needs, transfer needs, personal care needs, indoor and outdoor mobility needs, and transportation needs.

Researcher worked closely with the information technology (IT) support from the rural area clinics to deploy VISYTER at rural area clinics for the test-run. The most common task was to ensure that the setting from both network (metropolitan area clinic and rural area clinic) allowed a direct connection between the participants for a real-time teleconsultation session. In this task, all the network requirements are reviewed and implemented, such as opening ports in the firewall, creating forwarding protocol to allow both ends of the communication line to recognize each other, and filtering the packages to allow only connection from known sources.

Afterward, researcher conducted an introductory teleconsultation session with all generalist therapist from rural area clinic. Researcher found out that the system's point-and-click interface is relatively intuitive, and allows therapists to understand the system without a training session. Prior to any teleconsultation with real clients, both generalist therapists and expert therapists reviewed RWP workflow and protocols by going over a checklist to ensure smooth teleconsultation session. VISYTER's archiving feature was also tested prior to any actual assessment session.

We also provided an online portal to support the asynchronous collaboration of the multi-disciplinary service team in RWP. The online portal provides a way to share textual information, such as documents and survey results, and non-textual information, such as multimedia files. The online portal is designed to be modular and can be tailored easily. For example, within the portal, online forms can be created to collect data from multiple sites and a summary of therapy results can be produced for both the therapist and the client. The online portal serves as the information integrator to support the interaction between therapists, the client, and the client's family.

We deployed two types of online portal, service provider portal and client portals (Figure 5). The service provider portal was customized to be used by the TR service providers, including therapists, physicians and assistive technology device suppliers. This portal provided personal workspace for the TR service providers. The portal was equipped with features to track tasks across multiple clients, including online calendar, links to client information, documents storage, and links to online resources. The client portal was built to serve as the information integrator to support the interaction between the TR service team, the client, and/or caregivers. The portal was equipped with features to allow online interaction, such as rehabilitation progress tracker, rehabilitation issues tracker, online discussion forum, client document storage, and links to consumer-health online resources.

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The online portal allows TR service providers to access client information and advanced online collaboration features through the Internet. Rehabilitation progress tracker, issue tracker, and document management features were used to streamline documentation process. Using online collaboration tools, the online portal aims to reduce the documentation time by eliminating the delay in waiting for the documents to arrive physically via mail.

The following describes our experience in deploying VISYTER in Dubois Regional Medical Center, Dubois, PA:

We conducted our pilot study by connecting Dubois Regional Medical Center (DRMC) in rural Dubois (PA) with UPMC in Pittsburgh (PA). The two facilities are about 100 miles apart. A web camera (Logitech Orbit MX) was sent and installed on a computer in the wheelchair assessment clinic at DRMC. The clinic at DRMC is connected to the Internet by a wireless connection and by a DSL line with a downstream bandwidth of 5 Mbps and an upstream bandwidth of 728 Mbps. Installing ConferenceXP software at DRMC did not present any problem. We did, however, encounter problems connecting the video conferencing system due to network and firewall issues. The wireless connection was too slow for the video conferencing system. This problem was solved by connecting the computer directly to a DSL line. Another problem was the strict firewall setting at both sides (UPMC and DRMC). The strict firewall setting is common in health care institutions. ConferenceXP needs a specific path to be opened in the firewall system to allow communication with other peers on the network. The firewall problem was solved by opening five ports in the firewall system.

The videoconferencing system allows for a synchronous communication between the therapists at the rural hospital and experts at the University of Pittsburgh Medical Center (UPMC). This video communication is enriched with a multimodal information sharing capability of the system, including sharing of documents web browser, and of presentation. The system is supported by a database system capable of recording the teleassessment session. The recording can be retrieved later to assist the therapist to review the session. Deploying the system requires a minimal amount of effort to set up compared with high-end video conferencing solutions. The system employs a point-and-click interface to access most of its functions.

We did not encounter any difficulty in directing DRMC's therapists. The system's point-and-click interface is relatively intuitive for the therapist to understand without a training session. The remote therapist at DRMC and the expert at UPMC reviewed the system thoroughly by going over a requirements check list before conducting the real wheelchair assessment with the client. The archiving feature was also tested prior to the actual assessment session.

The teleassessment was done with a multidisciplinary team that included the client, the client's family member(s)/caregiver, local therapists, assistive technology suppliers, manufacturer representatives and remote expert therapists. The remote expert therapist agreed that our implementation of the conferencing system delivered an ideal video and audio quality for the teleassessment. The expert therapist was able to monitor the therapy session in a real time, ask necessary questions, and get responses in a timely manner. An abundance amount of communication went back and forth, and the virtual team was able to have a good flow on the assessment session. We also found that talking clearly and slowly increased the clarity of the communication. The DSL connection line dropped several time during the session but it did not hinder the assessment session as the problem can be fixed almost immediately (took less than a minute to rejoin the conference).

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The complete description of the project can be found at the R1 project page.

Remote Home Assessment Project

The remote home assessment project is a TR effort to streamline the process of assessing the accessibility of home environment by the use of 3D modeling technology. In this project, a set of home environment snapshots are sent to a centralized database. These snapshots are then used to construct a virtual 3D model of the home. Based on this model, architects can assess and create a set of recommendations on how to improve the accessibility of the home environment.

The remote home assessment project utilizes the online portal to store picture set and the 3D model of the home environment. Clients can also access the online portal to interact remotely with the assessment team, utilizing several asynchronous collaboration features, such as surveys and discussion forum. Figure 6 displays a screenshot of the online portal for remote home assessment project.

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Figure 6. Online Portal for Remote Home Assessment

The project also develop a virtual reality player that can be used to navigate through the model. The complete description of the project can be found at the R2 project page[S4].

Tele-speech Language Pathology Project (TeleSLP) for Children with Learning and Cognitive Disability

Children with a range of disabilities such as autism spectrum disorder, ADHD, cerebral palsy, and learning and cognitive disabilities can be impacted by disorders of communication. Current studies show that it is vital for children with disabilities who also have communication delays to receive early intervention and effective treatment through age-appropriate activities that target specific aspects of speech and language development. However, the availability of treatment is usually constrained by several factors, such as remote locations and transportation difficulties, lack of available clinicians and specialists, and funding and payment concerns.

Fortunately, disorders in communication development can often be successfully ameliorated through speech-language therapy activities that can be adapted to a telerehabilitation framework. This project offers a unique therapeutic intervention that targets specific communication goals and integrates fun and therapy for speech-language disorders with the use of teletherapy.

The proposed architecture provides telemonitoring via a store-and-forward method over the Internet where the therapist monitors the child upon completion of a therapy session. Store-and-forward monitoring provides the therapist with a means to evaluate the child's progress in performing at-home therapy exercises. Telemonitoring provides a solution for no therapy or infrequent therapy due to location, transportation, or clinician availability issues. This approach enables the therapist to accurately and objectively assess the child's ability, dedication, and interest in performing therapy exercises at home, as opposed to relying on the child's and/or the parents' reporting of therapy homework. Furthermore, this type of monitoring allows for the therapist to add to the body of evidence-based practice and to adjust therapy to better suit the needs and interests of the particular child.

Since the therapy data are sent to the central server, the telemonitoring system can be used to collect data on users over time or aggregate data across users. This is important in light of the increased pressure for clinicians to perform and confirm subjective results with detailed data collection and analysis.

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Figure 7. Online portal for Telemonitoring in TeleSLP

Figure 7 displays the online portal used to show the aggregate data across student participants. The complete description of the project can be found at the D3 project page[S5].

Cognitive Skills Enhancement Program (CSEP) Portal

The University of Pittsburgh's Department of Rehabilitation Science and Technology conducts clinical, academic, and research activities in its Johnstown location at Hiram G. Andrews Center (HGAC). HGAC is a state-operated vocational rehabilitation facility, primarily serving consumers of Pennsylvania's Office of Vocational Rehabilitation (OVR). The Cognitive Skills Enhancement Program (CSEP) is integrated into the larger service structure of HGAC. CSEP is a 15-week, full-time, pre-vocational training program specifically designed for OVR clients with cognitive disabilities. CSEP accepts approximately 15 participants per term, and staff consists of approximately 13 full- and part-time clinicians and consulting neuropsychologists who are employed by and located at the University of Pittsburgh or HGAC.

The CSEP Portal was developed based on the RERC-TR's PITT Model. The result is a secure infrastructure, accessible from any computer with an Internet connection, customized to address various TR needs specific to CSEP. The CSEP Portal supports a variety of clinical activities in order to increase efficiency and improve clinical practices, including: methods of gathering and updating individual participants' information and progress reports, planning and updating the group schedule of sessions and activities, organizing the assistive technology program's daily notes and reports, documenting referral screening information, storing program evaluation data, and improving methods of staff communication during meetings, trainings, and supervisions. The CSEP Portal was launched in the summer term (May, 2009). Given experiences and feedback thus far, the Portal has provided functional benefits, including improved communication and increased efficiency, compared to the old system of paper records and a written curriculum.

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The role and scope of the CSEP portal continues to expand. Future plans include:

Autism Service Education Research and Training (ASERT) Western Region Portal

Autism Service, Education, Research, and Training (ASERT) Regional Center of Western Pennsylvania, funded by the Pennsylvania Department of Public Welfare, is a collaborative model of western region providers of comprehensive, high-quality, state-of-the-art diagnostic assessments, research, education, and training programs for staff, clinicians, and families who serve and support individuals with autism spectrum disorders (ASD). The focus of the center is to collaborate with service providers and parent groups in the region to enlarge the capacity to serve individuals with ASD and to build a cohesive network and service delivery system with clear outcome measures for individuals with ASD. In addition to the many resources currently existing within the University of Pittsburgh and the University of Pittsburgh Medical Center (UPMC) itself, the University has developed collaborative relationships with the Watson Institute, the Barber National Institute, the LEADERS Program of the Achievement Center, and Children's Hospital of UPMC. Combined, these providers serve all 23 counties in the Western Region of Pennsylvania.

An ASERT Portal was created, based on the RERC-TR's PITT Model, to provide a place for collaborators to share information and documents. The Portal includes a calendar and task list that helps to disseminate information regarding collaborators' progress in various projects. Meeting agendas, surveys, and links to Adobe Connect videoconferencing rooms are available on the portal. Given that collaborators are spread out across western Pennsylvania, holding quarterly collaborators' meetings via teleconference reduces cost and driving time and increases productivity.

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Many ASERT projects will benefit from the application of the information infrastructure technologies developed by the RERC-TR:



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Overview for the Telerehab Web Conference Portal By: Bambang Parmanto, Ph.D., University of Pittsburgh

Update for the Telerehab Web Conference Portal By: Bambang Parmanto, Ph.D., University of Pittsburgh

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Saptono, A., Schein, R., Telerehabilitation in Remote Wheelchair Prescription: Workflow to Improve Usability, Proceeding of RESNA Conference 2009, June 23-27, 2009, New Orleans, Louisiana


The RERC on Telerehabilitation State of the Science Conference


D1-01: Information Technology Infrastructure for Supporting Telerehabilitation

Bambang Parmanto, Ph.D., Andi Saptono, MS, Wayan Sugiantara, MS, David Brienza, Ph.D. and Bart Nnaji, Ph.D.
University of Pittsburgh, Pittsburgh, PA 15260

D1-02: Online Portal Technology to Manage Information in Remote Wheelchair Teleassessment Project

Andi Saptono, MS, Bambang Parmanto PhD, David Brienza PhD
School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA

D1-03: Online Portal to Deliver Rich Services in Telerehabilitation

Andi Saptono, MS, Bambang Parmanto, PhD
University of Pittsburgh, Pittsburgh, PA 15260

D1-04: Telerehabilitation in Remote Wheelchair Prescription: Workflow To Improve Usability

Andi Saptono, MS
RERC on Telerehabilitation, University of Pittsburgh, Pittsburgh, PA 15260

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