R1 - Remote Wheelchair Prescription

Task Leader: Mark R. Schmeler, PhD, OTR/L, ATP

Co-Investigators:

Collaborators:


Project Overview

Remote areas often experience shortages of professionals and technical resources crucial to the delivery of services related to specialized medical fields. As a result, when individuals in rural areas need an assessment, specific treatment, or both, they may have to travel long distances to receive specialized healthcare necessary to address their needs. Current research studies have proven that wheelchairs are viewed as one of the most important Assistive Technology devices, whereby it is estimated that about 6M Americans have mobility impairments and about 2.2M people use wheelchairs/scooters.

A report by the Office of Management & Budget in 2004 stated that 25% of US population lives in rural areas and 22% are senior citizens. It is estimated that <10% who need a wheelchair have access to one. The need for wheeled mobility devices is increasing as our population is aging and people are surviving trauma and disease. The availability of practitioners with specific expertise in wheeled mobility and seating is also limited especially in rural/underserved areas and travel to specialty clinics by people with disabilities is often problematic.


Objective

The objective of this study is to determine the effectiveness and accuracy of procuring wheeled mobility and seating devices for individuals with mobility impairments through the use of a telerehabilitation (TR) consultation model. TR uses videoconferencing, data acquisition, and sharing of technologies to establish a secure connection between individuals. The specific aims of the project include:

  1. Evaluate the effectiveness of remote telerehabilitation consultation using both the Functioning Everyday with a Wheelchair (FEW) and Functioning Everyday with a Wheelchair - Capacity (FEW-C) outcome measure tools.
  2. Evaluate the effectiveness of wheeled mobility and seating assessments delivered under two conditions: In-Person vs. Telerehabilitation
  3. Develop a web-based Multimedia Decision Support System tool to be used by service providers, remote consulting practitioners, clients, or other stakeholders to reduce the complexity of navigating the web to obtain mobility product information.

Methods

Study Design- multicenter prospective controlled nonrandomized study of 100 people

Assessment Protocol

TR; ATP consults to generalist practitioners and suppliers via telerehabiltiation at remote sites

Telerehabilitation Capabilities


Progress to Date

Four remotely located wheeled mobility and seating clinics have been established and sustained with the use of a telerehabilitation consultation model:

  1. DuBois Regional Medical Center, DuBois, PA
  2. Charles Cole Memorial Hospital, Coudersport, PA
  3. Meadville Medical Health Center, Meadville, PA
  4. Elk Regional Health Center, Saint Mary's, PA

All of the remote clinics were at least 125 miles away from the CAT-UPMC and contacted research investigators to assist them in developing a wheelchair clinic.

Map of western Pennsylvania showing 4 locations

Each participant was evaluated through a comprehensive initial assessment with regard to their needs, preferences, and goals with the Generalist Practitioner who received consultation from the Expert Practitioner observing via telerehabilitation. During the visit, a baseline administration of the FEW (http://www.few.pitt.edu/) and FEW-C was given in their current wheeled mobility and seating device and then a FEW follow-up two weeks later after delivery of their new device. The same was done IP, however; without the consultation. The complete service delivery protocol is shown below and published in Telemedicine and e-Health.

graphic showing D1 infrastructure

The D1 infrastructure allowed for a secure connection among our remote sites to exchange video, audio and data during consultations. By providing greater access to clinical expertise, telerehabilitation reduced the geographical variability of evaluation and clinical management. The expert practitioner observing via telerehabilitation was able to collect and store this information, expand on questions to assist with the generalist practitioner's assessment, and later uphold their recommendations along with the generalist and rehabilitation technology supplier.

The goal of the integrated infrastructure is to provide real-time access to any client sessions held at the rural sites to either the generalist and/or expert practitioners (i.e. synchronous collaboration) and to support online collaboration efforts to document and archive the results of the sessions (i.e. asynchronous collaboration) for clinical processes. Below is a flow chart assessment of our telerehabilitation consultation model and a progression of the information infrastructure created, developed, and deployed in conjunction with our D1 investigators. The videoconferencing component is used for synchronous collaboration and the online portal is used for asynchronous collaboration. These two components have now been integrated into one cohesive information infrastructure based on the PITT Model (see D1 Project). Figure 1-3 show the progression of the infrastructure starting with figure 1 incorporating only the videoconferencing system; figure 2 incorporating the videoconferencing system along with data collection tools; and figure 3 incorporating the videoconferencing system along with the online portal including task management modules, documentation, scheduling, and clinical workflow.

Figures 1, 2, 3

The FEW self-report tool indicated that over time having a generalist practitioner consult with an expert clinician via TR for wheeled mobility and seating assessments yielded change in function for each of the measured items. When compared to IP assessments, there were no significant changes in TR FEW scores for Pre and Post yielding similar scores for the two service delivery methods. The telerehabilitation consultation model constituted an integrated system of healthcare delivery that employed telecommunications and information technology as a means of evaluating the participant's function while seated in their mobility device performing specific activities being observed over 125 miles away. The FEW-C performance-based outcome tool illustrated high levels of both inter-rater reliability and internal consistency among raters via telerehabilitation.

The Remote Wheelchair Selection-Advisor (RWS-A) is a software tool used to assist in selecting a power mobility device given a set of clinical and/or technical parameters. Primarily because three years ago the Centers for Medicare and Medicaid Services changed the coding structure, it is quite cumbersome and difficult to follow and also remember which codes fit within each group. This tool is a way to assist consumers, clinicians, and suppliers to navigate the complexity of manufactures' websites to make a selection.

The specific features include:

graphic of Stand alone RWS-A

(a) Stand alone RWS-A

graphic of Web-based RWS-A

(b) Web-based RWS-A

Version 2.1 of the RWS-A was demonstrated to clinicians, suppliers, and manufacturer representatives at the Center for Assistive Technology within the University of Pittsburgh Medical Center. The Web-based RWS-A has been developed for:

  1. Editable knowledge repository to maintain WMS product performance and payment policy information
  2. A user-friendly means to search for specific products and associated HCPCS code and coverage policy
  3. A web-based forum for stakeholders to report feedback on specific devices
  4. A decision supporting environment to select appropriate devices for a specific person with a disability

An on demand "Webinar" and Questionnaire have been developed demonstrating the RWS-A.


Accomplishments

The first Telerehabilitation evaluation took place at DuBois Regional Medical Center on November 22, 2006. Feedback from the evaluation included:


Conclusion

The service delivery protocol assisted service providers in meeting the challenges of wheelchair prescription as it demonstrates the capacity to effect change and influence outcomes by addressing factors thought to contribute to poor assessment and generating important outcome data that has not been reported in telerehabilitation applications. The protocol also assisted in improving prescription practices by reducing variations in clinical practice and provided opportunities for professional development and education for generalist practitioners at the remote sites. The FEW demonstrated that change in function does occur using a telerehabilitation consultation model assisting generalist practitioners at a remote location in assessing individuals with mobility impairments. In addition, using the telerehabilitation model a practitioner had the ability to assess the type of function that a second practitioner sees face-to-face at a remote site. The findings indicated that the FEW-C is a valid tool for assessment and warrants continued development of using telerehabilitation to validate performance-based outcome tools not only in-person but via different methods of delivery. The RWS-A has provided a means for searching and pooling information related to specific search criteria for wheeled mobility and seating devices in a timely manner. Helping to establish the wheelchair clinics in these remote areas allowed for patients to stay within the same healthcare system, thus allowing the hospital to increase referrals and offer sustainability. The remote wheelchair sites along with the use of telerehabilitation provided a closer, easier, and less expensive mode for evaluation.


Output

Publications

Schmeler, M., Schein, R., McCue, M., & Betz, K. (2008). Telerehabilitation and clinical applications: Research, opportunities, and challenges. International Journal of Telerehabilitation, Special Prepublication Issue, 12-24.

Schein, R.M., Schmeler, M.R., Brienza, D., Saptono, A., & Parmanto, B. (2008). Development of a service delivery protocol used for remote wheelchair consultation via telerehabilitation. Telemedicine and e-Health, 14(9), 932-938.

Kim, K.Y., Kim, Y.S., Schmeler, M.R, Schein, R.M., "Remote Wheelchair Selection: Supporting Wheeled Mobility and Seating Device Stakeholder's Decision in Telerehabilitation," Handbook of Research on Developments in e-Health and Telemedicine: Technological and Social Perspectives, Ed. M. Manuela Cunha et al., in print.

Presentations

Schmeler, M.R. & Schein, R.M. Telerehabilitation application: Potential impact on wheelchair provision & service delivery. Paper Presented at the European Seating Symposium. Clontarf Castle, Dublin, Ireland, May, 2007.

Schein, R.M., Schmeler, M.R., Brienza, D., & Saptono, A. Telerehabilitation assessment using the Functioning Everyday with a Wheelchair-Capacity outcome tool. Panel presentation at the Rehabilitation Engineering and Assistive Technology Society of North America. Washington, D.C. June, 2008.

Schein, R.M., Schmeler, M.R., & Brienza, D. Measuring change in function following the provision of a wheeled mobility and seating intervention via telerehabilitation. Panel Presentation at the American Telemedicine Association. Seattle, WA. April, 2008.

Saptono, A., Schein, R., Parmanto, B., & Brienza, D. Remote wheelchair prescription: Initial system evaluation. Panel Presentation at the Rehabilitation Engineering and Assistive Technology Society of North America. Phoenix, AZ, June, 2007.[S5]

Schein, R.M., & Schmeler, M.R. Telerehabilitation: Expanding access to wheelchair provision and service delivery. Panel Presenter at the American Telemedicine Association. Nashville, TN, May, 2007.

Kim, Y.S., Kim, K.Y., Schmeler, M.& Schein, R. A decision support system for remote wheelchair selection in telerehabilitation. Paper Presented at the Industrial Engineering Research Conference. Nashville, TN, May, 2007.

Schein, R. Service delivery: Setting up and running a successful seating & mobility devices. Panel Presenter at the 23rd International Seating Symposium. Orlando, FL, March, 2007.

Schein, R., Schmeler, M.R., Kim, J, Kim, KY, Regulski, A., & Fatulla, A. Proposed protocol for remote wheelchair consultation using telerehabilitation. Poster Presented at the Rehabilitation Engineering and Assistive Technology Society of North America. Atlanta, GA, June, 2006.

Schein, R.M., Schmeler, M.R., & Brienza, D. Remote wheelchair prescription using telerehabilitation. Poster presentation at the International Conference on Aging, Disability, and Independence. St. Petersburg, FL, February, 2008.

Schein, R.M. & Schmeler, M.R. Systematic Development and Outcome of a Protocol for the Provision of Wheelchair Service via Telerehabilitation. Paper Presented at the European Seating Symposium. Clontarf Castle, Dublin, Ireland, September, 2009.

Charles Cole Presentation By: Mark Schmeler, PhD

Remote Wheelchair Selection Advisor Demonstration Schein, R., Schmeler, M.R., Kim, KY, Presented via Media Site Live (2008)

News Articles

Schein, R.M. & Schmeler, M.R. (2008). From a distance: Telerehab delivers skilled wheelchair services to remote areas and home-bound patients. Advance for Directors in Rehabilitation 17, 26-28.

Fabregas, L. (2007, July 13th). Newsmaker Richard M. Schein. Pittsburgh Tribune Review, City and Region Section.

Barlow, K. (2006, December 7). From a distance: SHRS tests telerehab for wheelchair users[S8]. University Times, pp. 5-6.

Beaulieu, L. (2007, March). Telerehab takes major step. HMENews.

Beaulieu, L. (2007, March). UPitt covers all bases. HMENews.

Grote, M. (2007, June). University of Pittsburgh School of Health and Rehabilitation Sciences Student Wins American Telemedicine Association 2007 Student Paper Award. UPMC News Bureau.

Events

The RERC on Telerehabilitation State of the Science Conference

Posters

R1-01: Proposed Protocol for Remote Wheelchair Consultation Using Telerehabilitation

Richard Schein, MS[1], Mark Schmeler, Ph.D., OTR/L, ATP[1], Jongbae Kim, Ph.D.[1], Kyoung Yun Kim, Ph.D.[2], Colleen White, MS, OTR/L[3], Tammy Munro, PT[3], Amy Zakel, OTR/L[3], Kim Ferry, PTA[3]

[1] Department of Rehabilitation Sciences and Technology, University of Pittsburgh, Pittsburgh, PA 15261 [2] Department of Industrial and Manufacturing Engineering, Wayne State University, Detroit, MI 48202 [3] Department of Rehab Services, Charles Cole Memorial Hospital, Coudersport, PA 16915

R1-02: Telerehabilitation: A Proposed Innovative Approach for Rural Wheelchair Service Delivery

Richard M. Schein, MS [1], Mark R. Schmeler, PhD, OTR/L, ATP [1], David Brienza, PhD [1], Angela Regulski, OTR/L [2], Amy Fatulla, COTA/L [2]

[1] Department of Rehabilitation Sciences and Technology, University of Pittsburgh, Pittsburgh, PA 15261 [2] Department of Rehab Services, Dubois Regional Medical Center, Dubois, PA 15801

R1-03: Remote Wheelchair Consultation Using Telerehabilitation

Richard M. Schein, MS, Mark R. Schmeler, PhD, OTR/L, ATP, David Brienza, PhD,

Department of Rehabilitation Science and Technology, University of Pittsburgh, Pittsburgh, PA

R1-04: Telerehabilitation Assessment Using the Functioning Everyday with a Wheelchair-Capacity (FEW-C) Outcome Tool

Richard M. Schein, MS, Mark R. Schmeler, PhD, OTR/L, ATP, David Brienza, PhD,

Department of Rehabilitation Science and Technology, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, PA 1526

R1-05: Effectiveness of Wheeled Mobility and Seating by Telerehabilitation and In-Person Evaluation

Richard M. Schein, PhD, Mark R. Schmeler, PhD, OTR/L, ATP, David Brienza, PhD, Andi Saptono, MS

Department of Rehabilitation Sciences and Technology, University of Pittsburgh, Pittsburgh, PA

Other Invited Workshops

Overview of the RERC on Telerehabilitation. Workshop presented at the Rehabilitation Engineering and Assistive Technology Society of North America. Phoenix, AZ, June, 2007.

Home Telehealth and the Delivery of Remote Rehabilitation Services. Pre-Conference Workshop presented at the International Conference on Aging, Disability, and Independence. St. Petersburg, FL, February, 2008.

Opportunities and Threats to Clinical Application of Telerehabilitation: An Interdisciplinary Discussion. Workshop presented at the Rehabilitation Engineering and Assistive Technology Society of North America. Washington, D.C. June, 2008.


Return to RERC TR 2