Methodology for Analyzing and Developing Information Management Infrastructure to Support Telerehabilitation
Andi Saptono1, Richard M. Schein2, Bambang Parmanto1, Andrea Fairman2
1 Department of Health Information Management at the University of Pittsburgh,
2 Department of Rehabilitation Science and Technology at the University of Pittsburgh
The proliferation of advanced technologies led researchers within the Rehabilitation Engineering Research Center on Telerehabilitation (RERC-TR) to devise an integrated infrastructure for clinical services using the University of Pittsburgh (PITT) model. This model describes five required characteristics for a telerehabilitation (TR) infrastructure: openness, extensibility, scalability, cost-effectiveness, and security. The infrastructure is to deliver clinical services over distance to improve access to health services for people living in underserved or remote areas. The methodological approach to design, develop, and employ this infrastructure is explained and detailed for the remote wheelchair prescription project, a research task within the RERC-TR. The availability of this specific clinical service and personnel outside of metropolitan areas is limited due to the lack of specialty expertise and access to resources. The infrastructure is used to deliver expertise in wheeled mobility and seating through teleconsultation to remote clinics, and has been successfully deployed to five rural clinics in Western Pennsylvania.
Keywords: Telerehabilitation, Information Management, Infrastructure Development Methodology, Videoconferencing, Online portal, Database
Advances in telecommunication technologies have opened new possibilities to deliver rehabilitation services to rural and remote areas. This approach, commonly known as telerehabilitation (TR), has the potential to bring rehabilitation services to previously limited areas. For example, in teleconsultation, a clinician from rural clinic can remotely consult an expert clinician from a metropolitan specialty center during an assessment.?
In a TR application, an information management infrastructure is required to deliver rehabilitation services over telecommunication networks. The infrastructure is responsible for managing information across multiple sites. Properly addressing the requirements of the TR application allows the infrastructure to efficiently support rehabilitation services.
Within the University of Pittsburgh’s Rehabilitation Engineering and Research Center on Telerehabilitation (RERC-TR), researchers created an Internet-based information management infrastructure to support TR. The infrastructure was developed through a design process that focused on the following characteristics: openness, flexibility, extensibility, cost-effectiveness, and security (Parmanto, Saptono, Sugiantara, Brienza, & Nnaji, 2006). The presence of these five characteristics contributed to the creation of an ideal TR platform, referred to as the PITT Model.
In this paper, we explain the methodological approach to employ the PITT Model in the design and development of an information management infrastructure to support TR. The remote wheelchair prescription project was chosen as a case example to explain the implementation of the model in an authentic TR application. In this project, the methodology is used to develop the information management infrastructure to deliver expertise in wheeled mobility and seating through teleconsultation to rural clinics.
Telerehabilitation (TR) is the application of telecommunication technology to provide long-distant support, assessment, and intervention to individuals with disabilities (Ricker et al., 2002). The field of TR exists under the assumption that the barrier of distance can be minimized to deliver rehabilitation interventions remotely across the continuum of care (Winters, 2002). Specific TR advantages include: 1) decreased travel from rural communities to specialized urban health centers; 2) enhanced clinical support in local communities; 3) improved access to specialized services; 4) expanded delivery of local healthcare in rural communities; 5) educational benefits for remote clinicians participating in teleconsultations; 6) reduced feelings of isolation for rural clinicians; 7) improved service stability in regions with excessive staff turnover; and 8) multimedia communication (Lemaire, Boudrais, & Greene, 2001). Information technology (IT) is central to TR in minimizing the barrier of distance and achieving these advantages (Bashshur, Shannon, & Sapci, 2005).
The common approach to building an IT infrastructure to support TR application is to purchase IT systems that will create experiences that are similar to those experienced in traditional face-to-face encounters. These systems can typically be deployed quickly and easily to support common tasks and services. For example, popular videoconferencing systems are commonly purchased to provide real-time communication in a remote assessment. The complexity of the TR application determines the number of systems that must be utilized. A simple TR application can employ only one or two systems, while a complex TR application may utilize more than three systems.
Brennan & Linsey (2008) argued that usability of the technology to provide TR is the key to TR’s adoption in day-to-day activities. Two components of usability were listed: ease of use and efficiency. In a complex TR application, clinicians are required to use multiple IT systems. These IT systems are not tailored for TR setting; they are usually multi-purpose equipments. For example, the videoconferencing equipment used in TR is the same as the equipment used for providing videoconference in corporate meetings. For these multi-purpose equipments to work, clinicians must be trained to follow the complex steps required to manually set up each piece of equipment.
The use of multiple IT systems to deliver TR application also leads to information being scattered across many systems. To gain access to a client’s complete information, clinicians must retrieve data from multiple sources, including printed documents, outcome measurement tool results, and annotations derived from recordings of TR sessions. This scenario increases the potential for latent problems that include but are not limited to: inefficiency in service delivery due to limited access to data; lost and misplaced data which results in reduction of data integrity and security; and inefficient use of the clinician’s time to engage in manual data management.
A solution to mitigate the problems of multiple IT systems is to develop an integrated information management infrastructure. The integrated infrastructure functions as a bridge for the information and data flow between systems supporting TR application. This approach allows the data to be streamlined and stored in a centralized, secure location, thus ensuring the integrity of the data. As a result, the overall usability of the system for clinicians is expected to increase. Proper management of data will also increase the efficiency of the TR application, resulting in the reduction of the total cost of service (Goldschmidt, 2005).
To develop an integrated infrastructure, the IT platform must be able to: bridge multiple IT systems/components; interface with centralized data management system; provide clinicians access to different types of data; and provide access from any location. These requirements make the Internet an obvious platform to build the integrated infrastructure for TR.
Until recently, use of the Internet was not considered an option due to several limiting factors, including small bandwidth size, limited access from rural areas, and lack of integrated environmental support. However, by the end of 2006, access to broadband connections among Internet users in the United States (US) was estimated to reach 80% (Madden, 2006). The availability of these high-bandwidth connections provides a channel for various types of data to be transmitted between locations. The advent of Web 2.0 further increases the appeal of the Internet as a platform for a wide range of services from simple services such as online document storage to demanding, interactive services such as videoconferencing.
Fitting Internet technologies to build an integrated infrastructure to support TR involves extensive customization to properly meet the requirements of a TR application. To overcome this challenge, RERC-TR researchers developed a methodology that simplifies the process of customizing and developing the integrated infrastructure.
The PITT Model
Prior to the formulation of the integrated infrastructure development methodology, we identified five important characteristics for a TR infrastructure: openness, extensibility, scalability, cost-effectiveness, and security. These characteristics were used to develop a model TR infrastructure that is generalizable across various TR applications, and led to the development of the PITT model (Figure 1):
Figure 1. The PITT Model
In multiple IT system environments, each IT component requires specific interfaces to interact with other components. With the PITT Model, these complex interfaces can be simplified by creating a single interface to the centralized IT platform (Figure 2).
Figure 2. Integration of System: With and without PITT Model
of the TR Infrastructure
System Development Life Cycle (SDLC)
The development of the integrated infrastructure follows the standard information system development life cycle methodology. However, TR development principles are utilized in each step of the process to shape the infrastructure according to TR characteristics. In each cycle, the development of the infrastructure follows these systematic steps:
Remote Delivery of Wheelchair Prescription
The rehabilitation field considers wheelchairs one of the most successful assistive technology devices to improve independence and enhance physical functions (Russell, 2007). Assessing a user’s needs and matching them to an appropriate wheelchair is essential to a successful outcome. This process requires clinicians to look beyond the physical needs of the wheelchair user to other external factors, such as the functional environment and funding issues. The delivery of wheelchair prescription services in rural areas is limited due to several issues, including inadequate availability of clinicians with the proper assessment skills, and their limited knowledge of wheelchair prescription.
Access to clinicians with specific training and knowledge skill sets in wheeled mobility and seating is limited, thus narrowing the locations where individuals with mobility impairments can receive appropriate care. A small number of experts in this specific field are expected to serve 2.2 million people who use wheelchairs for their daily mobility (Kaye, Kang, & LaPlante, 2000). This number will continue to grow as the baby boomer generation comes of age, and individuals increasingly survive traumatic events due to medical advancements.
Individuals with mobility impairments who reside in rural and/or remote areas are often underserved (Cooper, Trefler, & Hobson, 1996; Batavia, Batavia, & Friedman, 2001). To overcome this challenge, TR is viewed as a potential option to deliver clinical service in these areas (Kinsella, 1998). For example, the process of assessing an individual for a wheeled mobility device by a generalist practitioner at a remote clinic can be supported by an expert practitioner through the use of a TR consultation using an integrated infrastructure.
The goal of the integrated infrastructure is to provide expert practitioners real-time access to any client sessions held at the rural clinic (synchronous collaboration), and to support online collaboration efforts to document and archive the results of the sessions (asynchronous collaboration) for clinical processes. In this project, a videoconferencing component is used for synchronous collaboration, and an online portal used for asynchronous collaboration.
Step One: Requirement Identification and Workflow Analysis
The following are the requirements identified to support the synchronous collaboration in the remote wheelchair prescription project:
In addition to the synchronous collaboration requirements, the following are the requirements identified to support asynchronous collaboration:
Figure 3 illustrates the team members and workflow of the remote wheelchair prescription project. The project is composed of an expert practitioner from the University of Pittsburgh Medical Center – Center for Assistive Technology (UPMC-CAT) in Pittsburgh, PA, and a multi-interdisciplinary team from a rural clinic.
Figure 3. Conceptual Interaction Flow of the Remote Wheelchair Prescription Service Team
Figure 4 lists the phases and activities identified for the workflow in the remote wheelchair prescription service. These activities require support from either the synchronous or the asynchronous collaboration component of the infrastructure, or both. For example, assessing a client’s physical ability requires the use of synchronous collaboration support to allow seamless remote interaction between the expert practitioner and the multi-interdisciplinary service team. Creating and storing documentation requires the use of the asynchronous collaboration infrastructure. The fitting and (if needed) reassessment activities require both synchronous collaborative support for assessing the client and asynchronous collaborative support for providing access to client’s pre-existing data.
Figure 4. Phases of Remote Wheelchair Prescription Service
Step Two: System Design
Based on the requirements, a matrix is created to map the workflow with infrastructure components. The matrix ensures that all workflow phases have corresponding support technologies within the infrastructure (Table 1).
Table 1. Matrix of Phases and Components
Three infrastructure components are identified to support the remote wheelchair prescription project: videoconferencing, content management, and database systems.
Step Three: Development of
Components and Infrastructure
ConferenceXP was chosen as the core of our videoconferencing component. This videoconferencing technology originates from Microsoft Research and is based on AccessGrid (Daw, 2005), an open source web conferencing system developed from the Internet2 project.
In this project, developers redesigned and simplified the interface of ConferenceXP to provide easy access to all real-time interaction features, such as archiving and document sharing tools. Additionally, developers built an interface component to seamlessly connect videoconferencing with the content management system. This interface provides clinicians with easy access to client information stored in the online portal.
Data Management Component
The data management component provides a platform to store, manage, and collaborate using stored textual and non-textual data. In the remote wheelchair prescription project, Windows SharePoint Service (WSS) was used to build the online portal (Figure 5).
Figure 5. Remote Wheelchair Prescription Online Portal
One of the advantages of WSS was the ability to create Webparts, small modules within the portal designed to do specific tasks. These components are lightweight, can interact with each other, and are reusable across the project. Another advantage was the ability to create automatic workflow tracking. With workflow tracking, the portal can manage documents automatically with little or no intervention required from clinicians. In addition, service team members can track the progress of the service to solve any issues encountered during service delivery.
The database component is used to store any information gathered during service delivery. Information stored within the database comes in many forms, including demographic documents, client intake data, assessment related files, and records of the TR consultation sessions. This information can be retrieved anytime for review at a later point in time.
A role-based access system is employed to protect the database. Information stored in the database can only be retrieved by individual with proper access rights represented by the individual’s role in the service.
Step Four: Deploying the System
in Pilot Sites: PA Rural Clinics
To deploy this infrastructure, a set of videoconferencing equipment (USB Web Camera, USB desktop microphone, and external speakers) were sent and installed on a personal computer within the RERC-TR and several rural clinics located outside of Pittsburgh, PA. The initial TR consultation efforts with these sites were successful; all participants were able to collaborate in real-time without disruption, both in audio and video. Figure 6 shows a snapshot of the infrastructure being used by practitioners during a remote assessment session. The infrastructure was able to connect an expert practitioner with generalist practitioners from Dubois Regional Medical Center, located in Dubois, PA, 100 miles away from Pittsburgh, PA.
Figure 6. Customized Videoconferencing System
TR has obvious advantages in remote or rural areas where there are relatively few experts in a concentrated field. Even in urban areas, the introduction of TR has been shown to speed the referral process, reduce unnecessary referrals, and improve the consistency and quality of healthcare (Lemaire et al., 2001). In this paper, we presented a methodology to build an integrated IT infrastructure, and used the methodology to build an infrastructure to support the remote wheelchair prescription project. We believe that the PITT Model and this methodology will be helpful across other TR applications to further improve healthcare service delivery in remote areas.
Although newer network technologies, such as fiber optics, have become available for commercial use in metropolitan areas, it will take some time for the same technologies to be available in rural areas. However, despite the limited bandwidth, services were still able to be effectively provided (Schein et al., 2008).
Proponents argue that TR integration into mainstream healthcare delivery must be supported by scientific evidence demonstrating its efficacy, effectiveness, and acceptability (Grigsby, Schlenker, Kaehny, Shaughnessy, & Sandberg, 1995; Mair & Whitten, 2000; Whitten & Mair, 2000). This issue is being addressed in the fifth step of the System Development Life Cycle. Future reports will include client perceptions and satisfaction, and the advantages and disadvantages of TR personnel, technology acceptance, and utility in other clinical services.
We have shown that the PITT Model can guide the development of an integrated information management infrastructure for TR application. The PITT Model is a design process which focuses on five important characteristics of a TR platform: openness, extensibility, scalability, cost-effectiveness, and security. This model was applied in the development of the infrastructure of a TR application: remote wheelchair prescription. Using these guiding principles, researchers were able to build an integrated information management infrastructure that conformed to the needs of a specific TR application. This infrastructure has been successfully deployed to provide TR services to rural clinics in Western Pennsylvania.
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