The use of telerehabilitation in assistive technology.

Abstract

Telerehabilitation is an evolving technology designed to assist rehabilitation practitioners and caregivers in delivering rehabilitative services to consumers at a remote site. In its simplistic form, it is a way of providing patient information between rehabilitation practitioners who are physically separated from patient. It offers an ideal tool to promote this sharing of information and help in managing patients with chronic health diseases and persons with disabilities. Telerehabilitation involves telecommunications applications and other information technologies that promote independence and improve quality of life for persons with disabilities. For a person with a disability, access to appropriate assistive technology (AT) can mean a more independent, productive life. Selecting assistive technology is usually not so simple. Finding the "best fit" between person, environment, and technology is a multi-step process. Poorly chosen equipment may be of little help to the user, or even end up unused in a closet. The paper begins with a general overview of key issues related to telerehabilitation. It further discusses the legal and ethical issues in telerehabilitation. The types of technologies used in telerehabilitation, assistive technology, human factors related to assistive technology and barriers and advantages of telerehabilitation have also been talked about.

Telerehabilitation is that part of all of telehealth practice that allows the delivery of medical rehabilitative services at a distance, using modern information technologies. Telehealth is the application of computer, communication, and information technologies to improve the access to and the quality of healthcare assistance. While incorporating the health management aspects of telehealth, telerehabilitation also utilizes telecommunication technologies to improve access to rehabilitation services that support independent services for persons with disabilities. This definition of telerehabilitation covers a broad range of services such as communications, health management, education, environmental control, and community access. New wireless technologies are making it possible to provide portable devices that support the same health monitoring, communication, and information resources associated with telerehabilitation in the home. It may be as simple as two professionals discussing a case over the telephone, or as sophisticated as using satellite technology to broadcast a consultation between providers at facilities in two countries, using videoconferencing equipment. The first is used daily by most rehabilitation professionals, and the latter is used by the military and some large medical centers (Brown, 2001).

Telerehabilitation should be extended beyond the home into the community. Applying wireless technologies will allow persons with disabilities that may otherwise have kept them home bound--to move independently in the community. Wireless communication, videoconferencing, and the Internet have made telerehabilitation a reality. Applications are as vast and exciting as the technology they employ (Meloro, 2001). It is important to remember that it is not new rehabilitation or new types of rehabilitation care management systems, but rather new technology that is being incorporated into rehabilitative services. Incorporation of technology is not unique--in fact, the development and use of new technology and equipment in rehabilitation is common. What is different, however, is that the communication technology that enables telerehabilitation has the potential to impact all general and subspecialty areas in rehabilitation and eventually all people (Viegas & Dunn 1998).

Tele is the Greek root word meaning "far off" or as Webster's defines it, "distant, remote, whence, from, or to a distance" (Guralnik, 1967). Just as telephone means sound (phone) across distance, telerehabilitation is rehabilitation across distance. The specific technology will change, and the networks used will evolve and expand. The process by which people communicate and interact and the extent to which people communicate and interact and the extent to which communication takes place are changing quickly and continually. It is telerehabilitation technology that will enable rehabilitation practitioners to do what they have always done, making it available to more people. Telerehabilitation involves new, multidisciplinary ways of working and can bring rehabilitation directly to common people. It is a huge new field of endeavor and one in which many of the waters are uncharted. Uncertainty and challenge coexist with excitement in developing telerehabilitation. Not only have we many unknowns in telerehabilitation, what is known changes all the time--new facts are learned and old concepts discounted. It should be properly introduced and based on evidence of effectiveness. Achieving these goals requires that communication channels develop between the different disciplines involved in delivering telerehabilitation services (Darkins & Cary 2000).

Legal and Ethical Issues

The development and use of new technology or new applications of existing technology have legal and ethical implications that arise subsequent to the use of such technology. Often, these legal and ethical implications themselves are not new but rendered so because their context may be new or changed. This is the case in telerehabilitation, in which the use of "electronic information and communications technology to provide and support care when distance separates the participants" alters the context in which services are provided (Viegas & Dunn 1998).

Telerehabilitation raises a number of legal issues. The possibility of disclosure of the private information, thus licensing, rehabilitation malpractice, and standards of care are of legal importance (Viegas & Dunn 1998). Licensing is intended to protect a state's citizens from the unlawful or unauthorized practice of rehabilitation. Malpractice refers to professional misconduct that includes an unreasonable lack of skill or failure to execute professional or fiduciary duties that are owed to a client. Such misconduct could include, for example, negligence in providing or failing to providing treatment, failure to obtain a patient's informed consent to treatment, or improper disclosure of confidential or private information. Viegas & Dunn (1998) also emphasize that there are other issues to be considered such as antitrust, confidentiality and privacy, and reimbursement. Telerehabilitation also presents ethical issues centered on maintaining traditional aspects of medical practice. Among the humanistic ethical concerns raised by telerehabilitation, three of them are: (a) professional-client relationships, (b) confidentiality and privacy, and (c) consent to treatment. Professional and client relationships play an important role in the success of any social care and management. Respect for client privacy and confidentiality is essential to the long-term professional-client relationship. Informed consent is one of the cornerstones of responsible professional practice. The client should always be informed of and understand the risks and benefits of all devices and agree to those before they are applied (Viegas & Dunn 1998). Other legal and ethical implications are posed by the use of electronic information and communications technology to deliver rehabilitation care over distances for which time and space constraints do not permit examination. Practitioners should come away with the understanding that although law and ethics may tend to follow developments in new technology or applications of existing technology to new fields, consideration of potential legal and ethical issues can help prepare practitioners for the inevitable conundrums that will arise (Viegas & Dunn 1998).

Telerehabilitation: New tools, not new rehabilitation

Telerehabilitation, the electronic extension of rehabilitation, is already an integral part of treatment: Every time a rehabilitation practitioner picks up a phone, that's telerehabilitation and yet everyone is asking what is telerehabilitation? All that's really in question today is how quickly and in what form the rash of new and newly affordable tools--video camera, video compression, electronic scopes, interactive software, fiber optics and cable, to name a few--will extend rehabilitation electronically even further than it has already been extended.

Telerehabilitation provides new tools, not new rehabilitation. These new tools allow rehabilitation workers to transmit more and better data farther and wider, whether it's a digitally enhanced image, the salient points of a mental health exam replayed for colleagues or the videotape assessment of a person with disability for an assistive technology device. Drastically lower telecommunication and technology costs have begun to speed up the introduction and use of these tools. Most important, however, is the realization that the Internet can propel telerehabilitation into a bigger role. The Internet and intranets are disseminating clinical information which makes telerehabilitation systems more useful and financially feasible. They provide a cheap, standardized environment in which to conduct telerehabilitation. As the Internet continues to become more forceful and incorporates voice and video, telerehabilitation, will become ubiquitous.

Types of Technology

Two different kinds of technology make up most of the telerehabilitation applications in use today. The first, called store and forward, is used for transferring digital images from one location to another. A digital image is taken using a digital camera, (`stored') and the sent (`forwarded') to another location. This typically used for non-emergent situations, when a diagnosis or consultation may be made in the next 24-48 hours and sent back. The image may be transferred within a building, between two buildings in the same city, or from one location to another anywhere in the world (Brown, 2001). The other widely used technology, two-way interactive television (IATV), is used when a `face-to-face' consultation is necessary. It is usually between the client, their provider and a specialist, but may be any combination of the three. Videoconferencing equipment at both locations allows a `real-time' consultation to take place. The technology has decreased in price and complexity over the past years, and many programs now use desktop videoconferencing systems. There are many configurations of an interactive consultation, but most typically it is from urban-to-rural location. It means that the client does not have to travel to an urban area to see a specialist, and in many cases, provides access to specialty care when none has been available previously. Brown (2001) opines that there are also many peripheral devices, which can be attached to computers, which can aid in an interactive assessment and evaluation. Many rehabilitation and assistive technology professionals' involved in telerehabilitation are becoming increasingly creative with available technology. For instance, it is not unusual to use store-and-forward, interactive, audio, and video still images in a variety of combinations and applications. Use of the web to transfer clinical information and data is also becoming more prevalent (Brown, 2001).

It is important that training programs in telerehabilitation should be evolved based on protocols/guidelines into which evidence of clinical effectiveness is incorporated. Professionals must have adequate training and education to help them use telerehabilitation systems effectively and appropriately. They need to learn the basics of why, when, and how they should teleconsult. Expecting professionals to be skilled in teleconsultation simply because they have practiced conventional methods is a dangerous assumption since they may be some additional aspects to be looked into.

Basic Principles of User Training

Vesmarovich (1999) has outlined some of the basic principles of user training, that can be useful if incorporated for the best utilization of technology.

* Keep it simple;

* Clearly demonstrate, explain and allow lots of time for practice;

* Base training on something the user already knows;

* Model interest, enthusiasm, and an expectation of success for the user;

* See one, do one;

* Initiate the "user-success/more use/more success" cycle;

* Nothing succeeds like success;

* Do not model exasperation or frustration (may lead to rejection of technology);

* Beware: Experiences of failure and learned helplessness can occur, without our knowledge;

* Training can be further complicated by type and extent of disabilities;

* Special medical, psychological, educational and vocational needs of users must be considered.

Assistive Technology and Rehabilitation Management

Assistive technologies have enabled millions of children with disabilities to lead independent, secure, and productive lives. The impact of assistive technologies is evident in the growth of both the number of devices and the number of users over the past several years (Galvin & Scherer, 1996). It can be a powerful tool, but only if it has been designed with consumer input and selected with full knowledge of what is available, how it works, and how it interacts with the environment. Assistive technologies help children with disabilities live more independent lives in their communities by minimizing "disability" and the need for assistance from other people. Assistive technology by telerehabilitation includes any interaction between a client and a provider--or other source of advice, information, and treatment--that is not face-to-face and that can be delivered over the telephone, the Internet, or wireless technology. Telerehabilitation merges computers, teleconferencing equipment, interactive television, interactive telephones, pagers, and the Web for the delivery of e-care services (Nevins & Pion, 2000).

Wehmeyer (1998) investigated the use of assistive technology by adults with mental retardation. The results of this national survey suggest that in many cases people with mental retardation and their families are unaware of the potential benefit they could derive from assistive technology and, if aware, are not informed about the types of devices available, how to fund them, and where to obtain adequate assessment and training. Beyond awareness and information, there is a need to create alternative and more flexible sources to fund such devices and to emphasize principles of universal design to ensure that people with mental retardation can benefit from readily available devices. Availability and cost were reported as primary barriers.

Telerehabilitation can support the use of assistive technology. For example, telerehabilitation can help in improving the interface between videoconferencing and augmentative communication devices; telerehabilitation can be used for seating and mobility follow-up; and home/work accessibility can be improved via telerehabilitation. Telerehabilitation programs can help persons with disabilities in various ways:

* Provide post-discharge follow-up as a means of assisting newly injured clients with psychosocial adjustments, and preventing secondary complications;

* Monitor and guide persons with disabilities in the management and care of their disabilities and other critical issues;

* Provide persons with disabilities with assistive technology;

* Evaluate and recommend modifications to the home;

* Train individuals in the use of augmentative communication devices;

* Inspect and recommend changes in equipment (e.g. wheel chair adjustments);

* Evaluate persons to determine rehabilitative readiness.

Human factors in Telerehabilitation

Human factors are critically important, often unaddressed aspects of telerehabilitation, general consumer products and devices, as well as more specialized assistive technology. As practice in telerehabilitation and assistive technology developed in scope and effectiveness over the past few years, it has become evident to clinicians and users that focusing on the technology alone is generally not enough for efficacious results. Almost always, there are other influences on if, how, and how well an AT user may join efforts with a device for a purpose. These other influences and aspects of how human beings accept, learn, and effectively use (or not!) tools and devices are known as human factors (King, 1999).

Telerehabilitation should mandate quality rehabilitation and long-term support for persons with disabilities in the lowest cost environment (Vesmarovich, 1999). It should hence include: prevention and treatment of secondary complications; assistive technology support; and assistive technology device user training.

It is very important to know how human factors interact with devices and technologies--how various persons with disabilities accept and effectively learn to use, or do not use them. The human technology factors should include user characteristics, training in technology use and technology use itself. Telephone based technology is easy to use for persons with disabilities. It is low cost; most patients have access to telephones since transportation is the major barrier for persons with disabilities (Vesmarovich, 1999).

While considering human-technology factors, it is important to also note the user characteristics. These vary from individual to individual. It also depends upon the flexibility, adaptability, willingness to tolerate some frustration, failure and fine-tuning of the system. Motivation is also critical and is an intrinsic factor. Another factor to be considered is techno phobia. Every one has it to some degree. It can be real or related to the perceived complexity of the technology. Overcoming it will vary from user to user. There is lots of information that the user must learn to operate the equipment--it can be software, monitor, camera (video camera, document camera, remotes), and any peripherals, such as VCR, video printer, and document printer. To take care of all these factors, there are basic principles of user training that should be kept in mind (Vesmarovich, 1999).

Ergonomics in Assistive Technology

Assistive technologies have enabled millions of individuals with disabilities to lead independent, secure, and productive lives. The impact of assistive technologies is evident in the growth of both the number of devices and the number of users of devices over the past several years (Galvin & Scherer, 1996). This technology for persons with disabilities may start in a laboratory, a workshop, a university, research facility, or in a garage, but its importance is not realized until it reaches the individual for whom it was designed (Heumann, 1996). Of course, low technology, inexpensive solutions abound for many job-related and independent living challenges; however, the fact remains that many of the high technology devices many of us use in our daily lives cost a great deal of money. For many people, these are dollars well spent, and no value can be placed on the independence, quality of life, and self-sufficiency that technology can provide under the right circumstances.

The problem is that this is not always the case. There are many instances when a wrong technology was purchased for an individual that was either too big or too small. Much of this technology ends up gathering dust; neither the individual who needed it initially nor the one to whom it could go instead gather any benefit from it at all (Heumann, 1996). These inappropriate purchases have other tragic consequences as well, as they reinforce the misconceptions that exist among the general public about the capacity of the person with disability to function independently and to live normal and productive lives. Even worse, the person with disability often ends up taking the brunt of blame when the problem that was supposed to have been solved remains a problem. When the wrong device is bought, it can be easier to say, "He just doesn't want to work," than "We made a mistake in our evaluation of what he needed" (Heumann, 1996).

Technology is the culprit behind many ergonomic maladies; but it is also often the solution. History is rich with examples of technologies as both causes and cures for ergonomic maladies. Davis (2000), in his research found that high-tech solutions could be low-tech and very effective as interventions to improve workplace ergonomics. His North Carolina case studies validate the conclusion that technology-based solutions can be highly effective for alleviating or eliminating ergonomic hazards, and that such solution can still be low-cost. Ergonomists should recognize and appreciate the natural maturation that occurs for most technological innovations. Initially, a radically new technology will usually be costly and risky. As the technology matures, both the cost and the risk will decrease dramatically. Therefore, ergonomists should keep an open mind with regard to emerging technologies. His study also found that ergonomists should not be content to stop with low-tech solutions that produce limited results. If only low-tech solutions are used, ergonomic improvements should be expected to eventually stagnate and reach a plateau. To improve beyond such a plateau, other approaches will become necessary. Therefore, as technological advances occur and continue to make high-tech solutions easier to use, ergonomists should consider using them.

Communications

Telerehabilitation's vast potential is made possible by the unprecedented expansion in communications that has been a defining feature of the final years of the twentieth century. Never before has the world experienced such dramatic increases in the ways that information can be conveyed from one point to another, and telerehabilitation will undoubtedly take advantage of them all (albeit to varying degrees) (Bauer & Ringel, 1999). When the telephone was first introduced, manufacturers had to hold seminars about how to use it. One initial push was as a backup to the telegraph system. Few imagined it would ever be used outside of business.

Telemedicine began with the introduction of the telephone. For many years, health care providers have given advice, health education, and information to patients over the telephone. Then two pioneers emerged. Dr. Albert Jutras began teleradiology and Dr. Cecil Watson, a psychiatrist, began treating his patients through interactive video in the late 1950s (Nevins & Pion, 2000). Telemedicine is an umbrella term that encompasses any medical activity involving an element of distance. In its commonly understood sense, in which a doctor-patient interaction involves telecommunication, it goes back at least to the use of ship to shore radio for giving medical advice to sea captains. A few years ago the term telemedicine began to be supplemented by the term Telehealth, which was thought to be "politically correct," but in the past year or so this too has been overtaken by even more fashionable terms such as online health and e-health (Wootton, 2001). Telerehabilitation involves using exciting new telecommunications technology to deliver rehabilitation services to individuals in remote and rural areas. Telecommunication systems, which utilize existing phone lines, allow the patient at home and the therapist at the rehabilitation site to interact. The system incorporates video screen, telephones and televisions. Telerehabilitation has increased access to care and has created new, innovative ways for therapists to delivery services to hard-to-reach patients more easily and frequently. Telerehabilitation also utilizes telecommunications technologies to improve access to rehabilitation services that support independent living for persons with disabilities (Peifer, 2001). Improved video clarity and speed, ease of installation and uses, high quality video freezes and software upgrade capability important features of the new telerehabilitation has seen many successes including cost effectiveness, efficiency of treatment, patient outcomes, and provider satisfaction.

Telerehabilitation is not limited to providing therapeutic services only to the patient. Remarkable benefits have been demonstrated for caregivers of patients with spinal cord injuries (Sabharwal, Mezaros, Duafenbach, & Zablocki, 2001). Telerehabilitation has the potential to enhance the health status and rehabilitation throughout the continuum of spinal cord injuries care. Continued collection of meaningful and objective outcomes will help enhance planning for future spinal cord injury telerehabilitation services. Many private insurance providers recognize the benefits of telerehabilitation and are currently reimbursing under traditional Current Procedural Terminology (CPT) codes. However, both public and private payers are concerned with the possibility of overuse of services and cost effects. There are three facets to telerehabilitation. First, there is training and counseling. Somebody has gone back to his or her community; but still requires frequent access to professional care. Telrehabilitation affords the clinician the opportunity to better understand the patient's home environment and community situation. The second facet is assessment and monitoring of a person's condition. This should allow the clinician to follow the patient for a longer follow up were the only option. Finally, telerehabilitation can be used as a therapy delivery system. The third facet may be the most challenging aspect of telerehabilitation. For example, a thorough physical therapist will maintain that unless they can actually get his or her hands under the patient's back, they cannot assess whether their seating system is properly designed. The question becomes is it possible to find a remote way to deliver the same technology, it may be possible to assess, from a remote location, what problems are occurring.

Another way to consider telerehabilitation is point of delivery. There are two possibilities. On a macro level, telerehabilitation attempts to bring the comprehensive expert services of a large urban rehabilitation hospital to places where such care is not available, most notably in rural areas. After the acute rehabilitation care, a patient transfers to a local clinic, closer and more convenient to their home and community. Through telerehabilitation, original caregivers can follow and consult with local clinics where it may not be practical to have the level of expertise required for post rehabilitation care available on site. In this sense, the patient's care is enhanced through a community rehabilitation effort without having to travel what may amount to several hundred miles in some cases. The other possibility is delivery of service at home. Research in telerehabilitation strives to determine what care can be delivered at home, where a person's life is centered. The challenge is to put complex technologies into home setting with little or no technical support. At the same time, these technologies have to meet extremely high standards of reliability, ease of use, and ease of learning. For instance, computers may not be particularly friendly with people with cognitive disabilities. Or, patients and/or caregivers may have "techno phobia".

It is also important to distinguish between telerehabilitation and teleenhancement of independent living. The former delivers medical rehabilitation services. The latter focuses on the general enhancement of a person's life, along with their family and loved ones. Finally, not all telerehabilitation is patient oriented. The reasons to develop telerehabilitation capacities are many. The concern most often expressed is loss of the personal factor--the hands on the touch, the glint in the eye, the smell of the patient. However, in rural settings where comprehensive rehab services are scarce, the alternative may well be no service at all. Even in urban settings, immobility due to disability and poor transportation infrastructure can make three blocks as unrealistic as 200 miles. In addition, it is no secret that health care through telerehabilitation may provide a needed solution to maintaining quality care.

Telerehabilitation also stands to enhance quality of care. It should provide better continuity of care. It may also create more patient tailored rehabilitation to fit a person's environment and lifestyle. Ultimately, the availability of telerehabilitation services, may allow persons to remain at home rather transferring to a nursing facility. In this information age, where telerehabilitation is regularly used to give information to patients, there are two important components to assemble and link into processes for delivering care. One component is the technology necessary to deliver information and the second is the information itself. There is also a strong potential for reduced cost. Intuitively, it would seem remote care would save on travel, either for providers or for patients. If geographic scope of care can be expanded through the use physician assistants with the consultation of more precise expertise given from a central location, the need for large hospitals with their large overhead costs may be diminished. Then there is possible prevention of expensive secondary medical consequences.

Although telerehabilitation offers infinite possibilities to enhance care while reducing costs, there are few places where it is in place and able to be tested. However, telerehabilitation in its many forms will be the best way for rural areas and developing countries to access rehabilitation experts. It will also be a handy way for rehabilitation professionals in major cities to consult one another--from across the street.

The Changing Role of Professionals in the Information Age

As societies are moving from the industrial and postindustrial ages to the information age, we are seeing changes affecting the traditional professions of law, medicine, architecture, rehabilitation, education and many more. In many ways the historical function of these professions has been to act as specialized "knowledge keepers," requiring professional representation by bodies with purposes similar to those of the medieval guilds that protected aspects of commerce and trade in pre industrial society. We have all seen how industrial mechanization has changed medieval guild system forever. Machines are able to replicate the work of traditional craftsman faster, in greater volume, and at much lower cost. Computer technology and networks are rapidly evolving from menial calculating machines to "knowledge machines" able to provide specialist information and expertise to people. In many areas such knowledge machines are able to perform some of the tasks previously done by professionals and perform then faster, in greater volume, with higher accuracy, and at lower cost (Darkins & Cary 2000).

Traditional face-to-face professional-client interaction is often taken as a gold standard compared to which a telerehabilitation consultation is inferior. Areas of unreliability in both conventional face-to-face consultation and telephone consultations raise questions about the best way to structure a telerehabilitation consultation. Properly formulated and introduced, clinical guidelines and protocols retain the best of the humanity and diagnostic accuracy of conventional practice and remove unacceptable variations in clinical practice. Although this is a legitimate concern, telerehabilitation must use those tools to add structure, discipline, and systematization to the teleconsultation (Darkins & Cary 2000).

Advantages of Telerehabilitation

Providing rehabilitation care services via telerehabilitation offers many advantages. It can make specialty care more accessible to underserved rural and urban populations. Video consultations from rural clinic to a specialist can alleviate prohibitive travel and associated costs for patients. Videoconferencing also opens up new possibilities for continuing education or training for isolated or rural rehabilitation practitioners, who may not be able to leave a rural practice to take part in professional meetings or educational opportunities. While studies have yet to confirm this, it appears that the use of telerehabilitation van also cut costs of rehabilitative care for those in rural areas (Brown, 2001). Among the potential benefits for people with disabilities at home are:

* The provision of services locally so cutting down on time, cost and inconvenience for the person (although people might like the visit);

* Access to expert advice from home;

* Remote location--allowing services to be provided to persons with disabilities in remote areas;

* Better targeted treatments;

* More accurate records.

These may be useful for people in their own homes and for people who can get to a professional center or local care center but not to a more distant care provider. Similar developments in social care have sometimes been referred to as telecare.

Barriers to Telerehabilitation

There are still several barriers to the practice of telerehabilitation. One important factor is the acceptance of technology and lack of `hands-on' interaction with patients; although most patient satisfaction studies to date find patients on the whole satisfied with long distance care. Many telerehabilitation projects have been hampered by the lack of appropriate telecommunications technology. Regular telephone lines do not supply adequate bandwidth for most telerehabilitation applications any rural areas do not have cable wiring or other kinds of telecommunications access required for more sophistication uses, so those who could most benefit from telerehabilitation may not have access to it. Other hurdles include the high cost of implementing a network; lack of awareness about telerehabilitation among professionals; concerns about whether it is cost effective; and technology that is hard to use.

Telerehabilitation is an everyday tool. Some of the obstacles are lack of reimbursement, medico legal issues, and resistance within the physician community, "user-unfriendliness" of equipment, and lack of clinical evidence. The challenge posed to health-care providers was to embrace new technology by integrating it into everyday practice (Meloro, 2001). Chin (2000) has reported that telemedicine use is growing, but slowly. According to him, the number of doctors and hospitals delivering care via telemedicine is likely to stay small until reimbursement issues and other obstacles are addressed.

In order to overcome these barriers and work toward telemedicine integration, some objectives must be met. In order for telemedicine to become mainstream, the tools must: (1) work as well as the alternatives they would replace; (2) be seamlessly integrated into administrative functions (record keeping, billing, etc.); and (3) be universally available (Meloro, 2001). Darkins and Cary (2000) describing their experience with telemedicine and telephone consultation suggests the major challenge confronting the adoption of telehealth by health care organizations may not be associated with only the technology or its cost. Instead, it may be how readily people can adapt to using the new technology in practice. Another challenge is often to change the "culture" of an institution to embrace telemedicine initiatives that meet real needs (Wallace, 2001).

Accepting telerehabilitation challenges clinicians to change their accepted ways of practicing their profession, so they and the professional organization representing them are understandably concerned about telerehabilitation and its possible effects on the standard of care. Telehealth programs often seem to view telehealth as merely as assembly of various technological tools, such as a camera and remote stethoscope to which clinician and patient are attached and which reproduces conventional methods of clinical practice.

A major challenge for telerehabilitation is, therefore to setup the collaborations and alliances necessary to develop the intellectual products that patients and practitioners require if they are going to make decisions together in the rapidly changing world of health care. Technology manufacturers and telecommunications companies are already vying with each other to produce the low-cost equipment and bandwidth needed. Many states are creating networks which link education, government, business and rehabilitation. Distance education is commonplace and most educational institutions, and many companies allay travel costs for meetings by using video (Brown, 2001).

If these obstacles are addressed, however, telerehabilitation could be a boon to many rehabilitation professionals and persons with disabilities. People living in rural and remote areas throughout the world struggle for quality access to rehabilitation and assistive technology professionals in a timely manner. Because of the innovations in computing and telecommunications technology, many elements of rehabilitation management can be accomplished when the client and professionals are geographically separated.

Conclusions

Telerehabilitation is an exciting area to watch for new developments. It is the current focus of a social revolution at least as great as that created by the Internet and e-commerce on trade and industry. Events in this world are moving so quickly that the players, the ideas, and the technology are all rapidly evolving. It is to be found through researching and developing effective and efficient ways to use telecommunication technology to deliver services to patients. Acceptance and use of telemedicine involves more than just lower cost technology and information access: It requires acceptance by rehabilitation practitioners. Viegas & Dunn (1998) include "provider availability, consumer support, the nature of contractual arrangements, practitioner-practitioner relationships, rural practitioner familiarity with hub sites, and overall ease of use" as factors that will lead to the sustained use of telerehabilitation by remote users.

Since it is very difficult for the persons with disabilities to keep moving from one place to another and from going from professional to professional, telerehabilitation can be a boon to them. The problem of transportation can be solved to a great extent. All the information about assistive technology that they need can be given to them using instructional technologies. They can be demonstrated the use of the assistive technologies over the interactive video and teleconsultation can be given to them over telephone. Other related knowledge about the AT can be transmitted to them via web, Internet and Intranet. Once the current barriers are resolved, the practice of telerehabilitation will likely undergo a radical change and transition will take place for it to become a major industry within the rehabilitation field. Although significant hurdles remain, including legal and regulatory barriers and acceptance of the use of telerehabilitation by traditional practitioners. But these barriers are starting to come down, and there is a growing body of research data that indicate how telerehabilitation can improve client outcomes and reduce rehabilitation management costs.

The promise of telerehabilitation is providing significantly improved and cost effective access to quality life. The potential of telerehabilitation is helping to transform the delivery of rehabilitative care and improve the management of millions of people with disabilities throughout the world.

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Neena Khanna, University of Kentucky, KY Sonja Feist-Price, University of Kentucky, KY

Dr. Khanna is a graduate student in assistive technology in the Department of Special Education & Rehabilitation Counseling. Dr. Feist-Price is an Associate Professor in the Department of Special Education & Rehabilitation Counseling.