Enhancing the Quality of Life and Preserving Independence for Target

Enhancing the Quality of Life and Preserving Independence for Target Needs Populations Through Integration of Assistive Technology Devices

Eric S. Muncert, MHRM, Steven A. Bickford, M.B.A., Brenda L. Guzic, M.A., M.H.S., R.N., Barbara R. Demuth, R.N., M.S.N., Ashok R. Bapat, Ph.D., M.B.A., and Jay B. Roberts, M.A. Center of Excellence for Remote and Medically Under-Served Areas, Saint Francis University, Loretto, Pennsylvania.

Abstract Telehealth Test Bed—Quality of Life Studies is a research study investigating, testing, evaluating, and demonstrating technologies that have the potential to improve the quality of life for target populations, such as warriors in transition, veterans, individuals with physical and mental disabilities, and adults age 65 and older, who may require assistive technology devices to aid in maintaining or improving their quality of life. Thousands of soldiers who fought in Operation Iraqi Freedom and Operation Enduring Freedom have been wounded in action or have sustained injuries from noncombat accidents. Many of these injuries affecting military populations, as well as the general public, have resulted in amputations, traumatic brain injuries, and other physical or mental impairments. Depending on the severity of the injury, assistive technologies may be temporarily needed, or as a longterm solution, to regain and maintain normal daily functions. Saint Francis University’s Center of Excellence for Remote and Medically Under-Served Areas developed an evaluation matrix comparing assistive technologies to identify devices that will improve or maintain the quality of life for these target populations. The integration of telehealth and telerehabilitation applications into patients’ daily lives was examined to help improve home rehabilitation via access to healthcare specialties in rural and medically underserved settings. Researchers identified and tested assistive technology devices to be included in a selfsufficient living environment. The continuation of this research involves recruiting individuals to test and evaluate the functions of these commercially available technologies and to complete data collection surveys and questionnaires. The results are useful in selecting devices that will enhance or extend the quality of life of the target populations. Key words: technology, military medicine, home health monitoring

Introduction

I

n the United States today, warriors in transition, veterans, individuals with physical and mental disabilities, and older adults are healthier, living longer, and using technologies to assist in maintaining their independence in society, as well as within their own families. A warrior in transition is a medical hold-over, active-

478 TELEMEDICINE and e-HEALTH J U L Y / A U G U S T 2 0 1 1

duty medical extension, medical hold, or any other active-duty soldier who requires a medical evaluation board review or has complex medical needs requiring 6 months or more of treatment or rehabilitation.1 It has been estimated that 13.1 million people use assistive technology devices for mobility, communication, and assistance with performing activities of daily living.2 An assistive technology device is defined in the Assistive Technology Act of 1998 as ‘‘any item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities.’’3 The U.S. population in 2009 was projected to be 307,006,550 individuals.4 Recent statistics show that there are 9.7 million veterans over the age of 65.5 There are also 54.4 million people currently living with some level of disability6 and an estimated 49.6 million older adults in the United States.7 In 2011, the largest generation in American history, born between 1946 and 1964, the baby boomers, will start to turn 65. By 2050, there will be > 20.5 million people age 85 and above living in the United States, compared with only 2.2 million today.7 To these individuals, ‘‘independence’’ means maintaining private living accommodations, health monitoring, physical and mental regimes, and independently performing activities of daily living. Providing the delivery of quality and specialized telehealth and telerehabilitation services to a warrior in transition, an older adult, or an individual with a disability can be a demanding process for caregivers. Warriors in transition often face the challenge of grueling rehabilitation and an adaptation to a life that is different from the one they left before their military assignment. The Walter Reed Army Medical Center is 1 of 36 Warrior Transition Units in the United States and has over 2,000 patient visits per month. The types of treatment vary depending on the injury, and the rehabilitation programs can last for up to 1 year. LTC Stephanie Daugherty, Chief of the Occupational Therapy Department at Walter Reed, explains: ‘‘The goal is to maximize soldiers’ independence in basic living skills to returning them to their military jobs or transition to civilian life.’’8 The injuries that are treated consist of post traumatic stress disorder (PTSD) and poly-trauma, which includes amputation and brain injury. Consider these statistics retrieved in March 2009: . . .

U.S. troops wounded: - 39,7489 U.S. troops injured with brain injury: - 27%10 U.S. troops injured with serious mental health problems: - 33%11

Social isolation, decreased independence, decreased social interaction, and inclement weather can contribute to the decline of an

DOI: 10.1089/tmj.2010.0206

ENHANCING QUALITY OF LIFE AND PRESERVING INDEPENDENCE

individual’s physical and mental health and can further compromise the additional services that ensure an individual’s quality of life. Telehealth provides these individuals with access to care in their homes and local communities where possible and appropriate. Increased life expectancy creates a need to explore specialized living environments that promote independence for the target populations without sacrificing comfort. Recognition of the need to provide accommodations for these individuals, or their caregivers, focuses on the integration of assistive technology devices and practical and successful innovative telehealth applications. Individuals with disabilities can be monitored by, or receive healthcare through, technologies that enable telemedicine or telehealth applications. The American Telemedicine Association defines telemedicine as the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status.12 Telehealth is defined as the delivery of health-related services and information via telecommunications technologies and is an expansion of telemedicine.13 According to Intel Corporation, telehealth is also the use of information and communication technology to deliver health services, expertise, and information over distances. This concept includes Internet or Web-based ‘‘e-health’’ and video-based applications. Telehealth applications can be delivered in real-time (live) or through store-and-forward (record now, view later) mode using a communications network to provide, access, and manage any type of health information or service.14 Telerehabilitation can occur via telephone (including videophone), e-mail (text, graphics, and/or sound), or interactive websites, with robotics or in virtual environments. Telerehabilitation, when practiced as a hybrid of synchronous and asynchronous communication, can be augmented by informational web sites, mail/delivery services, and radio/television programming.15 Advanced technologies have created new opportunities for the target populations to enhance their living environments and improve their quality of life.

Fig. 1. Blueroof Independence module (BIM).

have the potential to enhance or extend the quality of life for the target populations. The BIM exemplified a home adaptable living environment, with assistive devices integrated into the facility, allowing individuals to test and evaluate the devices. These technologies demonstrated additions and modifications that can be added within a living space of targeted populations. The technologies that were integrated into the BIM include the following: .

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.

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Biolog Electrocardiogram: measures the electrical activity of the heart and indicates overall rhythm, as well as weaknesses in different parts of the heart muscle Pulse Oximetry: a non-invasive method of monitoring the oxygenation of a patient’s hemoglobin Spirometry Oximetry: measures lung function, specificially the amount (volume) and/or speed (flow) of air that can be inhaled and exhaled Video Gaming for Rehabilitation: activates and motivates eyehand coordination and increases muscle development and coordination.

Methods

Materials Saint Francis University’s Center of Excellence for Remote and Medically Under-Served Areas (CERMUSA) researchers identified telehealth and telerehabilitation assistive technologies to be evaluated in a comparison study. Areas of focus included technologies for the target populations that were comprised of individuals with disabilities including those with amputations, individuals with traumatic brain injury (TBI), PTSD, and others with speech, sight, hearing, and cognitive disabilities. CERMUSA collaborated with Blueroof Technologies, Inc., located in McKeesport, Pennsylvania. Blueroof develops smart-living facilities that promote self-sufficient, independent living capabilities for the target populations. CERMUSA staff with expertise in telemedicine and telerehabilitation initially tested several technologies for integration into the Blueroof Independence Module (BIM). The BIM, shown in Figure 1, is a 28¢ · 13¢6† mobile living environment that has provided CERMUSA with a setting for demonstrating telerehabilitation and telehealth applications that

Researchers at CERMUSA identified telehealth and telerehabilitation assistive technology devices that could be used by the target populations. The purpose was to perform research on numerous devices that could be used by the study’s target populations. The Internet and the resources of the Institute on Disabilities at Temple University affiliate, Pennsylvania’s Assistive Technology Lending Library, served as research assets. The ‘‘Lending Library,’’ as it is referred to throughout the state of Pennsylvania, is a free public service that loans assistive technology devices to individuals with disabilities. It is available to Pennsylvanians of all ages, with or without disabilities. Research was performed in the eight catalog areas of the library, which maintains an inventory of approximately 3,700 pieces. The categories included the following: . . .

Communication Computer Access Control

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. . . . .

Education House/Personal Professional Training Recreation Vocational Management

It was important to know the special needs of the target populations when determining the criteria for the assistive technology devices to be evaluated by CERMUSA staff; they included speech, sight, hearing, and cognitive disabilities. For example, could the device be utilized by individuals with varying special needs such as amputations, TBI, PTSD, or vision/hearing loss? Was the device available to be tested and evaluated, and was it appropriate for the needs of the specific population? It should be noted that staff members viewed many of the items borrowed from Lending Library to be inadequate and inappropriate for individuals over the age of 18. According to Lending Library personnel, it is not uncommon for an individual who has recently acquired a disability to physically or cognitively regress, making fundamental device choices appropriate for their rehabilitation. Many technologies available for testing and evaluation were large, bulky, colorful, and noisy devices that were designed for a much younger audience. Researchers identified 65 devices to be evaluated from both electronic sources and the Lending Library. As previously mentioned, the areas of focus included technologies for individuals with physical and mental disabilities, including amputees and individuals with TBI and/or PTSD. The devices were selected after extensive examination and review of product literature and ascertaining how the equipment will help the individual. For devices not available within the Lending Library, CERMUSA contacted the assistive technology companies and requested a loan of the selected technologies for evaluation. Most of the companies contacted did not want to lend their device for evaluation. The majority of companies requested either leasing or purchase of the device. This requirement restricted ability to evaluate greater number of devices with similar attributes and like applications. Of the assistive technology devices researched and evaluated, the following 10 were selected for inclusion into the study: 1. DynaVox V—DynaVox Mayer-Johnson Application: Augmentative and alternative communication including Windows XP computer, Internet access, e-mail, and text messaging 2. LifeVest—VivoMetrics, Inc. Application: Non-invasive continuous ambulatory monitoring 3. mPower—Dakim, Inc. Application: Cognitive learning system and specialized computer games designed to help fight and prevent dementia and Alzheimer’s disease 4. Nemo Magni—Universal Low Vision Aids, Inc. Application: Portable 4-inch viewing screen with digital magnification 5. Pen Elite—WizCom Technologies, Inc. Application: Collects notes electronically from printed text 6. SmartTalk—Freedom Scientific Application: A full-featured talking Windows XP computer


7. SmartView—Humanware Application: Compact handheld vision magnifier 8. Turtle 400—Visual Telecommunications Network, Inc. Application: A self-contained computer and touch screen monitor supporting commercial-off-the-shelf medical devices for telemedicine 9. Vivo Responder Belt—VivoMetrics, Inc. Application: Noninvasive continuous ambulatory monitoring 10. Wii—Nintendo of America, Inc. Application: Interactive gaming for rehabilitation using intuitive motion.

Results The technologies were selected because of their ability to assist those with sensory, cognitive, and physical disabilities. The evaluation matrix (Table 1) for this protocol was developed after it had been ascertained, through literature searches, that no matrices existed demonstrating an evaluation of assistive technology devices and their applications for maintaining and improving the quality for life for the target populations. It was found that matrices have been developed as evaluation tools for many applications, but none have focused on assistive technology devices for the three specific populations studied in this protocol. Determining factors that consumers consider in choosing an assistive technology are not well understood. However, the most important basis for evaluating an assistive device is whether it satisfies the needs of the consumer.16 It was determined at the beginning of this study that an innovative approach to evaluate these devices was to design a matrix using factors believed to be of importance to the target population. An unbiased evaluation of the devices would be completed by constructing a matrix that placed value to rank according to researchers’ personal preference of the believed use of technology by the targeted population. Based on the outcome of the study, the selected devices were to be included in a self-sufficient living environment. Each factor was given a numeric weight of, one (1) through five (5), with 5 having the highest weight and 1 the lowest. The factors were determined by collaborative opinions gathered from the researchers. Weight for each factor was assigned based on the perceived need, and the level of importance each had to potentially improving the individual’s quality of life. It was the opinion of the researchers that the two factors given the highest weight and viewed with having the most value were dependent on if the device met the need of the individual and if the device had a tele-application that saved time, was cost-effective, and was technologically advanced to meet the need of the populations. The remaining weights were viewed as important factors, but were not considered with as much significance in this evaluation.

FACTORS WEIGHT Did the device have a telehealth or telerehabilitation feature? 5 Was the device easy to use? 4 Did it meet the need of the individual? 5


Table 1. Validation Strategy Matrix

FACTOR

‘‘TELE’’ EASE ASPECT OF USE

MEET NEEDS OF TARGET POPULATION

ADAPTABILITY WITH OTHER INSURANCE COSTPORTABILITY STABILITY EFFECTIVE TECHNOLOGIES RECOGNIZED

VALUE INDEX

Technology: 1. DynaVox V—DynaVox

9

7

5

4

4

4

6

6

174

2. LifeShirt—Vivometrics

7

4

4

4

4

4

4

1

126

3. mPower—Dakim

4

7

4

2

4

2

1

5

114

4. Nemo Magni—Universal Low Vision Aids, Inc.

0

9

2

8

4

4

1

1

104

5. Pen Elite—WizCom Tech

0

6

2

8

4

3

1

1

89

6. SmartTalk—Freedom Scientific

8

5

4

8

4

3

6

2

153

7. SmartView—Humanware

0

7

2

8

4

4

1

2

99

8. Turtle 400- ViTelNet

8

5

5

2

4

2

1

2

122

9. VivoResponder Belt–Vivometrics

7

3

2

3

4

2

4

2

106

10. Wii—Nintendo Weight

8

7

5

4

4

8

3

4

166

Weight

5

4

5

3

4

3

3

3

Key: W · F = Value Index, where W is weight and F is factor.

Was it portable? 3 Was it stable? 4 Cost-effective: 3 Adaptability with other devices: 3 Insurance recognized: 3

Using the evaluation matrix shown in Table 1, the technology and the application for maintaining or improving the quality of life of the target populations were measured. The collection of opinions and results from in-house surveys were obtained from caregivers and people with healthcare backgrounds that are familiar with assistive technology. Their input was valuable in assigning the weight to each factor. No patients of caregivers provided input, because they were not consulted. Through this collaborative method, the gathering of information was collected for each device and was taken into consideration when developing the final factors to design the matrix. Each factor provided the opportunity for individuals in the target populations to evaluate the device and offer their technical and practical input. The lack of literature on matrices evaluating assistive technology devices prompted researchers to develop a benchmark range of numbers of >100, assigning each device a number based on its value to the consumer. This number then qualified the final eight technologies for public evaluation (Table 2). Staff ranked the importance of each factor on a scale of 1–10, 10 having the highest weight and 1 the lowest. Each factor was given a numeric weight of 1–5, with 5 having the highest weight and 1 the lowest. Each of the

eight factors was then multiplied ( · ) by the amount of weight assigned in the corresponding column. The total number of each column was added. The total score of >100 was the standard for inclusion in a self-sufficient, independent living environment (W · F = Value Index).

Table 2. Technologies Accepted Against the Evaluation Matrix TECHNOLOGY

USE

DynaVox V—DynaVox

Augmentative and alternative communication

LifeShirt—Viviometrics

Respiratory and cardiopulmonary monitoring

mPower—Dakim

Cognitive fitness

Nemo Magni—Universal Aids, Inc.

Pocket-sized digital magnifier

SmartTalk—Freedom Scientific

Small personal computer for visually impaired

Turtle 400- ViTelNet

Vital Sign monitoring unit

VivoResponder Belt—Vivometrics

Compact, continuous life-sign monitoring system

Wii—Nintendo

Video gaming for cognitive fitness




MUNCERT ET AL.

At the time of evaluation, five of the selected eight technologies, DynaVox V, Nemo Magi, Smart Talk, Turtle 400, and Wii, were available to the attendees of CERMUSA’s Assistive Technology Exposition. Before the exposition, Saint Francis University’s IRB had determined this was an exempt study. Two hundred seventy-two surveys were completed by members of the target populations, their caregivers, and those in clinical practices or in an educational setting preparing to enter the clinical practice. The surveys included both technologic and demographic questions. Survey results were then compared against the calculated value index tabulation. This comparison validated the initial matrix evaluation completed by staff members. A sample statistical tabulation of surveys illustrated 94% of individuals believe that the devices were easy to use, n = 256; and 53% thought the devices meet their need, n = 144. Sixty-eight (68%) would pay the cost of the devices, n = 185. For individuals 51 years of age through 64 years of age, 69% would not need assistance to use the devices, n = 187. The outcomes of these methods of collecting data will be useful in selecting which devices could develop or broaden the quality of life of a special needs population.

Discussion Innovative research is needed to develop the best combination of wellness, special needs education, and technologies that assist or maintain the preferred quality of life for transitioning warriors, older adults, and individuals with disabilities. The number of older adults in the United States is likely to double over the next two decades, and many of those individuals will be retired military personnel. Many soldiers returning from Operation Enduring Freedom and Operation Iraqi Freedom have suffered injuries that have resulted in permanent disabilities, potentially requiring life-long care. This creates an economic and social crisis; America struggles to care for these individuals as they develop, or continue to live with, disabilities. Continued research, evaluation, and integration of qualifying technologies into individual housing and healthcare living environments for these target populations is needed. A loss of independence can be very frustrating for the person experiencing the loss, as well as for their caregiver(s). Fortunately, there are many devices and technologies that can be utilized by both these individuals and their caregivers. The development of an independent living environment capable of providing a setting that allows the individual to maintain or improve their quality of life can offer alternative living accommodations for warriors in transition, individuals with disabilities, and older adults. Future healthcare technologies should be cost effective, portable, unobtrusive, noninvasive, and sustainable to ensure that the target populations will adapt to them. This study does not satisfy all the requirements necessary to meet every individual’s special need. The objective was to develop an evaluation matrix that demonstrates the correlation between an assistive technology device and the need of the individual. This method will allow the end user of the device to better determine what devices will satisfy their need and the requirements for maintaining or improving their independence.


Over the course of the study, researchers found that there was an abundance of assistive technologies available for the target populations. Several devices were not easily accessible for research evaluation or for consumer testing; many of the companies required either a physician referral or a lease agreement to be executed. Some devices required purchase, and this was not cost effective for these researchers. Age and disability appropriate devices were also difficult to access. Technology can be vital to a person’s well-being, particularly when new tools facilitate communication, lifelong learning, maintenance of health, and the ability to continue living independently. By using new and innovative technologies to enhance living environments, the quality of life for warriors in transition, older adults, and individuals with disabilities can be maintained or improved.

Acknowledgments This project was supported by and administered via the U.S. Army Medical Research and Materiel Command Telemedicine and Advanced Technology Research Center, Fort Detrick, Maryland— Contract Number W81XWH-06-2-0018.

Disclosure Statement No competing financial interests exist. REFERENCES 1. United States Army 2008 Posture Statement. Information papers. Available at www.army.mil/aps/08/information_papers/sustain/Warrior_in_Transition.html (last accessed April 30, 2009). 2. Ambrosio et al. Comparison of mobility device delivery within Department of Veterans Affairs for individuals with multiple sclerosis versus spinal cord injury. J Rehabil Res Dev 2007;44:693–701 . Available at www.rehab.research.va.gov/ jour/07/44/5/pdf/ambrosio.pdf (last accessed January 14, 2010). 3. Institutes on Disabilities at Temple University, Technology, Pennsylvania Assistive Technology Lending Library. What is assistive technology? Available at www.temple.edu/instituteondisabilities/programs/assistive/atlend/ (last accessed January 11, 2010). 4. United States Census Bureau. Newsroom. 2010. Available at factfinder.census.gov/servlet/DTTable?_bm = y&-geo_id = 01000US&ds_name = PEP_2009_EST&-mt_name = PEP_2009_EST_G2009_T001 (last accessed August 31, 2010). 5. Agingstats.gov. Available at www.agingstats.gov/agingstatsdotnet/Main_Site/ Data/2008_Documents/Population.aspx (last accessed March 20, 2009). 6. Disability.gov. 54.4 Million Americans Report Some Level of Disability. Available at www.disability.gov/search/list?q_id = undefined&q = number + of + americans + with + disability&format = html (last accessed June 8, 2010). 7. National Institute on Aging. Figure 4. U.S. population aging 65 years and older: 1990 to 2050. Available at www.nia.nih.gov/ResearchInformation/ ConferencesAndMeetings/Workshop Report/Figure4.htm (last accessed July 30, 2010). 8. Emax Health. Occupational therapy: Restoring the lives of wounded soldiers. 2007. Available at www.emaxhealth.com/24/10817.html (last accessed April 14, 2010). 9. United States Department of Defense. 2010. Available at www.defense.gov/ news/casualty.pdf (last accessed August 31, 2010). 10. Army Brig. Gen. Loree Sutton, USA Today, March 4, 2009. 360,000 veterans may have brain injuries. Available at www.usatoday.com/news/military/2009-03-04braininjuries_N.htm (last accessed March 13, 2009).


11. Navy Surgeon General Donald Arthur, Bio-Medicine. One third of US troops suffer from mental health problems. Defense Department task Force on Mental Health. Available at www.bio-medicine.org/medicine-news/One-Third-of-USTroops-Suffer-from-Mental-Health-Problems-22083-1/ (last accessed March 8, 2009). 12. American Telemedicine Association. Telemedicine Defined. Available at www.americantelemed.org/i4a/pages/index.cfm?pageid = 3333 (last accessed February 11, 2010). 13. United States Department of Veteran Affairs, Care Coordination Services– Telehealth. Available at www.carecoordination.va.gov/telehealth/index.asp (last accessed March 21, 2009).

16. Batavia AI, Hammer GS. Toward the development of consumer-based criteria for the evaluation of assistive devices. J Rehabil Res Dev 1990;27:425–436. Available at www.ncbi.nlm.nih.gov/pubmed/2089152 (last accessed January 7, 2010).

Address correspondence to: Eric S. Muncert, MHRM Center of Excellence for Remote and Medically Under-Served Areas Saint Francis University 117 Evergreen Drive Loretto, PA 15940

14. Intel Corporation. What’s in a name? 2010. Available at http://itcommunity .intel.co.uk/community/uk/blog/2009/11/03/whats-in-a-name (last accessed March 30, 2010).

E-mail: [email protected] Received: November 18, 2010 Revised: February 07, 2011 Accepted: February 10, 2011

15. Cohn, Ellen, Brienza, David. Telerehabilitation research [Internet]. Version 13. Knol. 2009 Mar 24. Available at http://knol.google.com/k/ellen-cohn/titletelerehabilitation-research/kff6clazg0p1/2 (last accessed January 15, 2010).


