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LEADER Focus
Q
Human factors in the development and
implementation of telerehabilitation systems
David M Brennan* and Linsey M Barker
†
*National Rehabilitation Hospital, Center for Applied Biomechanics and Rehabilitation Research, Washington, DC;
†
Virginia Polytechnic
Institute and State University, Grado Department of Industrial and Systems Engineering, Blacksburg, Virginia, USA
Summary
Telemedicine services must be designed and implemented with the users in mind. When conducting telerehabilitation,
factors such as age, education and technology experience must be taken into account. In addition, telerehabilitation must
also accommodate a range of potential patient impairments, including deficits in language, cognition, motor function,
vision and voice. Telerehabilitation technology and treatment environments should adhere to universal design standards so
as to be accessible, efficient, usable and understandable to all. This will result in improved access to a wider range of
telerehabilitation services that will facilitate and enhance the rehabilitative treatment and recovery of people living with
varying levels of injury, impairment and disability.
Introduction
Telemedicine services usually involve a patient, a clinician,
some form of medical information and a method of data
transmission. While the details (e.g. the diagnosis of the
patient, the specialty of the clinician[s], the content and
format of the medical information, and how and when the
information is transmitted) will vary depending on the
application, there are high-level goals such as patient
satisfaction, security of medical information, device
usability and clinician adoption which are common to all
telemedicine services.
In studying the human factors of telemedicine, it is
helpful to use a macroergonomic approach. Unlike
microergonomics, which considers only the users and their
relationship with technology, macroergonomics is a
top-down approach which considers the human–
technology relationship relative to the organizational
structure and external environment in which it occurs.
1
By
focusing equal attention on the four subsystems (personnel,
technology, organization and environment) (Figure 1),
valuable insight can be obtained into how telemedicine
programmes operate and how they can be optimized.
An important human factor in telemedicine is the role
that personnel play in all stages of planning, training and
implementation. In telemedicine programmes, the
definition of personnel (or ‘users’) is broad and
encompasses the entire range of people involved in a
telemedicine encounter, which may consist of primary care
and specialist clinicians, patients, administrators and
support staff such as technical support personnel and
caregivers.
2
Depending on the application, the number of
users during a telemedicine encounter could be as few as
two (e.g. a patient at home connected to a nurse at a
monitoring centre) or as many as a dozen or more (e.g. a
specialist consultation linking people at multiple sites).
Each user’s response to telemedicine will be affected by his
or her own level of technical expertise, physical capabilities
and organizational cultures.
Telerehabilitation
Telerehabilitation refers to the delivery of medical
rehabilitation services and the support of independent
living, using telehealth technologies.
3,4
It involves clinical
disciplines such as speech-language pathology,
occupational and physical therapy, neuropsychology,
assistive technology and cardiac and vocational
rehabilitation. Telerehabilitation patients include those
with stroke, brain or spinal cord injuries, amputation and
orthopaedic or developmental impairments. The types of
telerehabilitation interventions that can be delivered are
broad and include applications such as direct patient service
delivery,
5,6
specialist consultation,
7,8
remote monitoring
and home telehealth,
9–11
and telerobotics.
12,13
The demand
for rehabilitation services is growing as a result of the aging
population and improved treatment of patients with stroke,
brain injury and other disabling conditions. Because of the
increasing demand, as well as the problems of clinician
Accepted 10 November 2007
Correspondence: David M Brennan, National Rehabilitation Hospital, 102 Irving
Street, NW, Washington, DC 20010, USA (Fax: þ1 202 726 7521; Email: david.m.
brennan@medstar.net)
Journal of Telemedicine and Telecare 2008; 14: 55–58 DOI: 10.1258/jtt.2007.007040
..............................................................
shortages and decreased reimbursement, rehabilitation
practitioners are turning to telerehabilitation as a way of
improving access, enhancing the quality of care and
reducing costs.
Human factors in telerehabilitation
It is essential that all telemedicine services are designed and
implemented with the users in mind. While factors such as
age, education and technology experience must be taken
into account when conducting telerehabilitation,
consideration must also be given to patients’ impairment(s).
Deficits in cognitive, gross or fine motor, visual, language or
voice skills all play an important role in patients’ ability to
use the technology and their level of acceptance and
adoption of receiving services at a distance.
4
Tele-
rehabilitation technology should maximize a patient’s
abilities while minimizing the effect of any abilities that
may have been lost or impaired.
14
One way to accomplish
this is by applying basic universal design principles, for
example, providing a large button telephone, offering
alternative input methods to devices (such as a touch-screen
or voice recognition), or using simplified large-text or
graphic-based instruction manuals and troubleshooting
guides.
Telerehabilitation programmes must also account for the
range of different clinician users who are involved in all
aspects of service delivery. In addition to the consideration
given to clinicians’ technical knowledge, experience and
training, matters such as professional licensure and
professional scope of practice must also be recognized and
addressed. The American Speech–Language–Hearing
Association and the Canadian Association of Occupational
Therapists are two professional associations which have
tried to educate their members about telerehabilitation and
to develop policies on the delivery of remote rehabilitation
services.
15,16
It is paramount that telerehabilitation
clinicians ensure that the services they intend to provide are
within their professional scope of practice and that they
possess the knowledge and skills required to provide them.
Other important human factors issues in
telerehabilitation are the service delivery environment
and the training of users. The design of a telerehabilitation
space must allow patients with mobility aides such as
walkers and wheelchairs to access the facility. In normal
telemedicine practice, it is important to maintain an
uncluttered environment and minimize distractions in the
treatment space.
17
This is even more important for
telerehabilitation patients who may have decreased levels of
attention (e.g. following traumatic brain injury). In training
telerehabilitation clinicians and support staff, attention
must be paid to ensuring that everyone is familiar with
disability-related matters and is comfortable about
communicating with patients who may have impaired
speech or language. For telerehabilitation patients,
alternative educational techniques and informed consent
procedures (e.g. simplified demonstration rather than
course-based instruction) may be needed to ensure they are
able to fully understand the procedures and the tasks that
will be required of them.
Much as general medicine has seen a gradual shift
towards preventative, proactive and continuous care,
18
rehabilitation has also become increasingly focused on the
prevention of secondary complications. Rehabilitative care
following a stroke, spinal cord or traumatic brain injury is
often a lifelong process, with recovery occurring at different
rates for each patient. Telerehabilitation for these patients
can be approached using established techniques for disease
management and care coordination.
19 – 21
Home health and
monitoring technologies can be used to help reduce or
avoid dangerous medical consequences (e.g. pressure sores
in patients with spinal cord injuries) and
re-hospitalizations.
22,23
While placing technology in the
rehabilitation patient’s home is the most direct way to
improve access to care, it magnifies some of the
considerations already mentioned and raises additional
concerns as user roles become more dynamic and the
service delivery environment becomes less controlled.
In the normal telemedicine delivery model, there are staff
available at each site to assist users during the telemedicine
encounter and help with the set-up and use of any
equipment. However, the home environment is an
unsupervised setting, with on-site assistance only available
from the caregiver. Thus it is essential to provide training for
caregivers who may be asked to act as an impromptu
scheduler, clinician assistant, audiovisual technician or
technology support person. Devices placed in the home
must be simple to operate, reliable and have a high level of
fault tolerance. Remote system diagnostics may be useful for
troubleshooting and maintenance of the equipment at a
distance. Patient privacy must always be protected, so as to
comply with the relevant legal and regulatory requirements,
and also to give patients confidence that they are active
participants in their care, rather than being watched by ‘big
brother’.
Given the broad scope of telerehabilitation, there is no
single generic system that meets the needs of all
applications; rather systems need to be flexible based on
their entire context of use. Figure 2 summarizes and
illustrates several major subsets of human factors
considerations that should be used to guide planning and
delivery of telerehabilitation applications. For example, in
using a computer-based telerehabilitation system to deliver
speech-language treatment to a stroke survivor,
Figure 1 Macroergonomic model of relationships within telemedicine
subsystems
D M Brennan and L M Barker Human factors in telerehabilitation
56 Journal of Telemedicine and Telecare Volume 14 Number 2 2008
..............................................................
impairments in language, cognition and motor function
necessitate a simple user interface (e.g. with large on-screen
buttons and limited distractions such as toolbars and
menus), an easy way to interact with the system (e.g. a
touchscreen computer monitor) and an environment that
does not distract the patient or detract from the ability of
the clinician to deliver treatment.
Conclusion
Human factors and technology usability play significant
roles in the utilization, acceptance and economic viability
of telemedicine programmes generally.
2,14,24,25
Thus it is
essential that theories of human factors and user centred
design be applied to the planning and implementation of
new programmes and the design of new devices.
26
This is
supported by recent telemedicine practice standards and
technical guidelines that incorporate human factors
considerations.
27
Human factors principles are also central to the growth
of telerehabilitation. With a diverse group of clinicians
and patients, it is essential that all aspects of
telerehabilitation service delivery be accessible, efficient,
understandable and usable by all people regardless of
their age, background or abilities. This will result in
improved access to a wider range of telerehabilitation
services that will facilitate and enhance the rehabilitative
treatment and recovery of people living with varying
levels of injury, impairment and disability.
References
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D M Brennan and L M Barker Human factors in telerehabilitation
Journal of Telemedicine and Telecare Volume 14 Number 2 2008
57
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58 Journal of Telemedicine and Telecare Volume 14 Number 2 2008
