BACKGROUND

Rehabilitation Engineering Research Center on Telerehabilitation (RERC-TR) defined telerehabilitation (TR) as the remote delivery of rehabilitation and home health care services. One of the cost-effective solution to deliver rehabilitation and home health care services remotely is through the use of widely used information technology (IT) network, such as the Internet. At the RERC-TR, we build an Internet-based IT infrastructure to support delivery of remote wheelchair prescription service [1]. The remote wheelchair prescription project is supported by two main technology components: a videoconferencing system and an online portal. The videoconference system allows therapists from rural clinics to collaborate with an expert therapist from a metropolitan clinic in a real-time teleconsultation session. On the other hand, the online portal supports asynchronous collaboration between therapists, expert therapists, rehabilitation technology suppliers, and clients by providing a centralized data management system. Both systems are internet-based, allowing deployment to any clinic through a high speed internet connection. Researchers have been able to combine these components into an integrated therapist workbench to support TR activity.

Adoption of the therapist workbench  into not only a TR service but in everyday clinical practice depends on the system's usability. Generally, usability is defined as the measurement of the usefulness of a system [3]. A system is considered useful based on four aspects: 1) that the system helps its users to successfully complete their intended task (effective); 2) that the system helps the completion of the task in the most efficient manner possible (efficient); 3)  that the system helps user to fix their mistakes (error recovery); and 4) that the system is perceived as pleasant or easy to use.

Integrating workflow has the potential to increase the usability of the therapist workbench. A workflow is a logical step-by-step process taken from a traditional service delivery model. With workflow integrated into the therapist workbench, the flow of service can be monitored easily, potentially increasing both the effectiveness and efficiency of the system to support all members of the healthcare team involved in wheelchair prescription. This paper present the approach employed to identify the workflow in the remote wheelchair prescription project, and the implementation of the workflow into the therapist workbench.

METHOD

To identify the workflow of the service, the investigation started by comparing two wheelchair prescription models: through face-to-face assessment, and through TR. The face-to-face assessment was based on the standardized model currently employed at Center of Assistive Technology at the University of Pittsburgh Medical Center. The TR model was based on a  pilot TR clinic at Dubois Regional Medical Center, in DuBois, PA about 125 miles away from Pittsburgh, PA. Observation of the wheelchair prescription process resulted in the identification of four phases within the workflow: initial data collection, data documentation/reporting, finalizing the documentation through multidisciplinary team collaboration, and system delivery/fitting.

Initial data collection includes activities of gathering client's demographic information, initial assessment data, living environment assessment data, and other administrative data. Data documentation/reporting focus on activities to initialize letter of medical necessity, create medical documents, and track therapy progress. Finalizing the documentation involves multidisciplinary team supporting the client, thus requires heavy collaboration efforts, focusing on the communication between therapists, suppliers, and physicians. Finally, during the system delivery/fitting phase, therapist and suppliers focuses on the specifications and fit of the mobility device, training the client in the use of the mobility device, and that the client demonstrates safe and effective use of the device. Several system maintenance efforts were also performed in the system delivery phase, mostly focusing on giving the final recommendations to the system according to the therapist's recommendations. Table 1 list all the steps within each of the workflow phase.

Table 1. Phase and steps of remote wheelchair prescription

Service Delivery Process in Remote Wheelchair Prescription Project
Initial Data Collection	Initial evaluation by therapist with assistance of expert therapist through teleconsultation Document data, including demographic data Initial assessment by therapist with assistance of expert therapist through teleconsultation Device trial by device supplier with assistance of expert therapist through teleconsultation
Data Documentation	Document result of trial into letter of medical necessity
Finalize Documentation	Client’s home assessment by device supplier Send letter of medical necessity to physician for review and confirmation Device supplier submit completed form to funding agency
System Delivery and Fitting	Fitting and delivery of assistive device by therapist and device supplier with the assistance of expert therapist through teleconsultation Document outcome data Document final result data by contacting client several weeks after delivery

In order to integrate the workbench system into this workflow, identification the requirements were needed for each step. The process of analyzing the workflow were based on the following guided principles:

1. Removal of automated steps. Removal of steps that can be automated from the workflow is necessary to simplify the traditional workflow. A step can be automated if it does not require an active intervention from a human component to finish the task. For example, the process of confirming a letter of medical necessity requires the therapist to manually confirm the letter (such as by pressing a button, or adding digital signature into the document). However, the process of sending letter of medical necessity can be automated once the therapist confirmed the letter.
2. Identify the role responsible for the step. Observations of the existing roles within the remote wheelchair prescription project resulted in identification of three type of roles: therapist, physician, and rehabilitation technology supplier. Tying the role with the steps allowed investigators to:
3. create a role-controlled workflow. Every person has a role in the project, and every role has a specific responsibility according to the workflow.
4. create a tracking system. Therapists can monitor the progress of the service delivery for each client by looking at the workflow progression.
5. create a reminder system. The workbench system can trigger automated messages to remind each role of their responsibilities to advance the service progression.
6. Identify the information managed in the step. Identifying the type of information managed in the step helped identify the documents associated with each step. For example, in the initial assessment, client's data such as demographic information and health status data will be collected. Therefore, to manage this type of data, investigators needed to connect the step with the client intake document.
7. Identify the type of IT component to support the step. Several steps, such as assessment steps, require the use of videoconferencing system to connect a rural therapist with an expert therapist. The documentation phase; however, focused more on managing the information, requiring more use of the online portal. The workflow became a guiding tool for therapists, allowing them to access particular document necessary to perform a particular step.

The result of this method is a matrix of steps, responsible roles, supporting documents, and IT components for each step within the remote wheelchair prescription project:

Table 2. Matrix of steps, responsibility, and information requirements

	Role	Step Name	Document Associated	IT Components
Phase 1 Initial data collection
01	Physician	Initial Assessment	Client Intake Document	Online portal
Phase 2 Data documentation
01	Therapist	Initial Assessment	Client Intake Document	Online portal Videoconferencing
02	Therapist	Functional Assessment	Functioning Everyday with Wheelchair Form - Pre	Online portal Videoconferencing
03	Therapist	Client's Demographic Information Collection	Demographic Data - Pre	Online portal Videoconferencing
04	Therapist	Device Trial	Client Intake Document	Online portal Videoconferencing
Phase 3 Finalizing the documentation
	Supplier	Home Assessment	Client Intake Document	Online portal
	Therapist	Review Client Information	Client Intake Document	Online portal
	Physician	Approve Recommendation	Final Recommendation Document	Online portal
	Therapist	Device Fitting and Delivery	Final Recommendation Document	Online portal Videoconferencing
Phase 4 System delivery/fitting
	Therapist	Functioning Everyday with Wheelchair Form Post Service	Functioning Everyday with Wheelchair Form - Post	Online portal Videoconferencing
	Therapist	Demographic Data Post Service	Demographic – Post Form	Online portal Videoconferencing
	Therapist	Telerehabilitation Questionnaire	Survey Document	Online portal

As listed in Table 2, not all of the steps are translated into the final matrix. Steps that can be automated were taken out, while steps that require the use of more than one type of document were simplified, either by combining the documents or by splitting the steps.

RESULTS AND DISCUSSIONS

The following is an illustration of the workflow that was implemented to support the research project entitled remote wheelchair prescription within the RERC-TR. Figure 1 illustrates the workflow implemented in the online TR portal. With the workflow, a therapist, physician, rehabilitation technology suppliers and in the future a client can track the service delivery system and access information readily with a high speed internet connection. Permission rights can also be applied to allow certain roles within the system as to who can edit and only view specific steps.

Currently, the infrastructure of the workflow system created for the remote wheelchair prescription project is being modified and deployed to several other rehabilitation services, including traumatic brain injury service. Investigators believe that this method is transferable to any TR service, and has the potential to improve the usability and efficiency of the systems currently used to support TR.