TOOL KIT FOR PROVIDING HOME BASED TELE

TOOL KIT FOR PROVIDING HOME BASED TELE
TOOL KIT FOR PROVIDING HOME BASED
TELE-REHABILITATION SERVICES
USING AN iPAD
TOOL KIT FOR PROVIDING HOME BASED TELE-REHABILITATION SERVICES USING AN iPAD
E-Health Project Officer
Senior Technical Officer
Manager of Tele-Rehabilitation
Tele-Rehabilitation Speech Pathologist
Tele-Rehabiliation Physiotherapist
Tele-Rehabilitation Occupational Therapist
Marisa Barbarioli
Greg Morris
Clarie Morris
Karina Quince
Jill Garner
Adele Braiotta
This resource was developed as part of the Telehealth in the Home project.
Telehealth in the Home is led by Flinders University, in partnership with SA Health and includes the SA
Rehabilitation Statewide Clinical Network, the SA Older People Clinical Network and the SA Palliative Care
Clinical Network.
An initiative of the Australian Government.
Adelaide, South Australia, 2014.
The steering committee of the Telehealth in the Home project;
Michael Kidd, Tom Symonds, Colin Carati, David Currow, Maria Crotty, Craig Whitehead, Jennifer Tieman,
Kate Swetenham, Peter Chapman, Sarah Mahoney, Alan Taylor.
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Oh, I was a bit
nervous the first
week because it was
something
new. “Will I do it
right? Have I
remembered what to
do?” That sort of
thing… It was easy
to pick up
Tele-Rehabilitation
Patient
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Contents
......................................................................................................................................................... 1
Thinking about doing Tele-Rehabilitation? ............................................................................................. 7
Overview of Tele-Rehabilitation Publications ................................................................................... 9
List of Tele-Rehabilitation Publications ......................................................................................... 10
International Tele-Rehabilitation Research Units ........................................................................... 14
Things you need to know about doing Tele-Rehabilitation ..................................................................... 15
Tele-Rehabilitation – Policies and Guidelines ................................................................................. 19
Things you need to consider before starting Tele-Rehabilitation ............................................................. 23
Safety- How Did We Assess The Risks? ............................................................................................. 27
Risk Readiness for Tele-Rehabilitation Services .............................................................................. 27
Identifying Risks in Clinical Processes ............................................................................................ 28
Assessing Risk in the Clinical Environment ..................................................................................... 31
Managing Risk in Tele-Rehabilitation ............................................................................................ 34
Managing Change ...................................................................................................................... 35
Stakeholder Engagement Process................................................................................................. 35
Communication Strategy ............................................................................................................. 36
Quality in Tele-Rehabilitation .......................................................................................................... 37
Standards and Accreditation in Australia ....................................................................................... 37
Guidelines for Tele-Rehabilitation ................................................................................................ 38
Improving Processes in Tele-Rehabilitaton .................................................................................... 39
Training in Tele-Rehabilitation ..................................................................................................... 41
Development of training tools and practice resources .................................................................... 42
Providing a Tele-Rehabilitation Service ................................................................................................ 45
Tele-Rehabilitation Service Model ................................................................................................... 47
Who was Suitable for Tele-Rehabilitation? .................................................................................... 47
Translating Standard Clinical Service Delivery to Tele-Rehab Delivery ............................................... 51
Delivering Tele-Rehabilitation Services ......................................................................................... 55
Clinical Principles and Lessons Learned ......................................................................................... 63
Conclusion................................................................................................................................. 64
Resources to support aTele-Rehabilitation Service ................................................................................ 65
Clinical Resources .......................................................................................................................... 67
Information and Communications Technology Resources ................................................................. 127
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Thinking about doing Tele-Rehabilitation?
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Overview of Tele-Rehabilitation Publications
A review of the literature over the last 10 years reveals mounting evidence in the field of telerehabilitation regarding effectiveness and efficacy (Kairy et al 2009). Baron et al (2005) reported
that ‘tele-rehabilitation overcomes issues relating to access to services such as distance and
immobility, as well as assisting in caseload prioritisation, allowing for intensive treatment regimes,
reduced length of stay in hospital, longer term rehabilitation management, and meeting the
increased demand of speech services’. Onor et al (2008) compared the effectiveness of telecare in
three elderly populations and found that it could provide health services in rural areas, enlarge the
rehabilitation opportunities by using computer aided systems, improve the quality of life and
reduce medical costs.
Sanford et al (2004) and Bendixen et al (2007) used tele-video to accurately identify home
modifications needs, Schein et al (2008) demonstrated positive outcomes associated with teleconsultation between a remote seating specialist and a local therapist for evaluating wheelchair
prescriptions and the American Speech- Language-Hearing Association endorsed tele-rehabilitation
as an appropriate and suitable service delivery model for speech pathologists provided that the
services are of the same quality as those delivered face to face.
Finkelstein et al (2006) found that tele-rehabilitation has the capability to improve quality of life
and reduce medical costs by increasing number of patients seen whilst in 2008, Dellifraine et al
stated that tele-rehabilitation was an ‘Effective clinical intervention in many settings with different
patient groups’.
More recently, a review of the evidence by Ward and Burns (2014) supported the use of telerehabilitation in dysphagia management and Ng et al (2013) investigated tele-rehabilitation as a
way to address executive dysfunction after traumatic brain injury, finding it could deliver cognitive
re-orientation and promote community integration.
Rogante et al ( 2010) report in their review of the literature that there is a ‘Lack of comprehensive
studies’ providing evidence to integrate tele-rehabilitation technologies into clinical practice. More
evidence is needed to investigate how tele-rehabilitation can be provided within the context of an
ageing population, shrinking health dollar and increasing access to high end technology including
wearable technologies, virtual reality platforms, mobile devices, avatars and commercially available
apps. There has been recent growth in the number of tele-rehabilitation services available to
clients due to advances in technology and more attention is being paid to accessible and familiar
technologies. Lim et al (2012) and Gatsou et al (2013) explored the use of tablets with older people
and concluded that ease of use is extremely important and Alvseike et al (2012) reported that
perception of use were often based on a misunderstanding of the requirements for technical
competence.
Liu et al (2014) found that rehabilitation professionals who are faced with using new technologies
are less concerned about effort and social pressures than they are about what the technologies can
do for them or their clients. Rehabilitation professionals’ acceptance and adoption of technologies
rely on conditions that facilitate their use. These conditions include scheduling, support and a
conductive environment.
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List of Tele-Rehabilitation Publications
1. Agostini, M., Garzon, M., Benavides-Varela, S., De Pellegrin, S., Bencini, G., Rossi, G., ... &
Tonin, P. (2014). Telerehabilitation in Poststroke Anomia. BioMed research international,
2014.
2. Alvseike, H., & Brønnick, K. (2012). Feasibility of the iPad as a hub for smart house
technology in the elderly; effects of cognition, self-efficacy, and technology experience.
Journal of multidisciplinary healthcare, 5, 299.
3. American Speech-Language-Hearing Association. (2005). Evidence-based practice in
communication disorders.
4. Barlow, I. G., Liu, L., & Sekulic, A. (2009). Wheelchair seating assessment and intervention:
A comparison between telerehabilitation and face-to-face service. International Journal of
Telerehabilitation, 1(1), 17-28.
5. Baron, C., Hatfield, B., & Georgeadis, A. (2005). Management of communication disorders
using family member input, group treatment, and telerehabilitation. Top Stroke Rehabil,
12(2), 49-56.
6. Bendixen, R. M., Horn, K., & Levy, C. (2007). Using telerehabilitation to support elders with
chronic illness in their homes. Topics in Geriatric Rehabilitation, 23(1), 47-51.
7. Bensink, M., Hailey, D., & Wootton, R. (2006). A systematic review of successes and
failures in home telehealth: preliminary results. Journal of Telemedicine and Telecare,
12(suppl 3), 8-16.
8. Bittner, A. K., Wykstra, S. L., Yoshinaga, P. D., & Li, T. (2014). Telerehabilitation for people
with low vision. The Cochrane Library.
9. Botsis, T., & Hartvigsen, G. (2008). Current status and future perspectives in telecare for
elderly people suffering from chronic diseases. Journal of Telemedicine and Telecare,
14(4), 195-203.
10. Cason, J. (2012). Telehealth opportunities in occupational therapy through the Affordable
Care Act. American Journal of Occupational Therapy, 66(2), 131-136.
11. Cason, J. (2014). Telehealth: A Rapidly Developing Service Delivery Model for Occupational
Therapy. International Journal of Telerehabilitation, 6(1), 29-36.
12. Chumbler, N. R., Quigley, P., Li, X., Morey, M., Rose, D., Sanford, J., ... & Hoenig, H. (2012).
Effects of Telerehabilitation on Physical Function and Disability for Stroke Patients A
Randomized, Controlled Trial. Stroke, 43(8), 2168-2174.
13. Cimperman, M., Brenčič, M. M., Trkman, P., & Stanonik, M. D. L. (2013). Older Adults'
Perceptions of Home Telehealth Services. Telemedicine and e-Health, 19(10), 786-790.
14. Constantinescu, G. A., Theodoros, D. G., Russell, T. G., Ward, E. C., Wilson, S. J., &
Wootton, R. (2010). Home-based speech treatment for Parkinson's disease delivered
remotely: a case report. Journal of Telemedicine and Telecare, 16(2), 100-104.
15. Coupar, F., Pollock, A., Legg, L. A., Sackley, C., & van Vliet, P. (2012). Home-based therapy
programmes for upper limb functional recovery following stroke. Cochrane Database Syst
Rev, 5.
16. Cranen, K., Drossaert, C. H., Brinkman, E. S., Braakman‐Jansen, A. L., IJzerman, M. J., &
Vollenbroek‐Hutten, M. M. (2012). An exploration of chronic pain patients’ perceptions of
home telerehabilitation services. Health Expectations, 15(4), 339-350.
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17. DelliFraine, J. L., & Dansky, K. H. (2008). Home-based telehealth: a review and metaanalysis. Journal of Telemedicine and Telecare, 14(2), 62-66.
18. Eriksson, L., Lindström, B., & Ekenberg, L. (2011). Patients' experiences of
telerehabilitation at home after shoulder joint replacement. Journal of telemedicine and
telecare, 17(1), 25-30.
19. Finkelstein, S. M., Speedie, S. M., & Potthoff, S. (2006). Home telehealth improves clinical
outcomes at lower cost for home healthcare. Telemedicine Journal & e-Health, 12(2), 128136.
20. Forducey, P. G., Glueckauf, R. L., Bergquist, T. F., Maheu, M. M., & Yutsis, M. (2012).
Telehealth for persons with severe functional disabilities and their caregivers: facilitating
self-care management in the home setting. Psychological services, 9(2), 144.
21. Gatsou, C., Politis, A., & Zevgolis, D. (2013, September). Exploring inexperienced user
performance of a mobile tablet application through usability testing. In Computer Science
and Information Systems (FedCSIS), 2013 Federated Conference on (pp. 557-564). IEEE.
22. Georgeadis, A., Brennan, D., Barker, L., & Baron, C. (2004). Telerehabilitation and its effect
on story retelling by adults with neurogenic communication disorders. Aphasiology, 18(57), 639-652.
23. Hermann, V. H., Herzog, M., Jordan, R., Hofherr, M., Levine, P., & Page, S. J. (2010).
Telerehabilitation and electrical stimulation: An occupation-based, client-centered stroke
intervention. American Journal of Occupational Therapy, 64(1), 73-81.
24. Hill, A. J., & Miller, L. E. (2012). A survey of the clinical use of telehealth in speech-language
pathology across Australia. Journal of Clinical Practice in Speech-Language Pathology,
14(3), 110-117.
25. Hill, A. J., Theodoros, D. G., Russell, T. G., Cahill, L. M., Ward, E. C., & Clark, K. M. (2006). An
Internet-based telerehabilitation system for the assessment of motor speech disorders: a
pilot study. American Journal of Speech-Language Pathology, 15(1), 45-56.
26. Hill, A. J., Theodoros, D., Russell, T., & Ward, E. (2009). Using telerehabilitation to assess
apraxia of speech in adults. International journal of language & communication disorders,
44(5), 731-747.
27. Hoffmann, T., & Russell, T. (2008). Pre-admission orthopaedic occupational therapy home
visits conducted using the Internet. Journal of telemedicine and telecare, 14(2), 83-87.
28. Hoffmann, T.C., Russell, T.G., Cooke. (2007). Remote measurement via the Internet of
upper limb range of motion in people who have had a stroke. Journal of Telemedicine and
Telecare, 13, 401‐405
29. Jones, T., Kay, D., Upton, P., & Upton, D. (2013). An Evaluation of Older Adults Use of iPads
in Eleven UK Care-Homes. International Journal of Mobile Human Computer Interaction
(IJMHCI), 5(3), 62-76.
30. Kairy, D., Lehoux, P., Vincent, C., & Visintin, M. (2009). A systematic review of clinical
outcomes, clinical process, healthcare utilization and costs associated with
telerehabilitation. Disability & Rehabilitation, 31(6), 427-447.
31. Khan, F., Amatya, B., & Kesselring, J. (2013). Telerehabilitation for persons with multiple
sclerosis. The Cochrane Library.
32. Koch, S. (2006). Meeting the Challenges-the Role of Medical Informatics in an Ageing
Society. In Ubiquity: Technologies for Better Health in Aging Societies: Proceedings of
MIE2006 (Vol. 124, p. 25). IOS Press.
33. Langhorne, P., & Widen-Holmqvist, L. (2007). Early supported discharge after stroke.
Journal of Rehabilitation Medicine, 39(2), 103-108.
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34. Liu, L., Miguel Cruz, A., Rios Rincon, A., Buttar, V., Ranson, Q., & Goertzen, D. (2014). What
factors determine therapists' acceptance of new technologies for rehabilitation-a study
using the Unified Theory of Acceptance and Use of Technology (UTAUT). Disability &
Rehabilitation, (0), 1-9.
35. Lim, F. S., Wallace, T., Luszcz, M. A., & Reynolds, K. J. (2012). Usability of Tablet Computers
by People with Early-Stage Dementia. Gerontology, 59(2), 174-182.
36. Mashima, P. A., & Doarn, C. R. (2008). Overview of telehealth activities in speech-language
pathology. Telemedicine and e-Health, 14(10), 1101-1117.
37. Ng, E. M., Polatajko, H. J., Marziali, E., Hunt, A., & Dawson, D. R. (2013). Telerehabilitation
for addressing executive dysfunction after traumatic brain injury. Brain Injury, 27(5), 548564.
38. Onor, M. L., Trevisiol, M., Urciuoli, O., Misan, S., Bertossi, F., Tirone, G., ... & PascoloFabrici, E. (2008). Effectiveness of telecare in elderly populations–a comparison of three
settings. Telemedicine and e-Health, 14(2), 164-169.
39. Ortiz-Gutiérrez, R., Cano-de-la-Cuerda, R., Galán-del-Río, F., Alguacil-Diego, I. M., PalaciosCeña, D., & Miangolarra-Page, J. C. (2013). A telerehabilitation program improves postural
control in multiple sclerosis patients: a spanish preliminary study. International journal of
environmental research and public health, 10(11), 5697-5710.
40. Palsbo, S. E., Dawson, S. J., Savard, L., Goldstein, M., & Heuser, A. (2007). Televideo
assessment using functional reach test and European stroke scale. stroke, 12, 14.
41. Piqueras, M., Marco, E., Coll, M., Escalada, F., Ballester, A., Cinca, C., ... & Muniesa, J. M.
(2013). Effectiveness of an Interactive Virtual Telerehabilitation System in Patients After
Total Knee Arthroplasty: A Randomized Controlled Trial. Journal of Rehabilitation
Medicine, 45(4), 392-396.
42. Rahimpour, M., Lovell, N. H., Celler, B. G., & McCormick, J. (2008). Patients’ perceptions of
a home telecare system. International journal of medical informatics, 77(7), 486-498.
43. Rebola, C. B., & Jones, B. (2013, September). Sympathetic devices: designing technologies
for older adults. In Proceedings of the 31st ACM international conference on Design of
communication (pp. 151-156). ACM.
44. Rogante, M., Grigioni, M., Cordella, D., & Giacomozzi, C. (2010). Ten years of
telerehabilitation: A literature overview of technologies and clinical applications.
NeuroRehabilitation, 27(4), 287-304.
45. Sanders, C., Rogers, A., Bowen, R., Bower, P., Hirani, S., Cartwright, M., ... & Newman, S. P.
(2012). Exploring barriers to participation and adoption of telehealth and telecare within
the Whole System Demonstrator trial: a qualitative study. BMC health services research,
12(1), 220.
46. Sanford, J. A., Hoenig, H., Griffiths, P. C., Butterfield, T., Richardson, P., & Hargraves, K.
(2007). A comparison of televideo and traditional in-home rehabilitation in mobility
impaired older adults. Physical & Occupational Therapy in Geriatrics, 25(3), 1-18.
47. Sanford, J. A., Jones, M., Daviou, P., Grogg, K., & Butterfield, T. (2004). Using
telerehabilitation to identify home modification needs. Assistive Technology, 16(1), 43‐53.
48. Schein, R. M., Schmeler, M. R., Holm, M. B., Pramuka, M., Saptono, A., & Brienza, D. M.
(2011). Telerehabilitation assessment using the Functioning Everyday with a WheelchairCapacity instrument. Journal of rehabilitation research and development, 48(2), 115-124.
49. Schein, R. M., Schmeler, M. R., Holm, M. B., Saptono, A., & Brienza, D. M. (2010).
Telerehabilitation wheeled mobility and seating assessments compared with in person.
Archives of Physical Medicine and Rehabilitation, 91(6), 874-878.
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50. Schein, R. M., Schmeler, M. R., Holm, M. B., Saptono, A., & Brienza, D. M. (2010).
Telerehabilitation wheeled mobility and seating assessments compared with in person.
Archives of Physical Medicine and Rehabilitation, 91(6), 874-878.
51. Sherer, M., Evans, C. C., Leverenz, J., Stouter, J., Irby Jr, J. W., Eun Lee, J., & Yablon, S. A.
(2007). Therapeutic alliance in post-acute brain injury rehabilitation: predictors of strength
of alliance and impact of alliance on outcome. Brain Injury, 21(7), 663-672.
52. Sim, S., Barr, C. J., & George, S. (2014). Comparison of equipment prescriptions in the
toilet/bathroom by occupational therapists using home visits and digital photos, for
patients in rehabilitation. Australian occupational therapy journal.
53. Tindall, L. R., Huebner, R. A., Stemple, J. C., & Kleinert, H. L. (2008). Videophone-delivered
voice therapy: A comparative analysis of outcomes to traditional delivery for adults with
Parkinson’s disease. Telemedicine and e-Health, 14(10), 1070-1077.
54. Wakeford, L., Wittman, P. P., White, M. W., & Schmeler, M. R. (2004). Telerehabilitation
position paper. The American journal of occupational therapy: official publication of the
American Occupational Therapy Association, 59(6), 656-660.
55. Ward, E. C., & Burns, C. L. (2014). Dysphagia Management via Telerehabilitation: A Review
of the Current Evidence. Journal of Gastroenterology and Hepatology Research, 3(5).
56. World Health Organization, & World Bank. (2011). World report on disability. Geneva:
World Health Organization. Retrieved from
http://whqlibdoc.who.int/publications/2011/9789240685215_eng.pdf
57. Zucchero, R. A., Hooker, E., & Larkin, S. (2010). An interdisciplinary symposium on
dementia care improves student attitudes toward health care teams. International
Psychogeriatrics, 22(02), 312-320.
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International Tele-Rehabilitation Research Units
Summary of research units from http://www.habiliseurope.eu/?q=node/529
A number of important Tele-rehabilitation Research Units are described below;
AETMIS
AETMIS (the Québec government agency responsible for health services and technology
assessment, www.aetmis.gouv.qc.ca)
The Agency proposes some guidelines and technical standards and recommends that the Quebec
Ministere de la Sante et des Services sociaux adopt them in cooperation with the authorities
concerned.
ATA Tele-rehabilitation SIG
ATA Tele-rehabilitation SIG (American Telemedicine Association; Tele-rehabilitation Special Interest
Group, media.americantelemed.org/ICOT/sigtelerehab.htm)
The Tele-rehabilitation SIG mission is to enhance access to rehabilitation services and support
independent living through the use of telehealth technologies. Basically the group: i) develops
innovative systems "tools" to be used for tele-rehabilitation; ii) collects data of evidence-based
outcomes of tele-rehabilitation clinical applications; iii) acts as a resource for reimbursement issues.
Scottish Centre for Telehealth
Scottish Centre for Telehealth. (http://www.sct.scot.nhs.uk/ )
The Centre committed a Tele-rehabilitation Scoping Study whose main starting points were:
1) Rehabilitation services which may use tele-rehabilitation should include:
• Direct intervention with the client (assessment, treatment, monitoring and education)
• Care coordination
• Caregiver education
• Consultation with specialist clinicians.
2) While tele-rehabilitation is an emerging field in healthcare, research from around the world is
building an evidence-base for this model of service delivery.
3) It is essential to review areas of rehabilitation need, especially in countries with dispersed
population like Scotland.
Tele-rehabilitation Research Unit - The University of Queensland
(http://www.uq.edu.au/telerehabilitation )
“The overall objective of the Tele-rehabilitation Research Unit is to develop, validate and
implement tele-rehabilitation applications to improve access to allied health services for persons
with communication disorders, physical disability and/or hearing impairments both within the
home, and in rural and remote environments”.”
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Things you need to know about doing TeleRehabilitation
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Health policy refers to decisions, plans, and actions that are undertaken to
achieve specific health care goals within a society. An explicit health policy
can achieve several things: it defines a vision for the future which in turn
helps to establish targets and points of reference for the short and medium
term. It outlines priorities and the expected roles of different groups; and it
builds consensus and informs people.
World Health Organization. Health Policy.
http://www.who.int/topics/health_policy/en/
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Tele-Rehabilitation – Policies and Guidelines
When looking at developing and delivering tele-rehabilitation services, it is useful to understand
both the broad context of tele-rehabilitation as it is practiced in other countries and cultures and
the specific policies and guidelines that pertain to how tele-rehabilitation is delivered.
In the Australian context, one of the standards that health services delivery is influenced by the
National Safety and Quality Health Service Standards. The Standards have been designed for use
by all health services and “are integral to theaccreditation process as they determine how and
against what an organisation’s performance will be assessed.” Australian Commission on Safety
and Quality in Health Care (ACSQHC) (September 2011), National Safety and Quality Health Service
Standards, ACSQHC, Sydney.
All health organisations have documentation which supports the way clinicians practice, non
clinicians perform their tasks and patients and carers are supported to engage with health services.
For health service employees policies, procedures and work instructions are ubiquitous. Policies
have wide application and describe standards that all users should normally follow. Clinicians have
access to guidelines to help support effective clinical practice. Guidelines are sets of best practices
that are supported by evidence or consensus. Clinicians attempt to follow guidelines, though the
strength of the evidence supporting the guideline varies and country and cultural considerations
may affect contextual relevance. Guideline recommendations would ideally translate into
operational documents such as policies, procedures and work instructions.
Listed below are links to relevant policies and guidelines that pertain to tele-rehabilitation service
development and delivery. They provide a context for practice and can assist to inform local policy
and processes.
Australia
Policy Paper: Implementing e-health across allied health to maximise
Outcomes
AHPA March 2013
http://www.ahpa.com.au/Portals/0/Representation/AHPA_Policy_Paper-eHealth-March_2013.pdf
Telehealth and Allied Health position paper
Services for Australian Rural and remote Allied Health, July 2012
http://sarrah.org.au/publication/allied-health-and-telehealth-position-paper
Video Conferencing Technology Policy Directive
July 2013, Dept of Health, Govt of South Australia
http://www.sahealth.sa.gov.au/wps/wcm/connect/88ed860040b7f6f38e11ee779c264138/Directiv
e_Video+Conferencing+Technology_Policy_Aug2013.pdf?MOD=AJPERES&CACHEID=88ed860040b7
f6f38e11ee779c264138
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Guidelines for Sub Acute Services Offering Digital Telehealth Network Consultations
July 2013, Dept of Health, Govt of South Australia
http://www.sahealth.sa.gov.au/wps/wcm/connect/68e53f8040b71583ad4dff809397f885/Guidelin
es+for+SubAcute+Services+Offering+Telehealth+Network+Consultations+August+2013.pdf?MOD=AJPERES&C
ACHEID=68e53f8040b71583ad4dff809397f885
SA Digital Telehealth Network- Best Practice Guidelines for Remote Clinical Sessions
Dept of Health, Govt of South Australia
http://www.sahealth.sa.gov.au/wps/wcm/connect/68e53f8040b71583ad4dff809397f885/Guidelin
es+for+SubAcute+Services+Offering+Telehealth+Network+Consultations+August+2013.pdf?MOD=AJPERES&C
ACHEID=68e53f8040b71583ad4dff809397f885
APA Background paper Telerehabilitation 2012
http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Background_Papers_Telerehabilita
tion.pdf
APA Position Paper Telerehabilitation and Physiotherapy 2012
http://www.physiotherapy.asn.au/DocumentsFolder/Advocacy_Position_Telerehabilitation_2009.p
df
International
EVIDENCE ON THE EFFECTIVENESS OF TELEREHABILITATION APPLICATIONS
Institute of health economics , Alberta Canada 2010
http://www.ihe.ca/documents/Telerehab%20Applications.pdf
A Blueprint for Telerehabilitation Guidelines
American Telemedicine Association Oct 2010
http://www.americantelemed.org/resources/standards/ata-standards-guidelines/blueprint-fortelerehabilitation-guidelines
American Telemedicine Association Standards and Guidelines
www.americantelemed.org/i4a/pages/index.cfm?pageid=3311
American Telemedicine Association: Telemental health practice guidelines
www.atmeda.org/files/public/standards/PracticeGuidelinesforVideoconferencingBased%20TelementalHealth.pdf
AOTA Tele-rehabilitation Position Paper 2005
http://www.ncbi.nlm.nih.gov/pubmed/16363187
http://ajot.aota.org/article.aspx?articleid=1872131
APTA Telehealth – Definitions and Guidelines
http://www.apta.org/Telehealth/
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American Physical Therapy Association: Definitions
www.apta.org/AM/Template.cfm?Section=Policies_and_Bylaws1&CONTENTID=67459&TEMPLATE=
/CM/ContentDisplay.cfm
American Speech-Language-Hearing Association: Professional issues in Telepractice
www.asha.org/docs/html/PI2010-00315.html
Expert Consensus Recommendations for Videoconferencing-Based
Telepresenting November 2011
American Telemedicine Association
http://www.americantelemed.org/docs/default-source/standards/expert-consensusrecommendations-for-videoconferencing-based-telepresenting.pdf
Home Telehealth Clinical Guidelines 2003
American Telemedicine Association
http://www.americantelemed.org/docs/default-source/standards/home-telehealth-clinicalguidelines.pdf?sfvrsn=2
Accreditation Canada, Telehealth Services Standard
http://www.accreditation.ca/telehealth-services
Taking Action Towards Optimal Stroke Care – a resource to support implementation of the
Canadian Best Practices Recommendations for Stroke Care
Canadian Telestroke Action Collaborative, Telestroke Implementation Toolkit Oct 2013
http://www.strokebestpractices.ca/wp-content/uploads/2013/05/CSBP-Taking-Action-ResourceOVERVIEW_EN_22May13F.pdf
Canadian Association of Speech-Language Pathologists and Audiologists: Position Paper
www.caslpa.ca/PDF/position%20papers/telepractice.pdf
Canadian Association of Occupational Therapists: Position Statement
www.caot.ca/default.asp?ChangeID=170&pageID=4005CAOT position statement 2011
Telehealthcare and evaluation toolkit, NHS Midlands and East, 2010
http://www.wmahsn.org/wp-content/uploads/2013/12/TeleHealthcare-Commissioning-andEvaluation-Toolkit-Overview-Version-Feb-2012.pdf
Ready, Steady, Go: A telehealth implementation toolkit. NHS National Institute for Health Research
http://clahrc-sy.nihr.ac.uk/resources-project-reports.html
Clinical Leading Environment for the Assessment of Rehabilitation protocols in home care (CLEAR)
http://www.habiliseurope.eu/?q=node/5
International Standards Organisation
ISO/TS :2014(E) Health informatics — Telehealth services — Quality planning guidelines
http://www.iso.org/iso/home/store/catalogue_tc/catalogue_detail.htm?csnumber=53052
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Things you need to consider before starting
Tele-Rehabilitation
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“The primary aims of the (Australian) National Safety Quality and Health
Service Standards are to protect the public from harm and to improve the
quality of health service provision. They provide a quality assurance
mechanism that tests whether relevant systems are in place to ensure
minimum standards of safety and quality are met, and a quality
improvement mechanism that allows health services to realise aspirational
or developmental goals.”
Australian Commission on Safety and Quality in Health Care (ACSQHC)
(September 2011), National Safety and Quality Health Service Standards,
ACSQHC, Sydney.
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Safety- How Did We Assess The Risks?
Risk Readiness for Tele-Rehabilitation Services
In 2012, the National Health Service (NHS) (United Kingdom) developed a risk appetite matrix (see
Appendix 5) which was used to assess the risk appetite of the NHS for a local program of telehealth.
It was developed for use at a senior governance and management level to assess organisational
readiness.
During this project, we have modified the document (see below) for use at operational level, to
assess the readiness of staff and patients to participate in delivering and receiving telehealth
services utilising data from staff focus groups.
Analysis suggests that the areas of greatest concern, with the lowest risk tolerance, were in the
areas of Compliance/Regulatory requirement (expressed mostly as duty of care and risk
management) and Innovation/Quality/Outcomes. This suggests that staff are most concerned with
the impact that telehealth services have on patient care, both as it is perceived by the
patient/recipient and the regulatory authorities. Financial concerns (expressed mostly as efficiency
and budget concerns) were present but uncommon. The financial concerns mentioned were mainly
around the perceived use of budget constraints as a strategy to introduce health services of a lower
standard. There were a few references to the cost savings that telehealth could offer to health
services.
Surprisingly, concerns about the impact of telehealth on reputation at both a professional and
organisation level were rare.
Summary of risk appetite elements
Summary of risk appetite levels
(number of comments)
(number of comments)
200
150
100
50
0
mature
seek
open
cautious
minimal
avoid
Blue: focus group 1; red: focus group 2; green: combined
A= Financial/VFM, B= Compliance/regulatory, C= Innovation/quality/outcomes, D=Reputation
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RISK APPETITE MATRIX (NHS)- Adapted for individual responses from focus groups
Risk level
Key Elements
0
Avoid
Avoidance of risk and
uncertainty is a Key
Objective
1
Minimal
3
Cautious
4
Open
5
Seek
Preference for ultrasafe delivery options
that have a low
degree of inherent risk
and only for limited
reward potential
Preference for safe
delivery options that
have a low degree of
inherent risk and may
only have limited
potential for reward
Willing to consider all
potential delivery
options and choose
while also providing
an acceptable level
of rewards and VfM
(value for money)
Eager to be innovative
and to choose options
offering potentially
higher business rewards
(despite greater inherent
risk)
Confident in setting
high levels of risk
appetite because
controls, forward
scanning and
responsiveness
systems are robust
Accept possibility
limited financial loss.
Value the primary
concern.
Willing to consider
other benefits or
constraints.
Resources to existing
commitments.
Regulatory compliance
is challenged and
problematic.
Gain will outweigh the
adverse
consequences.
Stick to the status quo. Innovation supported.
Innovations in practice Systems / technology
avoided unless really
developments used
necessary.
routinely to enable
Systems/ technology
operational delivery.
developments limited Responsibility for nonto improvements to
critical decisions may
protection of current
be devolved.
operations.
Tolerance for risk taking Appetite to take
limited to events where decisions with
little chance of any
potential to expose
significant repercussion the profession/
for profession/
organisation to
organisation in case of additional
failure. Mitigate any
scrutiny/interest.
undue interest in
Prospective
profession
management of
/organisation.
organisation’s/
profession’s
reputation.
Investing for the best
possible return.
Possibility of financial loss
(with controls in place).
Resources allocated
without firm guarantees of
return.
“Investment capital’ type
approach.
Significant challenge to
regulatory compliance and
consequences significant.
A win would be a great
coup.
Consistently focussed on
the best possible return
for stakeholders.
Resources allocated in
‘social capital’ with
confidence that process
is a return in itself.
Willingness to take
decisions that are likely to
bring scrutiny of the
profession/ organisation
but potential benefits
outweigh risks. New ideas
seen as potentially
enhancing reputation of
organisation/profession
Track record and
investment in
communications has
built confidence by
public, press and
politicians that
organisation will take
the difficult decisions for
the right reasons with
benefits outweighing
the risks.
Minimise financial loss
/invest for return.
Managing the risks to a
tolerable level.
Value and benefits
considered.
Resources allocated to
capitalise on
opportunities.
Compliance/ Play safe - avoid anything Acknowledgement that Limited tolerance for
which could challenge
similar situations
sticking our neck out.
Regulatory
regulatory compliance.
elsewhere have not
Reasonably sure we
breached regulatory
would meet regulatory
compliance.
compliance.
Financial
/VFM
(value for
money)
Avoidance of financial
Very limited financial
loss.
loss if essential.
Value for Money (VfM) is
the primary concern.
Innovation/
Quality /
Outcomes
Aim to maintain or
protect, rather than to
create or innovate.
Limited devolved decision
taking authority.
General avoidance of
systems/technology.
Innovations always
avoided unless essential
or commonplace.
Essential
systems/technology
developments to
protect current
operations.
Reputation
No tolerance for
decisions that could lead
to scrutiny of, or indeed
attention to, the
profession/ organisation.
External interest in the
organisation/profession
viewed with concern.
Tolerance for risk taking
limited to where there is
no chance of any
significant repercussion
for the profession/
organisation.
Senior management
distance themselves
from chance exposure.
NONE
LOW
1
APPETITE
MODERATE
6
Mature
Consistently pushing
back on regulatory
burden.
Front foot approach
informs better
regulation.
Innovation pursued –
Innovation the priority
desire to ‘break the
Consistently ‘breaking
mould’.
the mould’ and
Challenge current working challenging current
practices.
working practices.
New technologies a key
Investment in new
enabler of operational
technologies as catalyst
delivery.
for operational delivery.
HIGH
SIGNIFICANT
For operational staff this was expressed as efficiency and budget considerations
2
For operational staff this was expressed as duty of care and risk management considerations
This tool has helped us to identify the areas of risk perceived by staff and the readiness of the staff
in the organisation to engage in the introduction and use of telehealth services. This information
may assist managers and clinical leaders to plan to introduce telehealth services. Specifically, it
could help to manage clinical change processes by targeting education and training around the
areas of perceived risk and low risk appetite. It may also assist managers to target activity around
strategies that lead to risk mitigation, thereby improving the acceptability of the change.
Identifying Risks in Clinical Processes
Mapping processes
“A map of a patient journey is a visual representation - a picture or model - of the relevant
procedures and administrative processes. The map shows how things are and what happens, rather
28 | P a g e
than what should happen. This helps anyone involved see other people's views and roles. It can also
help
you
to
diagnose
problems
and
identify
areas
for
improvement.”
http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improv
ement_tools/process_mapping_-_an_overview.html#sthash.7DJodGCa.dpuf
The techniques used in mapping processes have their origins, for the most part, in manufacturing
industries. How to apply these approaches to improve health services is evolving rapidly and the
NHS Institute for Innovation and Improvement makes information about mapping and tools to
support it available on their website (see above link). Mapping it now used in many health agencies
as tools to support clinical safety and quality.
We used mapping for two purposes. The first was to capture the decision making process that
occurred when streaming patients into tele-rehabilitation, which will be discussed here (see remote
delivery tele-rehab model decision tree). The second was to track changes in process relating to
the introduction of the new tele-rehabilitaion services and to actively manage those changes in
work practice. This will be discussed more in the Quality section.
We were able to identify that there were key decision points in this process of admitting patients to
the tele-rehabiliation service. Furthermore, we were able to determine that the decisions were
more numerous and broad ranging when patients were having a service delivered in full remote
model (no in-person visits).
Having mapped the basic processes in the more demanding remote delivery service, we then
refined them in order to improve both consistency and rigour in our decision making.
The key decision points that were identified and the tools we used to futher support them, are
listed below;
Clinical decision points (orange rectangles)
1. Patient’s belief in their ability to manage (measured using Generalised Self Efficacy Scale).
Using this scale, scores between 28 and 40 represent a moderate to high perception of selfefficacy and patients with these scores should be considered for remote tele-rehabilitation
services
2. Patient’s ability to learn and behave in safe, adaptive ways (cognitive function using MMSE
and frontal behavioural characteristics (disinhibition, poor impulse control, poor judgement,
poor insight)
3. Carer’s level of stress (Modified Carer Strain Index)
Technical decision points (green rectangles)
1. There is only one technical decision point which occurs after the clinical considerations have
been undertaken. This relates to internet connection, signal strength and support with
technology.
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Assessing Risk in the Clinical Environment
All health services have in place existing risk management processes. The process for attributing a
level of risk to a situation or action is undertaken using a risk matrix. The SA Health risk matrix used
for patient and related incidents or near misses is attached below.
During the telehealth project it has become apparent that current training packages to use this tool
do not include telehealth modes of service delivery. Scenarios of typical risks, to both staff and
patients, encountered when delivering clinical services using telehealth, would assist telehealth
novices to both assess and manage risks using this type of risk assessment tool.
Assessing Risk
In line with SA health policies at an operational level, pre home visit safety assessments are
typically used to assess risk to staff in undertaking the visit to the patient’s home. An example of
that assessment used by Rehabilitation in the Home (RITHOM) therapists at RGH is below.
The assessment assesses risks relating to:
1. Location including access, accommodation, visibility from street; front door access, external
lighting, steps, portable ramp needed.
2. Client including cultural and language requirements, behavioural issues, violence, alcohol or
substance abuse, smoking, presence of weapons, physical mobility, falls, infection control
issues, and any special equipment required.
3. Medical status including, diet or fluids, medication, oxygen, diabetes etc.
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Pre-Offsite Visit Risk Assessment Checklist
Client Name: ..................................................................................
UR Number: ...........................
Address: ..................................................................................................
Phone: ...........................
...............................................................................................................
Person completing checklist: ..............................................................................................................
Department: ...............................................................................................
Checked / Comments
Date: ...........................
Action
LOCATION
Easy access available? (Accommodation
type; key; house visible from street; front
door access; external lighting; steps;
portable ramp required)
Map – special directions
PERSON/S PRESENT
Who is likely to be present during the visit?
Parents
Partner
Friends
Partner & Dependants
Other ……………………………………………………………………………
CLIENT DETAILS
Has client/carers consented to the visit?
No
Yes
Details:
Does client have any cultural
requirements? eg. ATSIC, non-English
speaking, interpreter required? Specify:
Any behavioural issues – Client / Carer /
others? e.g. history of aggression /
violence or alcohol / substance abuse?
Is the client/carer a smoker?
No
Yes
Details:
No
Yes
Details:
No
Yes
Details:
Any other known hazards? e.g. weapons
No
Yes
Details:
Physical mobility & any manual handling
issues? e.g. falls; needing assist,
Access Cab; transfer/mobility status?
Any infection control issues?
e.g. MRSA, VRE?
Any equipment required? e.g. shower
chair, TSR, W/C, urinal bottle, portable
ramp etc.
Does the client have any pets?
If ‘yes’, will they be securely locked
away?
No
Yes
Details:
No
Yes
Details:
No
Yes
Details:
No
Yes
Details:
MEDICAL STATUS
Modified diet or fluids
No
Yes
Details:
Any concern regarding medical
condition? (need for O2, medication –
diabetic)
Clearly indicated NFR status in medical
file?
No
Yes
Details:
No
Yes
Details:
SUMMARY: (use back page if required)
Signature:
Dat
e:
Signed by Senior Therapist (if required):
Tele-rehabilitation, if used unwisely, can increase risks for the patient and their family by leaving
them unsupported by physical presence and monitoring. In our trial, the standard risk assessment
was expanded to incorporate risk factors more pertinent to tele delivered services.
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A new risk assessment for home based tele-rehabilitation referrals was developed based on clinical
practice and failed tele-rehabilitation during the trial (see below).
Risk Assessment for Home Based Tele-Rehabilitation Referrals
PLEASE CONSIDER THE FOLLOWING WHEN REFERRING TO TELE-REHABILITATION
Red Flag = critical issue; discuss referral with Tele-Rehabilitation Manager
TeleRehab
ACCOMMODATION
ONLY
service
The patient is able to travel to their accommodation
Y
The patient is able get in and out of accommodation without difficulty
(steps/stairs/pathways/gardens/easy opening doors/key available)
Electricity is connected to the accommodation
NO
Key areas of the home are accessible
(toilet/kitchen/bathroom/bedroom)
Bed/chair/toilet are suitable for transfer
The inside of the home is suitable for therapy
(place for iPad/uncluttered walking space/table and chair suitable for transfers)
PERSON/S PRESENT IN ACCOMMODATION
There is someone else living in the home
The patient is on good terms with the person/s who share the accommodation
The person/s living with the patient have agreed to the patient’s return home
The person/s living with the patient are able/ prepared to assist the patient with telerehab?
CLIENT DETAILS
The patient has cultural requirements including non-English speaking; Aboriginal
Family; African Cultural
The patient demonstrates risky behaviours eg (disinhibition, poor insight, poor
YES
judgment, poor impulse control)
The patient has significant cognitive impairment (MMSE <21)
YES
There is a recent history of domestic violence
There is a recent history of alcohol or substance abuse
The patient currently has suicidal ideation
YES
There are significant infection control issues (eg shingles, VRE, MRSA, ESBOL)
The patient has pets which might represent a hazard
TECHNOLOGY
Mobile coverage is available in the patient’s accommodation
NO
A current active landline or mobile phone number has been confirmed
NO
SUMMARY
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In summary, this document recommends that tele-rehabilitation referrals be reviewed by the
service manager (or equivalent) if the following “red flagged” conditions exist;
1.
Electricity is not connected to the accommodation
2.
Mobile coverage is not available in the patient’s accommodation
3.
A current active landline or mobile phone number has not been confirmed
4.
The patient demonstrates risky behaviours e.g. disinhibition, poor insight, poor judgement,
poor impulse control
5.
The patient has a significant cognitive impairment (Mini Mental State Examination <21)
6.
The patient currently has suicidal ideation.
“Red flags” do not, singly or collectively, immediately disqualify patients from tele-rehabilitation as
actions may be taken to modify the risk sufficient to permit the service to go ahead. This risk
mitigation process and negotiation would need to be carried out by a senior clinician with service
level responsibilities.
Managing Risk in Tele-Rehabilitation
Managing Risk
Having identified risks relating to home delivered service, processes are enacted to minimise or
eliminate these risks. These processes routinely involve the prescription of equipment or small aids
to daily living to assist the patient to safely perform daily tasks at home and the selection and
measuring for modifications to the home to manage environment risk factors (e.g., grab rails in
bathroom) or improve home utility (e.g., ramps at access points).
This current telehealth project has demonstrated that when the patient or family member has been
able to safely walk through and around the home holding the iPad, the home safety assessment can
be successfully undertaken using iPad video conferencing.
There is evidence from previous research (Sim 2014) that equipment prescription can be safely
undertaken using digital photos. It was our experience during the trial that the live video
conference offered the same opportunity for prescription of simple equipment. Evidence for the
prescription of home modifications using remote viewing technology is yet to be published.
Although it might well be possible for simple modifications like installation of single grab rails or a
threshold ramp to be undertaken remotely, clinical concerns remain about the prescription of
complex modifications (bathroom makeovers, ramps on sloping sites etc) using this technology
until more research has been undertaken.
One of the advantages when providing services remotely is that health professional staff no longer
attends the patient’s home, so this staff risk assessment process is redundant in the telehealth
context. This delivery mode eliminates risk of injury to the staff through exposure to the patient’s
home and family environments, driving related hazards and manages any infection control matters
that may otherwise arise.
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Managing Change
Change can be potentially disruptive and destablising and represents a risk factor to the
implementation of new tele-rehabilitation services. There is increasing evidence of change fatigue
within health services. The introduction of tele-rehabilitation to the current Rehabilitation in the
Home has been an incremental process. During the initial phases, one clinician took the lead and
began to gradually change her practice from purely face-to-face therapy sessions to
videoconferencing supplemented by electronic tools and apps. As she became more confident and
developed new skills, she was then able to apply that knowledge to identifying other telerehabilitation approaches that could be used instead of, or as an adjunct to, traditional practice.
Smaller groups within the team were then identified and given basic training to begin changing
their practice with support from ‘champions’. Policies and procedures for patient admission to, and
journey through, the service were changed to support the transition and staff were provided with
checklists to assist.
Education process run in parallel to change process
Outline of education provided in trial

Presentations to health staff have focused on change management to encourage
uptake from staff. Information presentations have been made both intra and extraorganisation about the project and telehealth services.

Specifically, these presentations have described;

telehealth to the home;

telehealth equipment and applications;

telehealth services implications for the service provider; and

telehealth patient perspectives.
Stakeholder Engagement Process
Stakeholders need to be indentified and engaged in any change process. Clinicians working within
hospital and community based teams, those within the local health network, clinicians working in
state and country rehabilitation were all engaged at various levels to begin the implementation of
tele-rehabilitation. Those clinicians who saw the greatest beneifts to their patients especially from
an access and reduction of travel point of view were eager to be involved. Engagement from
General Practitioners, as members of the patient’s health care team, was considered to be
important and local non-for-profit organisations, universities and community organisations have all
been contacted and informed of the current telehealth trial. There needs to be an established
relationship with SA Health eHealth Sysytems in order to ensure future support of IT infrastructure
and local IT technical support with a plan to enage policy makers at the highest level to assist in the
integration of tele-health into usual practice.
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Communication Strategy
A broad communication strategy is required to engage with the identified stakeholders. General
Practitioners, local and country health services, in particular, allied health, and members of the
community were all provided with a range of material in different forms. A number of community
meetings and information sessions were conducted. Brochures, flyers and news articles were
arranged in both SA health publications and in the local press and a television news article was
organised. A website has been established to provide both background information and training
material including general and technical videos and the findings from the Telehealth in the Home
project have been presented at various national conferences with the intention of inclusion in a
range of journal publications.
Dissemination of telehealth project reports and materials, training and information sessions are
planned for the following year. Local hospital based forums including grand rounds and individual
discipline department meetings have been organised. Presentation and posters at local, national
and international conferences and publications are planned.
Existing professional, clinical and discipline links within SA Health will be leveraged to introduce and
progress use of telehealth services locally and within Country Health and existing reporting
mechanisms to record usage, occasions of service and related data will be employed. Further liaison
is being arranged with the manager of Casemix/ABF to investigate adequate collection and
reporting of activity data to ensure appropriate funding for telehealth interventions.
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Quality in Tele-Rehabilitation
Standards and Accreditation in Australia
The National Safety and Quality Health Service Standards are the tools used to assess Australian
health services for quality and safety. With the introduction of telehealth services during this
project, a search has been made for relevant safety and quality standards that relate to this mode
of delivery. Two documents that look specifically at quality and safety in telehealth were found.
They are:
• The “Proposed framework for telehealth evaluation in Australia” published in “A Unified
Approach for the Evaluation of Telehealth Implementations in Australia” (Dattakumar 2013)
• Draft ISO/PDTS 13131Health informatics — Telehealth services — Quality planning
guidelines (awaiting publication 2014)
A comparison of these two telehealth specific quality and safety standards was made with the
National Safety and Quality Health Service Standards. A detailed analysis has been undertaken (see
below)
The key finding from this analysis is that matters central to delivering quality and safety in
telehealth, such as facilities management, technology management and information management,
are not captured with the same specificity and detail in the National Safety and Quality Health
Service Standards. Transitioning from standard delivery health services to telehealth services is
likely to require a shift in the way that health services conceive of and manage safety and quality.
Comparison of Australian Safety and Quality Standards that relate to Telehealth
National Safety and Quality
Health Service Standards
Standard 1
Governance for Safety and Quality in
Health Service Organisations
Draft ISO/PDTS 13131
Health informatics — Telehealth
services — Quality planning
guidelines
Standard 5
Quality and risk management
Standard 6
Quality management of telehealth services
Standard 7
Financial management
Standard 8
Service planning
Standard 9
Workforce Planning
Standard 10
Healthcare planning
Standard 11
Responsibilities
Standard 14
Information management
ATHAC Telehealth Standards
Framework
Proposed framework for
telehealth evaluation in
Australia
1.1
In forming the patient about
Telehealth
Patient Control
1.2
Seeking patient consent
1.3
Selecting appropriate patients for
telehealth
1.4
Using telehealth in delivering care
Changes in indvidual’s productivity
Number of days of leave for health
reasons
Changes in access to required
healthcare service
Number of in person appointments,
number of telehealth appointments
1.5
Skills of practitioners
Clinician Quality of Care
1.6
Evaluating the use of telehealth
Mortality rate
Number of dealth of patients using
telehealth in comparison to in person
delivery of care
3.1 Management of physical
environment
3.3 Management of the logistical
environment
Standard 2
Partnering with Consumers
Standard 3
Preventing and Controlling Healthcare
Associated Infections
Standard 4
Medication Safety
Standard 11
Responsibilities
Standard 5
Patient Identification and Procedure
Matching
Standard 9
Workforce planning
Standard 11
Clinical indicators
The accuracy of a key measure in any
illness – BP, blood sugar, physical activity ,
movement etc
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Standard 6
Clinical Handover
Responsibilities
Standard 14
Information management
Standard 9
Workforce planning
Standard 7
Blood and blood products
Standard 8
Preventing and Managing Pressure
Injuries
Standard 9
Recognising and responding to Clinical
Deterioration in Acute Health Care
Standard 10
Preventing falls and Harm from falls
Standard 12
Facilities management
Standard 13
Technology management
21. Adequate performance
Technology capability/capacity
2.2 Commissioning of equipment
Reliability
Number of successful consultations
Data quality
Number of instances data was re-sent
during/after tele-consultation (post
measure)
2.3 Risk management (technical)
3.2 Management of the business
environment
Organisation Sustainability
Cost to run the telehealth service for
healthcare provider
Fixed cost in comparison to alternative
modes of treatment
Variable cost is comparison to other
modes of treatment
Savings in Cost for health care provider
Savings per patient per year to healthcare
service provider
Guidelines for Tele-Rehabilitation
“Evidence-based clinical practice guidelines translate findings from health research into
recommendations for clinical practice” (NHMRC 1999) and, when implemented, can improve health
outcomes (Menendez 2005, Du Pen SL 1999). No evidence based guidelines currently exist for
delivering rehabilitation or geriatric services using telehealth. Frequently, telehealth has been seen
as a different way of delivering “normal” clinical services via video conferencing (ie the same tasks
delivered in a different way). If using this frame of reference, no new guidelines would apply to
telehealth services. However we have found during this project, in the case of tele-rehabilitation,
that telehealth/e-health technology also offers different ways for clinicians to practice. This
includes providing services via video conferencing, using electronic tools like web based and iPad
based applications, using remote monitoring tools like our falls diary and activity monitoring tools
like Fitbit ™. It also represents a shift in clinical culture (roles, responsibilities and power) and the
systems that support service delivery.
Although this project is not able to produce evidence based guidelines, we have been able to
develop processes for delivering tele-rehabilitation services. This includes decision trees for
streaming patients into telehealth, process maps for delivering tele-rehabilitation, procedures/work
instructions for delivering tele-exercise based therapy, tele-physiotherapy and tele-speech therapy,
instruction manuals for using the iPad for video conferencing and tele-therapy for patients, health
professionals and ICT professionals, and troubleshooting documents for iPad based service delivery.
Some of these documents have been referred to in other sections of this report. All of these
38 | P a g e
documents have been put together in this toolkit to assist other agencies and clinicians engage with
telehealth.
Improving Processes in Tele-Rehabilitaton
As described in the safety section, we also used mapping processes to monitior changes in
processes that emerged as tele-rehabilitation was introduced. This allowed us to track changes in
work load and work practices, to refine and streamline processes to increase efficiency and develop
policies and procedures that supported the new service modality.
Tele-rehabilitation processes: pre-discharge from inpatient service
Inpatient Rehabilitation Services
No
Is the patient suitable for
home based TeleRehabilitation?
Yes
Rehabilitation Service Coordinator:
•
•
Collects Information about patient’s function and risks
•
Determines program requirements
•
Determines rehabilitation equipment requirements
•
Determines technical requirements
•
Determines support service requirements
•
Undertakes environmental risk and access assessment including
technology setup
•
Orders rehabilitation and technical requirements
•
Equipment demonstrated to patient and undertakes an
“orientation to technology”
•
Sets up patient’s rehabilitation video conference schedule for the
first week at home
•
Organises delivery of rehabilitation and technical equipment to patient’s
home
•
Organises delivery of support services to patient's home
Bold – New or improved
process
Patient discharged from the
inpatient service and admitted to
home based Tele-Rehabilitation
Service
Home Based Tele-Rehabilitation
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In summary, this mapping process identified that new tele-rehabilitation processes were required
to determine technical service requirments including equipment, the need for a more
comprehensive risk assessment (see safety section) and improved organisation of the patient’s first
week in the programme prior to discharge from hospital.
Tele-rehabilitation processes: post-discharge from inpatient service
Home Based Tele-Rehabilitation
Initial assessment, treatment and scheduling
Multidisciplinary home
based telehealth program
Weekly multidisciplinary
case conference
Programmed specialist review:
Programmed family conference:
•
•
•
•
•
Organise for transfer of
electronic rehabilitation
resources and Apps to
patient as required
Organise for ongoing support services
•
Bold – New or improved
process
Pain Management review
Spasticity management
review
Mood disorders assessment
Review of driving status
Management of medical
issues e.g. low BP, wound
infection, shortness of breath)
•
•
•
•
Patient able to cope at home?
Care able to cope
Need for long term care and
support services
Provision of information e.g.
injury/illness, prognosis, recovery
Organise for return of rehabilitation and technical
equipment
Discharge patient from home based service
(to follow up services if required)
A comprehensive home rehabilitation service will include regular therapy interventions, equipment
provision, weekly mutlidisciplinary case conferences and discharge planning. Tele-rehabilitation
allows the introduction of a programmed medical specialist review and family conference without
the need for travel and the electronic transfer of therapeutic apps and rehabilitation resources
.
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Training in Tele-Rehabilitation
It has been clear that education and training are an essential component in implementing a safe
and effective telehealth service. Staff have delivered training to health staff in other facilities, RACF
carer staff and patients and family members/carers.
Presentations to health staff have focused on change management to encourage uptake from staff.
Information presentations have described;
• telehealth to the home;
• telehealth equipment and applications;
• telehealth services implications for the service provider; and
• telehealth patient perspectives.
Clinical training has been provided to all the involved disciplines both cross-departmentally, intradepartmentally and to individual therapists. Specifically, clinical training has consisted of use of
video conferencing, iPads by staff and students, use of applications and use of the wearable
technology e.g. FitBit ™.
Response to this training has been encouraging, with staff spontaneously beginning to consider
how to incorporate these technologies into their clinical practice.
Carer training has been provided to Carer staff at residential aged care facilities and family member
carers for patients living in their own home. Specifically, carer training consisted of:
•
Residential Aged Care Facility Carers are trained in how to support a resident during a video
conference and how to use video conferencing equipment. This involves a one off training
session with the RACF IT person, and support and hands on experience with a trial nurse
during the first video consultations, who provided input re role of the support person for
the resident and problem solving of technical issues.
•
Family member carers are trained how to set up an iPad, use the iPad tools and
applications.
Response to training for RACF carer staff has been enthusiastic. Anecdotal accounts from staff
indicate that they have learnt a lot, and feel that the service is beneficial. It has also been observed
by trial staff who support the RACF service that staff at the RACFs are now quite confident in the
use of the technology and comfortable in a videoconferencing consultation.
Family member carers have also been engaged with the training and are supportive of the service,
as it allows them to be actively involved in the recovery of their loved one. 35% of carers in the
rehabilitation component of the trial actively participated in the recovery process of their loved
one.
The following case study provides an example of the role a carer plays in a tele-rehabilitation
process.
41 | P a g e
Tele-Rehabilitation Case Study
Patient Background
• 66 year old male
• Presenting complaint: Left MCA Cerebrovascular Accident complicated by post thrombolysis
haemorrhagic transformation
• Social history: Lives with wife in country South Australia
• Psychosocial: Wife and patient extremely anxious/stressed on discharge home from
inpatient rehabilitation
• Diagnosis: Severe receptive, profound expressive aphasia compounded by apraxia of speech
Tele-Rehabilitation Service
• High dosage of therapy 4-5 x weekly
• Saved round trip of 100 mins travel
• Made very good progress considering initial severity
• Engaged with technology well
• Consistent positive feedback and indication would not prefer therapy via face to face
sessions
Carer Involvement
• Wife able to receive emailed updates of functional word lists after every therapy session
• Wife comfortable to email with concerns that she didn’t want to raise in front of her
husband
• Required support of another person to comfortably use technology, 1 x attempted session
when wife out, wife needed to call and talk him through the process of answering
• Involvement of wife as therapy assistant required negotiation within relationship to manage
new role
• Communication skills learnt by wife as therapy assistant helped when communicating with
speech impaired husband and helped to support their relationship
Development of training tools and practice resources
A suite of videos have been developed to provide training around iPad delivered telehealth
rehabilitation. One set of videos looks at telehealth from a clinician perspective. They illustrate:
•
•
•
•
•
•
setting up a patients home for iPad based video conferencing /and tele-rehabilitation;
delivering tele-physiotherapy using an iPad;
delivering tele-speech therapy using an iPad;
using electronic tools to support tele-rehabilitation;
using an iPad to deliver remote video conferencing from a car; and
a patient’s perspective on rehabilitation delivered remotely via iPad based video
conferencing.
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Another set of videos focus on the technical aspects of delivering rehabilitation via telehealth using
an iPad. The videos illustrate:
• setting up an iPad for clinical video conferencing;
• setting up a video conferencing suite to deliver tele-therapy; and
• using a Mobile Device Manager to organise and streamline apps used in tele-rehabilitation.
All of these videos will be available to all interested parties on a web page on the Flinders University
telehealth web site at http://www.flinders.edu.au/mnhs/telehealth/telehealth_home.cfm
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Providing a Tele-Rehabilitation Service
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Tele-Rehabilitation Service Model
Who was Suitable for Tele-Rehabilitation?
Eligibility for Tele-Rehabilitation
Affordable, easily accessible technology can be used to deliver multidisciplinary home based telerehabilitation. One of the potential barriers to using this approach is the perception that age and
unfamiliarity with technology may make it less feasible for older patients. In a group of people
receiving home rehabilitation, we examined what the effect of age and technological familiarity
was on the utilisation of tele-rehabilitation services.
During our trial, information was collected on age, sex, occasions of service and time spent in video
conferencing. At baseline, the Technology Familiarity Scale (TFS) and the Modified Computer Self
Efficacy Scale (MCSES) was completed by all participants. At discharge they completed the System
Usability Scale (SUS) and reported on percentage of goals attained.
Seventy-two community-based participants, 41 male, mean age 73.4 yrs took part in the telerehabilitation programme. We found that older people were less familiar with technology. There
was a high correlation between Technology Familiarity Scale scores and both the number of video
conferences and the total time spent video conferencing. Finally, a positive correlation was found
between confidence in using technology (MCSES scores) and the percentage of goals attained.
Acceptability, as measured with the System Usability Scale (SUS) was not correlated with age or
previous exposure to technology.
In summary, our results suggest that
• the patient’s age should not be considered a barrier to telehealth use with older adults.
• Familiarity with technology and age were not related to the acceptability of telerehabilitation services.
• Technology familiarity is related to therapy dosage and therefore access to adequate
training needs to be considered to enable successful participation.
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Intake Process for Tele-Rehabilitation
Prior to admission to Rehabilitation in the Home, a patient and their home is assessed for
appropriateness of the service for their needs. A referral for rehabilitation will accompany
information regarding environment, patient care support needs and their willingness to receive
rehabilitation at home. When considering a patient for tele-rehabilitation, intake processes will
include assessment of the home’s connectivity, provision of suitable technical equipment and
patient/carer familiarisation with technology. Key decision points are detailed below.
Summary of intake mapping process (Streaming into Tele-Rehab) findings which are describe in
detail on page 22.
Clinical decision points
1 Patient’s belief in their ability to manage (measured using Generalised Self Efficacy Scale). Using
this scale, scores between 28 and 40 represent a moderate to high perception of self-efficacy
and patients with these scores should be considered for remote tele-rehabilitation services
2 Patient’s ability to learn and behave in safe, adaptive ways (cognitive function using MMSE and
frontal behavioural characteristics (disinhibition, poor impulse control, poor judgement, poor
insight)
3 Carer’s level of stress (Modified Carer Strain Index)
Technical decision points
1. There is only one technical decision point which occurs after the clinical considerations have
been undertaken. This relates to internet connection, signal strength and support with
technology.
General Self Efficacy Scale
1
Not at all
true
1
2
Hardly true
3
Moderately
true
4
Exactly true
I can always manage to solve difficult problems if I try hard
enough.
2
If someone opposes me, I can find the means and ways to get
what I want.
3
It is easy for me to stick to my aims and accomplish my goals.
4
I am confident that I could deal efficiently with unexpected
events.
5
Thanks to my resourcefulness, I know how to handle
unforeseen situations.
6
I can solve most problems if I invest the necessary effort.
7
I can remain calm when facing difficulties because I can rely on
my coping abilities.
8
When I am confronted with a problem, I can usually find several
solutions.
9
If I am in trouble, I can usually think of a solution.
10
I can usually handle whatever comes my way.
40 = all statements are exactly true
English version by Ralf Schwarzer & Matthias Jerusalem, 1995
10 = all statements are not true at all
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The Carer Strain Index
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Translating Standard Clinical Service Delivery to Tele-Rehab
Delivery
Translating Standard Therapy Practices into Tele-Rehabilitation
Phase 1
Task analysis
• First look at your therapy and analyse what a normal "therapy session" and
therapy program looks like for you, in terms of the tasks undertaken and the
timing and duration involved.
• Next look at what each session involves for the patient, specifically if it requries
the patient to speak, write, work at a desk, perform exercises seated or standing,
walking, performing an activity in a specific location or using equipment.
• You will need to identify any potential risks at the planning stage so that you can
plan solutions prior to running the session.
• Also look at what you as the therapist need to do in order to deliver that therapy,
specfically if it requires you to speak, write, show images, demonstrate exercises,
demonstrate a task or activity, be seated or standing, be in a specific location or
take in equipment to use during the video conference session
• Now, thinking about the session, do you only need to view the patient and have
them view you? Do they need to interact with an object/task while you are viewing
them? If yes, do you need to interact with that object/task as well as view them?
Can some of the tasks be done electronically with an app?
Phase 2
Technology assessment
• Next, once you know what you need to be able to do in your therapy
session/program, look at the your technology and see if it can do what you want it
to do.
• Specifically, is the video conferencing equipment in a room that is big enough for
standing and moving, has enough light, is sufficiently sound proof, has space for
"props" you might need to use or a second person if required.
• Can the patient access the equipment that will allow you to deliver the services, eg
one or two tablet devices, something to position the device appropriately
• Are they able to reliably connect to video conferencing?
• Is support (written or in person) available to help with problems with the equipment
and applications?
Phase 3
Synthesis
process
• Finally, look at tailoring the video conferencing facility and patient equipment to
better assist with tele-delivery of services
• Do you need anything extra to make it more workable for you? eg a document
camera to display images rather than holding them up to the vc camera, a two way
interactive whiteboard that allows you and the patient to write electronically during
the session, an application that allows you to switch between camera views
quickly and easily, an application that allows you to capture images of the patient
doing a task and play them back during the video conference?
• Can somethings be done better electronically? eg homework tasks that are apps
can be more engaging and get more use by the patient
• Can you easily access and download the apps you use onto the devices you use,
your own and the patients?
• Can you develop your own resources to help you to better use and problem solve
with tele-delivered therapy?
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Competency development by clinicians working in tele-rehabilitation
Benner's Stages of Clinical Competence describe the acquisition and development of a skill. In her
model a nurse passes through five levels of proficiency: novice, advanced beginner, competent,
proficient, and expert, each level defined by description. (1984. From novice to expert: Excellence
and power in clinical nursing practice. Menlo Park: Addison-Wesley, pp. 13-34). Alan Giles and John
Howard, in their paper (Alan Gillies & John Howard (2003) Managing change in process and people:
Combining a maturity model with a competency-based approach, Total Quality Management &
Business Excellence, 14:7, 779-787, DOI:10.1080/1478336032000090996) describe a modification
to this classification of competence. In their version, the level titles and their descriptions seemed
better suited to the competency development processes clincians working in tele-rehabilitation had
experienced. Therefore it is this competency model which we have used in developing telerehabilitation competencies (see below).
Six levels of the Performance Model (after Benner, 1984)
Level Designation Descripton
0
1
2
3
4
5
Unskilled/
The individual is unable to perform this skill even under
Not relevant is not required in this role.
Novice
The individual has little or no experience in this aspect. Able to
under close instruction or guidance.
Learner
The individual has some experience in this aspect and is able to
minimal day-to-day supervision but still requires regular
as new situations arise.
Competent The individual performs in this aspect regularly and is able to
without supervision, on a day-to-day basis, but may need
guidance or support when confronted with unusual situations.
Proficient
Skilful in this aspect. The individual has a wealth of experience
with only managerial supervision. Is capable of demonstrating
others.
Expert
Highly skilful in this aspect with several years experience. The
intuitive grasp of the aspect and requires no supervision other
governance. Acts as a mentor and innovator in this aspect.
We used this structure to describe levels of competency development which are outlined in the
following table. However, we also felt that it was important to add a timeline into the document to
incorporate timeframes into the maturation of competencies that is described. Like any
competency, tele-rehabilitation competencies start off at a basic level and this level is acquired
relatively quickly and this allows a clinician to use an existing service system. However, the
development and translation work in tele-rehabilitation requires higher level competencies which
can take as much as 18 months to evolve. It is at the higher end of these competencies that clinical
and technology innovation and synthesis most readily occur.
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Process and timeframe around development of tele-rehabilitation competencies
Change to Clinical Practice for Therapists involved in TeleRehabilitation
Novice*
Learner*
Competent*
Proficient*
The individual has little or no
experience in this aspect. Able to
perform only under close instruction
or guidance.
The individual has some experience
in this aspect and is able to perform
with minimal day-to-day supervision
but still requires regular instruction
or guidance as new situations arise.
Skilful in this aspect. The individual
has a wealth of experience and
functions with only managerial
supervision. Is capable of
demonstrating this aspect to others.
0 - 3 months
3 - 6 months
The individual performs in this aspect
regularly and is able to work
effectively, without supervision, on a
day-to-day basis, but may need
occasional instruction, guidance or
support when confronted with
unusual situations.
Learning to use the video
conferencing facilities
Feeling comfortable with
basic video conferencing
using standard set up
Feeling confident in using
video conferencing suite
facilities with pan tilt cameras
Now exploring how to use
cameras and use of the video
conferencing suite to show
therapy to better effect
Looking to replicate wider
range of normal therapy
using electronic tools so that
more tasks can be
undertaken during video
conferencing session
Doing therapy the
conventional way but in front
of a camera
Looking into use of
applications in therapy
Requires full on-site IT
support
Setting up therapy
“homework” using a small
selection of apps on iPad.
Therapists are being
conservative about what
therapy is delivered using
video conferencing
Requires full IT on-site
support for problem solving
but competent with usual
processes
Therapists are encouraged by
positive experience and
considering broadening
range of therapies delivered
using video conferencing
6 - 12 months
Using a wider range of “home
work” apps and incorporating
this as normal telerehabilitation practice.
Able to problem solve
common technology
problems but requires on-site
IT support for atypical issues
Therapists are excited by
emerging opportunities
demonstrated by early trials
to extend practice scope in
tele-rehab
12 – 18 months
Feeling confident using telerehabs set up video
conferencing suite with
pan/tilt and document
cameras, dual screens and
applications to manage
camera views
Desk based, writing based,
conversation based, exercise
based and activity based
therapy interventions all
undertaken using video
conferencing
A standard set of therapy and
“homework” applications is
now routinely downloaded
onto patient iPads
Routinely able to problem
solve technology problems
and manage using combined
on-site and remote IT
support
Therapists are now convinced
of the acceptability and
efficacy of this approach to
service delivery, and are
beginning to share
experiences and attitudes
with wider work groups.
*From Alan Gillies & John Howard (2003) Managing change in process and people: Combining a maturity
model with a competency-based approach, Total Quality Management & Business Excellence, 14:7, 779-787,
DOI:10.1080/1478336032000090996 based on Benner, P. (1984) From Novice to Expert: Excellence and
Power in Clinical Nursing Practice (California, AddisonWesley).
53 | P a g e
Tele-rehabilitation competencies for clinicians
In our trial we have become aware that two levels of competencies are relevant for telerehabilitation practice.
• User level - which allows a clinician to use tele-rehabilitation processes that have already
been developed
• Translator level – which allows a therapist to undertake the process of translating normal
therapy to tele-rehabilitation and develop new processes.
THERAPIST COMPETENCIES FOR TELE-REHABILITATION
THERAPIST – User Level
THERAPIST – Translator Level
Know how to:
Know how to:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Turn on the computer
Log in to the videoconferencing system
include awareness of correct password
details
Dial and hang up include awareness of
correct patient numbers/ID
Increase/decrease sensitivity of
microphone
Increase/decrease volume of speaker
Use cameras to best advantage
• Zoom in and out
• Alter camera angle
• Toggle between main camera and
document camera
• Instruct patient where to sit or
stand
• Instruct patient where to place
iPad
• Use lighting effectively
Project documents, videos, pictures to
patient
Use the interactive white board for therapy
Record and play back videos for
biofeedback
Schedule patient appointments remotely
Reboot computer in case of trouble
shooting
Promptly access IT support
Assess patient’s baseline technology
familiarity and confidence
Provide a patient with simple verbal
instructions to manage iPad
Be focused throughout the session
Engage in immediate feedback on
exercises/therapy
•
•
•
•
•
•
•
•
•
•
•
Assess and select relevant apps
Instruct patient on use of more
complicated apps
Translate therapy interventions and
assessments from traditional method to
tele-practice
Incorporate safety and quality
consideration into tele-practice
Change approach to ensure interventions
are effective
Understand the range of technologies that
can be used to support remote delivery
Engage and support carers in delivering
hands-on therapy
• Provide clear and reasonable
instruction
• Ask for and receive clear feedback
to guide practice
• build rapport for effective therapy
• understand carers’ limitations re
therapeutic intervention. Most
carers do not have formalised
carer training in manual handling,
motivational skills and therapeutic
intervention.
Explore new and innovative technological
solutions to therapy
Develop and access evidence for tele-rehab
Monitor available therapeutic apps for
usefulness
Be flexible in the delivery of tele-rehab
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Delivering Tele-Rehabilitation Services
Simple, affordable equipment / programmes / applications can be used to enable effective interventions via
tele-health. These can work alone or in conjunction with each other. See individual user guides for more
detail.
Tele-Rehabilitation Applications
1. Video-conferencing Platform
Name: Vidyo
Problem: Need for simple and secure video conferencing platform that would work on 3G enabled iPad.
Model chosen because:
- simple
- secure connection using encryption
- no need for patient to log in or dial out
- ability to work well over a low bandwidth
Use: The app is loaded on to the patient’s iPad so that they are able to open the app with one touch and
then wait for the call from the therapist. The therapist opens Vidyo on the desktop, types in the call number
specific for that patient or chooses the number from a drop down list (which if open on the patient’s iPad
will be green) and clicks call. The patient can choose between decline and answer on the iPad screen.
2. Exercise App
Name: T-Rex (Tele-Rehabilitation Exercises)
Problem: Traditionally clinicians have provided handwritten or standard exercise sheets in paper form. With
tele-rehabilitation there is a need for electronic versions, preferably with video to increase dosage, motivate
the patient and ability to regularly change programme as patient improves providing variety to keep
55 | P a g e
motivated. Commercially available apps did not provide opportunity for the programme to be remotely
updated by the therapist
Model developed because it:
- easy to use with no need for patient to log in or use their own email address
- enables remote set up or change in real time
- videos are of older models
- app is device agnostic
- programme can be left with patient post programme
Use: The patient is provided with app icon on iPad. The therapist can populate the programme and update
regularly via the T-Rex website.
3. Virtual Camera
Name: ManyCam
Problem: The therapist is using a variety of different video sources and applications in the one therapy
session. An application was sought to manage these easily.
Model chosen because:
-
we were unable to find an equivalent alternative, other applications are based around social media
and video creation and are not as well developed , less professional
- it is cheap and very easy to use
- it is possible to change between video sources, zoom in on each video, replay videos and change
resolution
Use: To manage videoconferencing source (Vidyo), interactive whiteboard and Bandicam on the one screen.
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4. Interactive Whiteboard
Name: Baiboard
Problem: A patient with aphasia may need to interact in therapy or be assessed using the written word or
may not be able to understand verbal information. Usually, a therapist will provide written information or
pictures to aid the therapy session or provide the patient with a pad and paper to record their responses.
Model chosen because it:
- easy to use with no need for patient to log in or use their own email address
- free and secure service working over encrypted connection
- enables remote set up using our mobile device manager
- allows therapist and patient to write information in free hand
- allows the therapist to download pictures or a document for the patient to see and interact with
Use: The patient is provided with two iPads – one for the videoconference and one for the whiteboard. The
therapist uses an iPad in the V/C suite. This functionality enhances desktop therapy in particular, speech
pathology and occupational therapy.
5. Desk Top Video Recorder
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Name: Bandicam
Problem: Visual feedback is a tool often used by therapists to assist patients to learn new skills, make
changes in technique or improve quality of movement or gait.
Model chosen because it:
-
is cheap and very easy to use
records content of videoconferences allowing an audio source which other products did not have
allows replay of video during the therapy session for immediate feedback
Use: The application is on the desktop in the V/C suite and is manipulated using Manycam (see below)
8. Scheduling App
-
assist with patient managing numerous appointments / visits / activities both therapeutic and
personal during rehabilitation
- available apps too high functioning / too complicated / too visually busy / require too much input
from patient eg outlook calendars
- particularly important when patient has cognitive or memory impairments
- need for reminders – visual and audio
- simplicity
- no log on
- family can interact and take over management post programme
Two web apps trialled:
a. Anna Cares – Clevertar© – adapted from standalone iPad app
b. My eCare Diary – adapted from Unicare© system-wide app for managing care services for older
community or residential care patients
Both apps developed:
- to allow remote appointment management by therapist, coordinator or family member
- provide reminders – Anna cares prior to event, My eCare Dairy at time of event
- provide simple visual prompts with colour coding depending on currency
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Tele-Rehabilitation Equipment
1. Activity Monitor
Name: FitBit - Zip
Problem: Monitoring of activity and motivation of patients to do their prescribed exercises or increase
physical activity other than during specific therapy times is a challenge for all therapists. Various activity
monitors and pedometers are available.
Model chosen because:
-
small and easy to wear
Low cost and available from local retail shops
Synchs with a free app easily downloaded on to a tablet or phone although can function well
without app. The information appears on the small screen with the tap of a fingernail.
Has long battery life and is durable
Can upload data to a central server for remote monitoring
Use: The patient wears this on their belt to measure the amount of activity, in particular steps taken, during
the day. An associated app can be downloaded to their iPad with which the FitBit synchs to record activity
over a period of time. The app allows ability to set daily goals, provides graphs of activity over time and
sends motivational comments once goals have been reached. It was noted that slow walkers’ steps may not
register with Fitbit placed at the waist. Studies have shown that placing it at the ankle or on the shoe
registers the steps more accurately for slow walkers.
2. Powered, adjustable iPad stand
Name: Mophie Powerstand
Problem: During video conferencing, the position of the iPad and the camera view are essential to provide
the therapist with adequate vision for effective therapy provision. The iPad needs to be upright and secure.
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Model chosen because it:
-
Allows the ipad to be positioned on different surfaces and be adjusted to obtain correct camera
view
- Is easy to carry
- Charges through the stand
- Charging port easily seen and manipulated
Use: The Ipad can remain in the stand at all times.
3. Document Camera
Name: Ipevo – Ziggi HD
Problem: During therapy, the therapist may need to show a patient a test, app, pictures or text. Initially, the
therapist needed to hold the item up in front of the main videoconferencing camera. This did not provide
close up and was awkward for therapist to be able to show the patient specific details.
Model chosen because it:
-
Has USB connectivity – able to connect easily to desktop
powers through the USB – did not need separate power source
has high definition and auto focus – providing better picture quality
is easily manipulated / positioned over the document
is the cheapest model on the market with USB capability – meeting our low tech, low cost brief
allows therapist to show a patient specific, close up details of a document or app
Use: The document camera is placed next to the main screen in the V/C suite. All therapists needing this
functionality have used the document camera.
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Tele-Rehabilitation Web Based Resources
Facilitating Utilisation of Commercially Available Apps
During the trial, it became clear that there were many relevant, commercially available apps that
could be used in the tele-rehabilitaion envirionment. It became clear that there were two ways in
which these apps could be utilised. Firstly, they are of use in delivering the primary therapy during
the program and secondly, in delivering the homework and therapeutic activity which supported it.
One constraint is that finding relevant apps within the sales environment can be time consuming
and frustrating. As our own “collection of apps” grew it made sense to organise them and to do so
in a manner which makes them available to other potential users.
Anecdotal feedback from trial participants is that, due to the engaging nature of these Apps, they
are spending more time on therapy and therapeutic activity involving the apps. There is evidence
that rehabilitation outcomes are related to therapy “dose” (Van Peppen 2004, Kwakkel 2004) so
activities which facilitate achieving that dose are likely to lead to improved outcomes and a better
quality service.
The key to using these Apps successfully is in selecting apps that match both the content required
for recovery with a design that facilitates use and engagement. In assessing Apps the following
criteria were used:
• therapeutic content
• provision of performance feedback to users
• use of graded levels to accommodate learning
• can return to a point in the application if use is suspended
• need for an internet connection to run
• presence of advertising
• sales content
The full version of this app sorting tool is displayed below.
The category of each App reflects the therapeutic content of the app with elements of the app
design either supporting or undermining the level suggested by therapeutic content. For example,
the gold apps have “Specific rehab content and are tailored for a specific diagnosis and disability”
and the design features either support or do not undermine that, so it is “gold”. Examples of design
features that can undermine therapeutic content are intrusive sales and advertising content and
features that support it are grading within the activity and the ability to return to the app at the
place/level you left it.
To facilitate use of these Apps as part of a recovery process, we developed a web based library of
commercially available Apps that therapists have determined have therapeutic value
(http://www.flinders.edu.au/mnhs/telehealth/resources/therapeutic-apps.cfm). Therapeutic Apps
web pages have been built as well as pages with web links to other sorted app web sites. The
Therapeutic Apps have been classified by the body part they target and the device they can be used
on (iPads, Android and Windows tablets). These pages are designed for both therapists and people
with a disability to use to support or extend therapeutic activity. The web links to other sites are
sorted by the discipline they are designed to serve and by diagnostic group.
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Therapuetic App Sorting Tool– Characteristics of Classification
APP
characteristics
Gold
Silver
Bronze
Specific rehab content
and tailored for a
specific diagnosis and
disability
Rehab content or
restoration focused with
broad application in
disabled and general
population
Improvement focus
aimed for general
population
Immediate and stored
for later review
Immediate only
None
Graded levels which occur
automatically
No levels
Remembers place If relevant to function
so can leave and allows you to return to
place in activity
return
If relevant to function
allows you to return to
place in activity
No memory
Activity
communicates
with internet
based content
Permits it through
voluntary option choice
Permits it through
voluntary option choice
Automatic connection,
no personal alterations
allowed
None
Shows once and easily
dismissed so not a
significant intrusion on
activity
Shows multiple times,
dismissed repeatedly
and a significant
distraction for activity
None
Shows once and easily
dismissed so not a
significant intrusion on
activity
Shows multiple times,
dismissed repeatedly
and a significant
distraction for activity
Therapy content
Performance
feedback
availability
Graded levels to
accommodate
learning
Advertising
content
Sales content
Graded levels with
voluntary movement
from one to another
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Clinical Principles and Lessons Learned
The delivery of tele-rehabilitation involved a trial and error approach by clinicans providing real
therapy to real patients. Whilst videoconferencing can be used effectively to provide therapeutic
interventions, there are key principles that, if followed, will ensure a quality intervention.
Tele-Rehabilitation Clinicians - Key lessons learned
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Be prepared; its better to do your thinking and problem solving outside of the video
conference
Be in the present throughout the session as the patient is focusing on you
Actively seek feedback from the patient re their performance and how they are
feeling
Check the view of yourself- that is what the patient is seeing
Know how to provide simple(jargon free) trouble shooting directions over the phone
Know what the patient will see on their home page, tool bar and when they open a
video conference, to help with trouble shooting
Be conscious of making eye contact; to achieve this you need to look at the camera.
Constantly looking at the image of the patient on the screen may give the illusion
that the patient is not receiving your full attention
Care giver presence is usually required for patients with at least moderate cognitive
impairment
Thinking about the modality of delivery of a task (e.g. visual, written) can help with
problem solving a way to translate it to telehealth
Always have the patient’s phone number on standby
Be aware of a patient’s technology familiarity
Know the most frequently encountered technical problems and possible solutions
When in doubt, turn the device off and on again (or instruct the patient to do so)
Be aware that there can be a difference between upload and download quality in a
video conference, as a result, although you may have a good connection, the patient
may not, it is always good to confirm that the patient has a good connection
If using an iPad for stimuli/interactive whiteboard, remember to charge it
Practice with your system before starting to see clients, this will help with building
confidence and understanding system capabilities
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Conclusion
In conclusion, Telehealth offers exciting opportunities for both clinicians and patients to not just
extend but also improve the way rehabilitation and aged care services are delivered. At their best,
telehealth services offer a way to redress disadvantage related to disability (inability to travel,
fragile health status etc) and residential location (country, outer metro) by offering high quality
services direct to the home. In some cases in tele-rehabilitation, the electronic interventions can
work better than conventional services at engaging the patient and delivering palatable, rewarding
interventions. However, translating normal practice to telehealth practice is an active process and
requires more than moving it to a video conferencing suite. Even when the intervention is the
same, the context is different and considerations such as risk and quality must be revisited. This
will prove challenging initially as existing safety and quality frameworks within health do not
provide an adequate framework for managing telehealth services.
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Resources to support a Tele-Rehabilitation
Service
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Clinical Resources
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INTRODUCTION TO TELE-REHABILITATION
A telehealth environment offers opportunity for remote based therapy in 3 general categories depending on
the nature of the intervention
• Interview
• Desktop
• Activity or Exercise
Set up and equipment will vary depending on:
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nature of intervention
needs of patient
number of people involved in session (carer, other therapists)
number of parties connected to videoconference call.
ETIQUETTE
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Start and finish on time there may be other room bookings, booked to begin immediately after yours
Ensure the door is closed and background noise is eliminated
Speak clearly and loudly but do not shout
Confirm the patient can see and hear you clearly
Allow for a delay in audio, pause and don’t rush responses.
Seek consent from the patient:
• To conduct therapy session
• For the presence of any observers in the room
Introduce all people in room, including people outside of the field of view
Provide regular eye contact by looking directly at the camera lens, rather than at the image of the
patient
Be patient and understanding in response to difficulty using or positioning equipment
Ask whether the patient has experienced any technical difficulties
Be prepared for the session
PREPARATION
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Book VC conference times via specified calendar.
Before beginning session, know of whereabouts of technical support and their contact details.
Sometimes other staff familiar with the system can help also.
Have contingency plan if things don’t go to plan. Discuss this with patient before beginning therapy
session.
Be prepared to contact patient by phone in case of connection issues.
Prepare patients for content of session in advance eg switching camera views, what will be required
of them and/or their carer
Be aware of patient capabilities and potential risks
Make sure all equipment both for patient and for therapist is readily available
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EQUIPMENT
EQUIPMENT FOR THERAPIST
To conduct interview based interventions via tele-health, the equipment set up is very simple: A cellular
enabled iPad with a videoconferencing app such as Vidyo for both therapist and patient. These can be placed
wherever convenient. For more complex interventions, the following equipment may be required:
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Computer hard drive
Two computer screens
Video conferencing program (E.g. Vidyo)
Internet access
Microsoft word
USB port
Keyboard
Echo cancelling speaker/microphone
Document camera
ManyCam program
DTN set –up as required with appropriate bookings made via Telepresence Management Suite
(TMS)
• Adequate space for therapy session.
o Enough room to demonstrate standing exercises with chair/step/wobble board/weights.
o plinth if required
o Consider the number of people in the room who will need to be seen by the camera.
• Appropriate therapy equipment – weights etc
Mobile equipment:
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iPad with 3G capability (visually similar configuration of home screen to patients’ iPads)
Video conferencing program
Relevant apps
Interactive whiteboard (E.g. BaiBoard)
Stylus (optional)
EQUIPMENT FOR PATIENT / CARER
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iPad with 3G capability loaded with suitable therapeutic apps
Adjustable iPad stand
Charger
Stylus (optional)
Optional second iPad loaded with interactive whiteboard program (E.g. BaiBoard)
iPad and videoconferencing instruction manual
Appropriate therapy equipment – weights etc
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POSITIONING FOR FACE-FACE / DESK TOP THERAPY
iPad Placement: The iPad stand should be placed on a stable surface at chest height.
iPad orientation: The iPad should be oriented in the horizontal plane (landscape) during video calls. In this
orientation, the patient will see a full screen view of the clinician, with a small self-view box in the bottom
corner.
If the iPad is positioned in the vertical plane (portrait), a split screen image will occur. This orientation also
results in a zoomed in effect
The patient may require simple instructions to rotate the iPad to the horizontal plane and position
themselves within the camera’s field of view. The patient may need to be prompted to use the self-view
image to assist positioning.
Lighting: Lighting should be directly on the patient. If lighting is behind the patient, it may create a silhouette
effect. The patient may require instructions to select an area with suitable lighting.
Sound: Video conferencing is best conducted in a quiet room with no background noise. Patients may need
to be prompted to close doors and windows, turn off the TV and move away from rooms with background
activity.
THERAPIST
Camera orientation: The therapist should be aware of their positioning in relation to the camera – this could
be attached to a wall bracket or on top of the desk top computer. For general discussions and desktop
activities the therapist’s face should be clearly visible in the centre of the frame. The therapist can check this
in the self-view in the bottom corner.
Note:
a) to establish direct eye contact with the patient it is necessary to look directly into the camera.
b) ‘self view’ is a mirror image
Lighting: The room should be well lit, preferable with natural sources of light in front or to side of the
therapist.
Sound: A well set up video conferencing suite should have good soundproofing to ensure confidentiality
during therapy sessions. It is recommended to avoid conducting a videoconference in an open office space
where there may be external distractions eg phones ringing, other conversations.
POSITIONING FOR FULL BODY / STANDING / EXERCISE THERAPY
PATIENT
iPad Placement: The iPad stand may need to be placed on a chair seat, floor or far enough away from the
patient to obtain a full body view of the patient lying, sitting, standing or walking. This can be changed
during the treatment as needed by the patient/carer e.g positioned at the side of the patient for sit to stand
practice and positioned facing the patient at the end of a walk way for walking practice.
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If possible, on initial assessment, the camera on the ipad (in landscape view) can be used to establish the
best position for:
a) the ipad
b) the patient.
These positions can be marked with tape for future reference.
iPad orientation: see above
Lighting: see above.
Sound: see above
THERAPIST
Camera orientation: The therapist should be aware of their positioning in relation to the camera – this could
be attached to a wall bracket or on top of the desk top computer. To enable the therapist to demonstrate
full body exercises, there needs to be sufficient room to move back from the camera and remain clearly
visible in the centre of the frame. The therapist can check this in the self-view in the bottom corner.
Lighting: See above
Sound: See above
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OCCUPATIONAL THERAPY VIA TELE-HEALTH
The following descriptions are based on the premise that assessment and therapy tasks can be described in
terms of the modalities of the stimuli and response (e.g. verbal, visual, auditory, gestural). For example, a
task may be performed with both the clinician and patient speaking (verbal stimuli with verbal response) or
with the clinician showing a pictures which the patient names (verbal stimuli with verbal response).
All videoconferencing for occupational therapy will require at least a main computer with a webcam,
microphone, speaker and videoconferencing program. A two screen set up is preferable. Recommended
equipment in this document is in addition to that required for a basic set up.
1. INITIAL ASSESSMENT
Conversational Assessment:
e.g social situation, home environment, occupational profile, concerns, goals and any relevant objective
information.
Can be performed using only the web main camera and speaker/microphone
2. COGITIVE ASSESSMENT
eg Mini-Mental State Examination (MMSE), Montreal Cognitive Assessment (MoCA), Addenbrooke’s
Cognitive Examination (ACE-R)
Equipment:
• Document camera
• ManyCam program
• Clinician iPad
• Second patient iPad
• BaiBoard app
(Refer to user guides)
Instructions:
• Obtain subjective information via the main camera and speaker/microphone
• Provide verbal task instructions via the main camera and speaker/microphone
i.e. “Tell me the date today”
i.e. “Count by subtracting seven from 100, and then, keep subtracting seven from your
answer until I tell you to stop.”
i.e. “Suppose you smelled a gas odour in your house, what would you do?”
• Provide visual tasks by placing pictures/images/objects under the document camera, then switch to
the document camera using ManyCam program.
i.e. naming tasks, object recognition, reading and comprehension of written instructions
• For tasks that require writing/copying/drawing, the clinician uses their iPad, and the client interacts
using the Baiboard app on their second iPad.
• Prior to appointment, clinician to take photos of stimuli using iPad camera or find images from the
internet. These will be stored in the clinicians iPad photo album
i.e. cube, intersecting pentagons, trail making task
• The patient is instructed to open the Baiboard app on their second iPad, and verbal instructions are
provided via the main camera
i.e. “copy this drawing”
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i.e. “write a sentence of your choice”
i.e. “draw a clock. Put in all the numbers and set the time to… ”
3. VISUAL/PERCEPTUAL ASSESSMENT
eg Spatial Relations, Agnosia, Neglect, Visual-perceptual, Functional Skills
Equipment:
• Document camera
• ManyCam program
• Clinician iPad
• Second patient iPad
• BaiBoard app
(Refer to user guides)
Instructions:
• Obtain subjective information via the main web camera and speaker/microphone
i.e. difficulties with perceiving depth, blurriness or double vision
• Provide verbal task instructions and observe function via the main camera and speaker/microphone
i.e. praxis – pen use for writing, “show me how you would smile”, “what is this object, how
would you use it?”
i.e. body scheme - “show me your left hand”
i.e. spatial relations – using objects in patients workspace, “nearest, furthest” etc
i.e. acuity – reading a medication label, bill etc
• Provide visual tasks by placing pictures and images under the document camera, then switch to the
document camera using ManyCam program.
i.e. Agnosia - Colour naming, figure ground, shape constancy, form discrimination, reading,
object naming
• For tasks that require writing/copying/drawing, the clinician uses their iPad and the client interacts
using the Baiboard app on their second iPad.
• Prior to appointment, clinician to take photos of stimuli using iPad camera or download images from
the internet. These will be stored in the clinicians iPad photo album.
• The patient is instructed to open the Baiboard app on their second iPad, and verbal instructions are
provided via the main camera
i.e. neglect – “copy this picture”, “draw a clock”, line bisection task, letter cancellation
task
i.e. functional skills – handwriting, telling the time
i.e. Reading - acuity
4. UPPER LIMB ASSESSMENT
eg Visuospatial Relations, Agnosia, Praxis
Equipment:
• Document camera
• Clinician iPad
• Second patient iPad
• BaiBoard app
(Refer to user guides)
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Instructions:
• Obtain subjective information via the main web camera and speaker/microphone
i.e. Pain (severity, type) and location, hand dominance, sensory changes, current level of
function and goals
• Obtain objective information visually via the main web camera and speaker/microphone.
• Verbal instructions are provided, and demonstration of tasks can be completed via the main web
camera. iPad positioning may need to be altered to ensure appropriate view.
i.e. Oedema, inattention, active ROM, passive ROM, co-ordination/ataxia and performance
of basic functional tasks
• If required, and if a carer/family member is available, the clinician can provide instructions to the
carer/family member via the main web camera to assist with assessment.
i.e. Protective and discriminatory sensation
i.e. Passive ROM
i.e. Subluxation
5. HOME ASSESSMENT
Equipment:
• For photos - Second patient iPad, BaiBoard app, camera app are used
Instructions:
• The main iPad camera and speaker/microphone can be used to view the home environment, in
order to make recommendations (i.e. falls prevention, home modifications, equipment needs)
• Patient/carer/allied health assistance carries iPad around the home, with iPad facing away from
them.
• It is possible to change the orientation of the camera if patient can follow instructions
• OT provides verbal instructions regarding positioning of iPad in order for required view/images to be
obtained
• Patient can use camera app on second iPad to take photographs of specific areas on instruction of
OT. Photo can then be uploaded via Baiboard app for OT to see (and save for use as part of a home
modification request if required).
6. INTERVENTION
Equipment:
• Document camera
• Clinician iPad
• Second patient iPad
• BaiBoard app
(Refer to user guides)
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Additional resources can be posted out to patient i.e. strengthening materials, bradflex, compression
gloves etc.
iPad applications (apps) can be loaded onto the patient’s iPad for use within therapy sessions, and
for self-directed practice.
Instructions:
• Clinician can use own iPad under the document camera, and then switch to Manycam app to
demonstrate and train in use of apps
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7. IPAD APPS AVAILABLE FOR THERAPY:
Cognition
• Fit Brains and Fit Brains Memory
• Lumosity
• Money Mind Au
Perception
• Clock face test
• Doodle find
• Recognise
Vision
• Visual attention TherAppy
• iOT session
Upper Limb
• Stroke Link
• Dexteria
FULL LIST OF CATEGORISED OT APPS:
Perception
Visual perceptual
• TriZen free
• Clockface test
• Imazing
• Tangram
• Doodlefit2
• Pair up Free
• Match that
• Matrix Game2
Figure ground
• Doodle find
• Look again
• Hidden objects
• Search 60
• Hidden Objects
• iOT session
Left/Right Discrimination
• Recognise
• Physio fun limbs
Visual Attention
• Eye chart pro
• React
• Visual attention TherAppy
• Dots fast tap
• Eye exercises lite
Cognition
Brain training
• Fit Brains
• Lumosity
• Elevate
• Brain Reactor
• Working Memory trainer
• Brainy App
• Clockwork Brain
• 11+ NVR
LimitlessPlanning/problem solving
• Flow free
• Blocks
• Bubble ball
• Brain games
• Left vs right
• Peg genius
• React Tap
Calendars, reminders, planners
• Wunderlist
• Do!
• EvernoteCalendars
Visual Memory/Attention
• Fit Brains Memory
• Matches2
• STT Casual
• Bonus games
• Colour Tapper
Money Management /Arithmetic/calculations
• Money Mind Au
• Arithmetic
• Train your brain
• Math board
Word and number games
• Guess a word
• Crosswords
• Word search
• Hangman
• I associate 2
• Letris 2
• Sudoku
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Upper Limb
• Dexteria
• Stroke Link
• Senso Move
• Bubble popper
• Fruit ninja
• Finger sprint
• Fast tap
• Piano Tiles
Handwriting/typing
• Doodle buddy
• Tap typing
• Colouring book
• Itype fast HD
• Finger Motion
• Handwriting
• Inkflow
Home Modifications
• idaptCalc
• Clinometer
• Magic Plan
• My Sketch Pro
• All level system
ADLs / Functional Tasks
• Telling time
• Can Plan
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Education
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Games
Functional Planning system
Routine
Beep me
Errands
Pill monitor
Big W
Woolworths
Yellow pages
30/30
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Stroke Link
SSRG - Senior Southern Services
Directory
3D brain
Anatomy
Brain Anatomy
Better health channel
Breathe to relax
Parkinson’s point of care
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Tertis blitz
Solitaire
Candy crush
4 in a row
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PHYSIOTHERAPY VIA TELE-HEALTH
PREPARATION: Essential in all aspects of assessing and treating via tele-health
Therapist
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Environment of the therapist determines the exercises that they can demonstrate to the patient. A
larger room may need to be booked if the therapist wishes to show exercises in lying, on a plinth, in
standing.
Prepare for the exercises that the patient will perform and any equipment needed
Know current mobility levels of the patient before the session. Observation of patient prior to
session will not be possible.
Be aware of relevant comorbidities that may impact on therapy i.e. Low BP, poor vision or hearing
Consider the patient’s level of risk taking, cognitive level and ability to follow instructions quickly
and accurately
Patient
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Prepare their environment- i.e. de-clutter, remove trip hazards, allow space and camera visuals for
walking and turning
Equipment or room markings need to be marked as part of preparation for mobility/standing and
collecting outcome measures. The patient or carer may be able to roughly estimate the distance i.e
by using large strides as 1 metre, know room dimensions and calculate from this
Ask the patient to feedback re:
- discomfort or pain during an exercise or walking so that they do not push their limb/body
beyond acceptable discomfort levels
- their performance
DURING SESSION:
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Provide clear outline of intervention/assessment to the patient/carer at the start of each session
Observation and patient feedback will replace therapist hands-on feedback.
Observe quality of performance. This will aid in assessing balance, muscle power and functional
ability e.g. if patient is standing up from a chair- as they stand, notice which leg is leading, if one leg
is forward of the other- this will give insight in to leg dominance and lead to muscle power
assessment
Communication is the key to delivering the session. Giving clear and easy instructions to the
patient/carer.
Seek constant feedback about discomfort or pain, the patients’ performance and from carer
Build rapport with patient/ carer leads to a shared understanding of the task and reduces risk
SAFETY / RISK ASSESSMENT:
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Assess risk taking levels of patient and carer
Estimate potential space needed for exercises- standing, lying, sitting, walking, jumping and turning
Be mindful of obstacles in patient’s environment
Be aware of type of flooring- noting hard versus soft flooring.
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Note patients clothing and shoes so that exercises are not compromised and clothing and foot wear
are not a safety risk.
Consider patient’s and carer’s cognitive level and ability to follow instructions and respond to
feedback i.e. so that they do not push their limb/body beyond acceptable discomfort levels.
Consider the carer’s age and their relationship to the patient.
Determine the level of the carer’s handling skills
Educate the carer around the exercises you wanting them to perform. Explain the exercises in more
general terms.
For example : When they are holding and moving a limb- ‘Sarah( carer),can you feel any resistance to
the movement, does it feel as if Mr X( patient) is pushing against you?’ ‘Mr X are you pushing
against Sarah?’
You are encouraging the carer/patient relationship around treatment and so sustainability of
practice.
Support and encourage the carer that they are helping and are doing well in providing the
intervention.
Teach a skill so that it easy to practice between sessions.
- step 1: show
- step 2: show and explain
- step 3: show and they explain
- step 4: they show and explain.
Give the carer information on how to adapt exercises.
ASSESSMENTS or INTERVENTIONS
For all Physiotherapy interventions the following equipment is required:
• Main web cam
To analyse movement and provide visual feedback :
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Bandicam – see user guide
RANGE of MOVEMENT
Prepare camera positions for the best view of the limb or trunk. The iPad cannot zoom in or out and will
need to be moved backwards or forwards for a side on view or whole body view.
1. Carer or assistant present
Clinician can measure ROM by using Goniometer on the screen.
Feedback from the carer and patient re: pain, how the movement feels especially with decreased sensation.
2. No carer or assistant present
Limited assessment of passive range is possible particularly rotation or accessory movements.
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STRENGTH:
1. Carer or assistant present
Have different weights available to the patient to aid with assessment and/or use functional tasks to assess
strength i.e. we know someone has 5/5 gastrocnemius power, if they can stand on the ball of one foot.
2. No carer or assistant present
Use other limb as resistance as possible.
PAIN:
1. Carer or assistant present
Ask the carer to palpate the affected area with constant discussion around what they might be feeling and
how firmly they are touching.
2. No carer or assistant present
Ask the patient to palpate the area that is painful with the other hand with specific instructions from the
therapist in simple layman’s terms:
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Locate using bony points
Seek feedback from patient about: level of touch that produces pain i.e.- light, medium, hard touch,
heat radiating compared to the other side
Use visual and patient’s feedback to assess swelling, comparing one side to the other.
SENSATION:
1. Carer or assistant present
Instruct the carer how to perform the test without the patient in hearing distance
2. No carer or assistant present
Limited ability
FUNCTION:
In lying, side view is easier to see most of the exercise. Patient to place the ipad on the affected side.
In sitting, for reaching exercises - iPad front on, for sit to stand - iPad side on.
In standing, good to view from front/back and side with carer moving iPad. If no carer present, perform a
few tasks/exercises in one position before moving iPad.
TRANSFERS:
1. Carer or assistant present
If carer and patient are performing a transfer that is usual for them, ask them to demonstrate and record
with Bandicam to trouble shoot.
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2. No carer or assistant present
Ask the patient to perform their usual transfer and record and trouble shoot with Bandicam.
TONE:
1. Carer or assistant present
Prepare the carer pre session. Constant communication regarding what the carer is feeling when they are
moving the patient.
2. No Carer or assistant to present
Assess using observation skills. Not able to formally assess.
BALANCE:
1. Carer or assistant present
Balance assessments can be modified as you go with feedback from the carer re the level of hands on
assistance they are giving.
2. No carer or assistant present
Assume reasonable functional balance if the patient is at home and they are independent with their
mobility. If they are using a walking aid, have this in front of them while they are performing the exercise.
Be aware of supports available - walls, kitchen benches and patient’s ability to respond to instructions and
modify their risk.
GAIT:
Ensure total body view of patient is available when assessing gait. This enables video-recording and re-play
for feedback.
ACTIVITY MONITORING/EXERCISE PRESCRIPTION / REVIEW:
Equipment and apps available to assist - www.flinders.edu.au/mnhs/telehealth/resources/therapeuticapps.cfm
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SPEECH PATHOLOGY VIA TELE-HEALTH
The following descriptions are based on the premise that assessment and therapy tasks can be described in
terms of the modalities of the stimuli and response (e.g. verbal, visual, auditory, gestural). For example, a
task may be performed with both the clinician and patient speaking (verbal stimuli with verbal response) or
with the clinician showing a pictures which the patient names (verbal stimuli with verbal response).
All videoconferencing for speech pathology will require at least a main computer with a webcam,
microphone, speaker and videoconferencing program. A two screen set up is preferable. Recommended
equipment in this document is in addition to that required for a basic set up.
1. CONVERSATIONAL INTERVENTIONS
1a Case History / Counselling / Verbal Education
Can be performed in an interview based interaction using only a basic set up.
1b Education with Visual Stimuli
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E.g. Training use of iPad, training use of apps, site of lesion education
1.
Hard Copy Picture stimuli & iPad based stimuli
Equipment:
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Document camera
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Multiple webcam operating program (E.g. ManyCam)
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iPad & apps (if relevant to activity)
Instructions:
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Provide verbal education via main webcam and microphone/speaker.
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Place stimuli under document camera.
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When visual stimuli required, use ManyCam to switch to document camera & adjust zoom, continue
with verbal explanation while pointing to picture or demonstrating process on iPad.
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Toggle back to main webcam when stimuli no longer required.
2.
Computer Based Stimuli (e.g. pictures, documents, websites, etc.) via ManyCam
Equipment:
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Electronic stimuli
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Multiple webcam operating program (E.g. ManyCam) set up with option to project desktop (see user
guide)
Instructions:
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Provide verbal education via main webcam and microphone speaker.
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Project second desktop using ManyCam (see user guide) and open stimuli on desktop at relevant
points in education session.
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Toggle back to main webcam when stimuli no longer needed.
3.
Computer Based Stimuli (e.g. pictures, videos, websites) via Vidyo
Equipment:
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Electronic stimuli
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Second desktop projecting feature in videoconferencing program (Vidyo)
Instructions:
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Provide verbal education via main webcam and microphone speaker.
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Open stimuli on second computer desktop.
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Project second screen using Vidyo (see user guide).
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Patient will see a three way split screen.
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Patient can enlarge target image by double tapping on it (same method for reducing).
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Cease projection when stimuli no longer required.
2. LANGUAGE
2a Verbal Stimuli with Verbal Response
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E.g. Repetition, word Fluency, responsive naming, sentence completion
Can be performed using only a basic set up.
2b Visual Stimuli with Verbal Response
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E.g. Picture Description
1. Hard Copy Pictures
Equipment:
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Document camera
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Multiple webcam operating program (E.g. ManyCam)
Instructions:
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Place stimuli under document camera.
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Use ManyCam to switch to document camera, to adjust zoom and to alternate between cameras for
cueing and feedback.
2. Electronic Pictures (via ManyCam)
Equipment:
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Electronic picture
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Multiple webcam operating program (E.g. ManyCam) set up with option to project desktop (see user
guide)
Instructions:
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Project second desktop using ManyCam (see user guide).
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Open picture on second desktop.
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Provide verbal cueing via microphone/speaker, toggle back to main webcam to provide visual cues.
3. Electronic Pictures (via Vidyo)
Equipment:
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Electronic picture
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Second desktop projecting feature in videoconferencing program (Vidyo)
Instructions:
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Open picture on second computer desktop.
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Project second screen using Vidyo (see user guide).
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Patient will see a three way split screen.
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•
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Patient can enlarge target image by double tapping on it (same method for reducing).
Provide verbal cueing via main webcam and microphone/speaker.
2c Picture/Object Stimuli with Verbal Response
•
E.g. Picture naming, Boston Naming Test, Western Aphasia Battery – Revised (WAB-R) Object
Naming Subtest
1. Holding up pictures or objects
This method relies only on a basic set up and a steady hand. This can be physically tiring for the clinician and
is not recommended.
2. Projecting pictures via a document camera
See section on Visual Stimuli with Verbal Response (2b)
2d Picture Stimuli with Gestural Response i.e. Semantic Matching Tasks
•
E.g. Pyramids and Palm Trees
1. Caregiver or assistant present
Equipment:
•
Document camera
•
Multiple webcam operating program (E.g. ManyCam)
Instructions:
•
Place stimuli under document camera.
•
Use ManyCam to switch to document camera to show stimuli and adjust zoom.
•
Instruct patient to point to correct image on their screen.
•
Instruct caregiver or assistant to describe where the patient pointed (e.g. left picture).
•
Use ManyCam to alternate between document camera and main webcam for cueing and feedback.
2. No caregiver or assistant present
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Prior to appointment, clinician to take photos of stimuli using iPad camera, these will be stored in
the iPad photo album.
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to import image of stimuli from photo album into BaiBoard.
•
Patient to circle/mark correct image.
•
Clinician to clear board and import next image.
•
Cueing can be provided via the main camera and speaker/microphone throughout the assessment.
2e Semantic Feature Analysis (SFA) & Phonological Components Analysis (PCA):
1. Projected word document
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Equipment:
•
2 computer screens
•
Microsoft Word or Publisher document
•
Second screen projecting feature in videoconferencing program (E.g. Vidyo)
Instructions:
•
Clinician to open document and import picture.
•
Clinician to project second screen or document to patient’s iPad (see Vidyo user guide).
•
Patient will see 3 way screen with image of clinician, self and document.
•
Clinician to cues patient to identify semantic features or phonological components.
•
Clinician to type around picture to map these.
•
Patient can enlarge view of projected document by double tapping on it (reduce via same method).
•
Clinician to stop projection of document at end of task.
2. Shared whiteboard
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to import image of stimuli from photo album or web into BaiBoard (see user guide).
•
Clinician to cue patient to identify semantic features or phonological components.
•
Clinician to hand write or type around the picture to map semantic features or phonological
components, these will immediately appear on the patient’s board.
•
Clinician to provide cueing via main webcam and microphone/speaker.
2. Projected handwritten document
Equipment:
•
Document camera
•
Paper & pen
•
Multiple webcam operating program (E.g. ManyCam)
Instructions:
•
Place paper with image of stimuli under document camera.
•
Use ManyCam to switch to document camera to show stimuli and adjust zoom.
•
Clinician to cue patient to identify semantic features or phonological components.
•
Clinician to hand write around the picture to map semantic features or phonological components.
•
Clinician to provide cueing via main microphone/speaker.
2f Auditory and Picture/Object Stimuli with Gestural Response
•
E.g. Western Aphasia Battery – Revised (WAB-R) Auditory Word Recognition Subtest,
Comprehensive Aphasia Test (CAT) Comprehension of Spoken Sentences Subtest
See section on Visual Stimuli with Gestural Response (2d)
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2g Auditory Stimuli with Verbal Response
•
E.g. Western Aphasia Battery – Revised (WAB-R), Yes/No Questions and Comprehensive Aphasia Test
(CAT), Comprehension of Spoken Paragraphs
Verbal question/answer tasks can be performed using only the main webcam and microphone/speaker.
2h Auditory Stimuli with Written Response
•
E.g. Western Aphasia Battery – Revised (WAB-R) Yes/No Questions
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Clinician and patient to open shared board on BaiBoard.
•
Patient to write “yes” or “no” in response to questions.
•
If unable, clinician to write forced choice options and patient to circle correct answer.
•
Clinician to clear board prior to next question.
•
Cueing via the main camera and microphone/speaker throughout the assessment.
2i Auditory Stimuli with Gestural Response
•
E.g. Western Aphasia Battery – Revised (WAB-R) Yes/No Questions
Tasks involving verbal questions with gestural responses can be performed using only the main webcam and
microphone/speaker, provided the patient’s movements are within the field of view of their webcam.
3. READING
3a Matching Tasks:
•
E.g. Boston Diagnostic Aphasia Examination (BDAE) Matching Across Cases and Scripts, Boston
Diagnostic Aphasia Examination (BDAE), Picture-Word Matching
1. Caregiver or assistant present
Equipment:
•
Document camera
•
Multiple webcam operating program (E.g. ManyCam)
Instructions:
•
Provide task instructions via main webcam and microphone/speaker.
•
Place stimuli under document camera.
•
Use ManyCam to switch to document camera to show stimuli and adjust zoom.
•
Instruct patient to point to correct response.
•
Instruct caregiver or assistant to describe where the patient pointed (e.g. top left).
•
Use ManyCam to alternate between document camera and main webcam for cueing and feedback.
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2. No caregiver or assistant present
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Prior to appointment, clinician to take photos of stimuli using iPad camera, these will be stored in
the iPad photo album.
•
Provide task instructions via main webcam and microphone.
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to import image of stimuli from photo album into BaiBoard.
•
Patient to circle/mark correct response.
•
Clinician to clear board and import next image.
•
Cueing can be provided via the main camera throughout the assessment.
3b Written Stimuli with Gestural Response
•
E.g. WAB-R Part II Written Word - Picture Choice Matching Subtest, Psycholinguistic Assessments of
Language Processing in Aphasia (PALPA) Sentence-Picture Matching: Written Version Subtest
See section on Visual Stimuli with Gestural Response (2d)
3c Written Stimuli with Verbal Response i.e. Oral reading tasks
•
E.g. Western Aphasia Battery – Revised (WAB-R) Reading Irregular Words Subtest, Psycholinguistic
Assessments of Language Processing in Aphasia (PALPA) Letter Naming & Sounding Subtest, Boston
Diagnostic Aphasia Examination (BDAE), Basic Oral Word Reading, Reading News Article
1.
Hard copy reading material
See section on Visual Stimuli with Verbal response (2b).
2.
Electronic reading material
Electronic reading materials can be projected via Vidyo or ManyCam, see section on Visual Stimuli with
Verbal Response (2b). Projected materials may include PDF, Publisher and Word documents or websites.
Make sure to take note of font type, size and paragraph spacing. News articles are best read when cut and
pasted into a zoomed in word document with these variables manipulated.
4. WRITING
4a Tracing / Copying Tasks:
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to write stimuli on whiteboard (select different font colour to patient).
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•
•
Patient to trace over clinician’s writing.
Clinician to clear board or provide instructions to clear board.
4b Writing to Dictation:
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Clinician and patient to open shared board on BaiBoard.
•
Patient to write words on whiteboard.
•
Clinician to provide verbal cueing via main webcam and microphone and written cueing in different
font colour on shared whiteboard.
•
Clinician to clear board or provide instructions to clear board.
4c Oral Spelling:
Oral spelling tasks can be achieved using only the main webcam and microphone/speaker.
4d Functional Writing
•
E.g. Completing forms
1. Creating forms
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to write question/prompt using pen or keyboard functions and leave space for patient
response (e.g. Name…)
•
Patient to write response on whiteboard.
•
Clinician to provide verbal cueing via main webcam and microphone and written cueing in different
font colour on shared whiteboard.
2. Importing forms
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (E.g. BaiBoard)
Instructions:
•
Prior to appointment, clinician to take photo/screenshot of form on iPad.
•
Provide task instructions via main webcam and microphone/speaker.
•
Clinician and patient to open shared board on BaiBoard.
•
Clinician to import form from photo album into BaiBoard.
•
Patient to write responses in appropriate spaces.
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•
Clinician to provide verbal cueing via main webcam and microphone and written cueing in different
font colour on shared whiteboard.
4e Visual Stimuli with Written Response
•
E.g. Written picture naming
1. Holding up pictures / objects
Equipment
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (e.g. BaiBoard)
Instructions:
•
Clinician to steadily hold object or image in front of the main webcam, using the small self-view
image to aid positioning.
•
Clinician and patient to open BaiBoard shared board on iPads.
•
Patient to write name on whiteboard.
•
Clinician to provide verbal cueing via main webcam and microphone and written cueing in different
font colour on shared whiteboard.
2. Projecting pictures via document camera
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (e.g. BaiBoard)
•
Document camera
•
Multiple webcam operating program (E.g. ManyCam)
Instructions:
•
Place picture under document camera.
•
Use ManyCam to switch to image from document camera.
•
Clinician and patient to open shared board on BaiBoard
•
Patient to write name of picture on whiteboard.
•
Clinician to provide verbal cueing via main webcam and microphone and written cueing in different
font colour on shared whiteboard.
4f Extended Writing Tasks
•
E.g. Writing cards & letters, narrative writing
1.
Shared whiteboard
Equipment:
•
Clinician iPad
•
Patient iPad
•
Shared whiteboard app (e.g. BaiBoard)
Instructions:
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See instructions for writing to dictation (4b). If the patient runs out of room on a page, they can flip to and
from a second, third, etc. page by pressing the arrows on the right and left of the board (see user guide).
2.
Email
Extended writing tasks can be more successful with the use of word processing documents and email.
Depending on system configuration, this may rely on a patient having a personal computer and email.
Patients can write passages and then send these via email to clinicians. These can then be independently
reviewed by the clinician, or jointly reviewed by pasting the text into a word document which is projected to
the patient, see section on Electronic Reading Material (3c).
5. SPEECH
5a Verbal Stimuli with Verbal Response i.e. Repetition
•
E.g. Apraxia Battery for Adults (ABA-2)
Repetition tasks can be performed using only the main webcam and microphone/speaker.
5b Written Stimuli with Verbal Response i.e. Reading Aloud
•
E.g. The Grandfather Passage, Assessment of Intelligibility of Dysarthric Speech (AIDS)
Speech tasks requiring reading aloud can be achieved with printed materials shown via the document
camera or electronic materials projected from a second computer screen.
See section on Visual Stimuli with Verbal response (2b)
5c Assessment of Oral Motor, Posture, Respiration, Phonation, Resonance, Articulation, Prosody
Conversational Intelligibility, Alternating Motion Rates (AMR), Sequential Motion Rates (SMR)
The above tasks can be achieved with only the main webcam and microphone/speaker.
Resonance may be more challenging to assess via videoconference than in a face-to-face environment. The
patient may need to be directed to change their positioning in relation to the camera in order to do tasks
requiring close up view of the face, versus view of the torso.
6. SWALLOWING
6a Cranial Nerve Examination / Oral Motor Examination
Can be achieved using the main webcam and microphone/speaker. A trained assistant may be required to
shine a torch into the oral cavity to visualise structures, to assess gag reflex and to palpate structures, for
example to assess jaw strength. It is important to be conscious of lighting and positioning and the patient
may need to be directed to change position to aid judgements of symmetry.
6b Clinical Swallowing Assessment
Can be achieved using the main webcam and microphone/speaker. It is recommended that an assistant
trained to support swallowing assessments and trained in basic life support/choking management is present
at the patient’s side in case of an aspiration/choking incident and to ensure the patient is following
instructions. It is recommended that fluids are presented in clear glass/plastic cups, with food dye added to
water, so it can be seen by the clinician. Surgical tape can also be stuck by the assistant to the patient’s hyoid
region to help the clinician visualise laryngeal elevation.
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6c Swallow Therapy activities
Can be achieved using the main webcam and microphone/speaker. A home visit may be required in advance
to trial optimal positioning for supine activities (e.g. Shaker Head Lifts). During therapy exercises, the patient
should be instructed to place the iPad in pre-determined places and perform exercises. The volume on the
patient’s iPad should be turned up sufficiently for verbal cueing.
7. COGNITIVE COMMUNICATION
7a Verbal Stimuli with Verbal Response
•
E.g. Mental Arithmetic, idea generation tasks, abstract thought tasks, recall tasks
Can be performed using only a basic set up.
7b Verbal Stimuli with Written Response
•
E.g. Written Sequencing
See section 4 for instructions on use of BaiBoard for writing tasks.
7c Visual Stimuli with Gestural Response
•
E.g. Picture sequencing, word Search
See section 4d on importing images/forms into BaiBoard.
7d Visual Stimuli with Verbal Response
•
E.g. Picture description using what’s wrong cards, interpreting bills
See section 2b on use of document camera and projection of second screen to show visual stimuli.
7e Visual Stimuli with Written Response
•
E.g. Written numerical processing, symbol trails, categorisation (list re-writing)
See section 4 for use of BaiBoard in writing tasks.
8. VOICE
8a Perceptual Assessment
Perceptual voice assessment can be conducted with the use of the main webcam and microphone/speaker.
At this stage, in order to do objective assessment of voice, for example fundamental frequency and volume,
the patient will need to have equipment in their home, operated by themselves or an assistant, with values
verbally relayed to the clinician. This may be via a designated tool such as a sound level meter, or via an app
loaded onto a second iPad in the patient’s home such as Voice Analyst.
8b Voice Therapy Exercises
Most voice therapy exercises can be conducted with only the main webcam and microphone/speaker. At
times visual stimuli are required for education (refer to section1b) and reading aloud stimuli (refer to section
2b).
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Loud Voice Therapy
A range of apps can be loaded onto the patient’s iPad to assist with loud voice therapy homework. If these
are on a second iPad, they can also be used concurrently with a videoconferencing session. Apps such as
Voice Analyst provide feedback about pitch and volume. The patient can use the stopwatch tool to track
maximum phonation time.
9. BIOFEEDBACK
Videos of patient performance can be recorded and played back within a video conference for biofeedback
purposes. Videos can be recorded with the use of a desktop screen recorder (e.g. Bandicam). Videos can be
played to patients through a multiple webcam operating program (E.g. ManyCam). See Bandicam and
ManyCam user guides for instructions.
Note, Bandicam will also allow clinicians to save recordings of patients for analysis post session, comparison
on admission versus discharge and for teaching purposes (with consent).
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TELE-REHABILITATION USER GUIDES
Intoduction to user guides
These use guides were developed during our telehealth in the home trial and grew from and
supported tele-rehabilitaion service delivery, both at the clinician level and the ICT support person
levels.
Inevitably, over time our applications, techniches and solutions will be superceded as technology
and tele-rehabilitation continue to develop. Until then, we hope that you find them useful.
The user guides for cliicians are listed below
1.
2.
3.
4.
5.
6.
7.
8.
Clinician User Guide to T-Rex
Clinician User Guide for Fitbit - Zip™
Clinican User Guide to Baiboard
Clinician User Guide to Bandicam
Clinician User Guide to ManyCam
Clinician User Guide to Vidyo
Clinician User Guide to Document Camera - Ipevo – Ziggi HD
Cliniican User Guide to iPad
The user guides for patients are listed below
1. Patient User Guide to T-Rex
2. Patient User Guide for Fitbit - Zip™
3. Cliniican User Guide to iPad
The user guides for ICT support persons are listed below
1.
2.
3.
4.
5.
6.
Vidyo user guide
Vidyo troubleshooting guide
TRex installation user guide
Telehealth room setting user guide
Meraki Mobile device Manager (MDM) user guide
Asset management database userguide
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Clinician User Guide to T-Rex
Opening website with internet explorer 8 (more functionality with internet explorer 10 or Google chrome)
•
•
T-Rex can be found at http://t-rex.net.au
Click the Start Button to go to the log in page
•
Input your Username and Password (which will be sent to your email by the system manager –
contact Claire Morris if you want access to site) and tick both the “I do agree to Terms and
Conditions” and the “Remember Me” boxes
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•
•
The next screen is called Exercise Plans
To view available videos, click exercise gallery
•
Find patient and click ‘Edit”
•
•
Next screen is called Edit Exercise plan
If blank exercise is not visible, click on number to left of exercise box to expand
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•
To Add New Exercises to plan (see below)
1. click plus sign to the right of the screen
2. type the name into the search box
3. click on the plus sign on the exercise description or double click the picture
4. click on Edit details – this will auto-populate the Exercise Label
5. click on Edit details again to add frequency / sets and edit the instructions (unnecessary step if
opened app in IE10 or Google chrome)
6. add another exercise box by clicking on the plus sign to the right of the screen and repeat the
process
7. when completed scroll to top of page and click on Save Exercise Plan
7
2
3
4
5
1
6
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Then click update – this will allow the patient to see the exercise plan on their ipad
•
To view what the patient will see on their i-pad, click view exercise plan
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Clinician User Guide for Fitbit – Zip™
Fitbit is an activity monitoring device similar to a pedometer useful for activity monitoring, motivation, goal
setting. It is available from Harvey Norman or similar retailers. It can be used independently of the App. It is
recommended that the Fitbit – Zip is worn at the waist. However, for slow walkers we recommend attaching
Fitbit - Zip to shoe laces or sock.
Instructions:
-
Tapping the screen with your fingernail will cycle through different views. Figures refresh each day.
Number of steps
-
Distance
Calories Burned
Time
Happy Face
Downloading App – the app can be downloaded from app store – see Setting up iPad for patient
User Guide
First screen seen is called the ‘dashboard’. When first opened, user is prompted to tap FitBit- Zip to
wake it up and synch it with the app.
To view a different day, touch backwards or forwards arrow (1)
To view graphs of steps for one day, touch screen over steps (2)
1
5
2
3
4
-
To view graph of steps over week, month, 3 months, year, touch screen over graph (3)
-
To set goal, touch account (4), then touch
number of steps (5) and alter using keyboard
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Clinician User Guide to Baiboard
Baiboard allows the patient to read and write in real time during therapy, view and interact with imported
forms and pictures, complete written assessments such as clock face, cancellation or trail making test and
can act as an aid for assisted communication in patients with aphasia.
Logging In for Clinician
-
Touch icon
Opens to home screen – multiple boards
1
3
-
For first session, Click ‘join meet’ (1)
Enter meeting number and password (established during set up phase), press join (2)
2
-
Meeting for particular patient will appear in My Meets on home screen (3)
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4
- For subsequent sessions, tap on the meet and enter password, join (4)
- Opens to blank board
Logging in for Patient
- Baiboard app installed on patient’s iPad so that password is not required
- Click on icon, press join (password already entered)
- Opens to blank board
Free writing
-
Instruct patient not to rest hand on board but use tip of finger or stylus
Select pen in top task bar (5)
5
8
9
6
7
-
10
Change colour and width of drawn line by tapping on colour splodge or horizontal line (6)
Free writing or drawing will appear on patient’s and clinician’s iPad at same time (7)
To delete (done by either patient or clinician)
1. Clear whole board – tap rubbish bin, clear all pages or current page (8)
2. Clear parts of writing or picture – tap eraser, tap line, word or letter (9)
Can select a number of new pages depending on length of narrative or to alternate between tasks
(10)
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11
Typing
12
-
Select Tt icon (11)
Tap on screen to insert text box
Keyboard will appear to enable typing of message
Can adjust font, text size at top of keyboard (12)
To finish, press ’done’ or tap main screen
To move text box, tap and drag
To modify typing tap on text, brings up 3 options – delete, duplicate, text
Importing document / pictures
-
Select mountains icon (13)
Import image, PDF or map
-
Press import image
13
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-
Photo album – camera roll, pictures stored on iPad
Search web – enter search term, press on selected picture
Camera - take a picture at that moment to use
Picture appears on board, can adjust sizing and position (14)
14
-
Tap on main screen to enable patient to see picture
Written documents or forms need to be stored in photo album or accessible on web via an image
search
For general information visit: http://www.baiboard.com/
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Clinician User Guide to Bandicam
Video paired with audio of a patient can be recorded and saved from within a video conference. This can
enable:
• Patient performance to be analysed and reviewed by the clinician offline
• Videos to be played back to patients for biofeedback purposes
• Videos to captured for use in teaching (with consent)
Equipment
• Main camera and microphone/speaker
• Desktop screen recorder (E.g. Bandicam)
• 2 screens are helpful to allow enough room for view of patient but it can be used on one screen
Patient does not need to have Bandicam installed on their iPad.
See below for tutorial: http://www.youtube.com/watch?feature=player_embedded&v=6OFcYgoeIr4
Instructions
•
•
•
•
Seek consent prior to recording and saving video files
Interact with the patient via the main camera
Open Bandicam by clicking on icon
Open recording window (1)
2
1
•
Position the recording window by dragging over the image of the patient on the video conference
screen
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Use the main Bandicam tool bar usually found on the second desktop or the record button in the top
corner of the recording window to press record, pause and stop (2)
• The video file will be saved to the desktop immediately on pressing stop
To replay video and audio recordings to patient – see ManyCam user guide
•
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Clinician User Guide to ManyCam
ManyCam allows you to use your webcam, document camera, Baiboard and Bandicam within the one
videoconference.
Main screen
-
Video tab - large image is what is being transmitted to patient (1)
Small boxes to right can be used to add extra camera views e.g. document camera or Bandicam
video (2)
3
1
2
-
Green live tab indicates which camera view the patient sees (3)
To switch camera views click on alternate picture, transmit or cut will appear
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4
-
Click on either to switch (4)
5
6
7
Zooming
- Select which camera to zoom by clicking on trans (5)
- Select image tab (6)
- Zoom function appears bottom left (7)
Switching to document camera
- IT can set up view from document camera to appear in one of the six boxes at right of main screen
- To switch to document camera view, follow steps above (4)
Replaying Videos recorded using Bandicam
-
Click on one of blank squares
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-
List appears with options for importing camera
8
9
-
Select conference cam (8)
Click on playlist tab (9)
Space appears in which to add video (10)
Drag video file from desk top to space
Click on it to play, above are options to pause, rewind, stop (11)
Delete video after use for confidentiality by hovering over selected video and clicking on cross
Select main web cam, click transmit to return to main view
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12
13
12
11
10
Projecting desktop documents
-
Click on top right hand corner of blank square
A dropdown box will appear. Select desktop (12)
A dropdown box will appear Select display 1 or display 2 depending on your system configuration
(13)
- Select show cursor (14)
- Entire desktop will be visible to patient
- Open document/website/picture and zoom in appropriately
- Confirm patient view by looking at self-view, bottom right hand corner
- Click transmit to project to patient
- Reduce ManyCam view so not obscuring document
For general information refer to the ManyCam User Guide and http://www.manycam.com/help
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Clinician User Guide For Vidyo
Vidyo is the videoconferencing platform installed to allow clinicians and patients to talk to and see each
other during the therapy session.
Instructions:
•
Click on video icon to open and click log in (1)
1
•
•
•
Type in call name (2) – this should produce a drop down list if call has been previously made (3)
Icon next to name should be green if patient has opened icon on iPad (4)
Patient may need reminder phone call to open icon on iPad
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2
3
5
•
•
4
Click on number and press connect directly (5)
Patient needs to accept call on iPad (6)
6
•
Clinician should see picture of patient in main screen and themselves in bottom right hand corner.
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Vidyo Tool Bar Explanation
1
2
3
4
5
6
7
8
9
10
1. Show participants in video conference. Bar will appear at side of videoconference. Relevant if
multiple participants involved in conference.
2. Show group chat. Chat bar appears on right of clinician’s screen.
3. Change layout. Clinician screen will split to show clinician, patient and document either: 1 large view
with 2 small views on side or three similar size pictures.
4. Expand/reduce window size
5. Project second screen or document
6. Toggle conference shares (on clicking it says “there are no shares in the conference”)
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11
7. Change self-view. Bottom right corner, no self-view or split screen with 2 equal boxes.
8. Camera  red with strike through, image is no longer projected to patient
9. Microphone  red and strike through, muted
10.Speaker (as above)
11.Settings
12.Duration of video conference, can switch to current time
13.Hang up call
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Clinician User Guide to Document Camera - Ipevo – Ziggi HD
The document camera allows the clinician to show pictures or text to the patient during a therapy
session.
• Plug in using USB
• Position documents directly underneath
• May need to lift base up for larger objects
To zoom in on picture or switch between shots – see ManyCam user guide
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Clinician User Guide to iPad Use
1. Power button
2. Volume button
3. Mute button
4. Home button
3
2
1
4
To navigate the iPad, tap or swipe with your finger tip on the screen
To turn iPad off, hold the power button until you see red ‘slide to power off’
Slide your fingertip across the switch
To turn the iPad on, press the power button until you see black ‘slide to unlock’
Sometimes the iPad screen is black with the iPad in sleep mode
To wake the iPad up, press the home button, and slide to unlock
To charge the iPad, either use the stand or connect directly to the iPad
To open an app, tap the icon quickly with your fingertip
If you press the icon for too long it will start to shake. You will also see a black cross on the icon
To stop the shaking , press the Home Button
To exit an app, press the home button on the front of the iPad
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To download an app, locate the App store app on the iPad (5). Enter the app name in the search
field, click on the cloud to download and then sign in using the assigned password (6). The app will
gradually download to the home page.
5
6
To change camera view for videoconferencing, use the Vidyo app.
9
8
11
10
7
Open Vidyo app. Tap on My Rooms (7), own room number (8) and then join room (9). With the iPad
in landscape orientation, tap on picture to show toolbar, then tap on the camera (10). Three options
are available – front or rear camera or turning off the camera (11). Use this view to assess
positioning of camera and patient for therapy session.
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Patient User Guide for FitBit
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Patient User Guide to TRex
Your Exercises
Your therapist will provide you with a set of exercises to help with your rehabilitation. These
exercises will be sent via the internet to your iPad.
You can access these using the T-Rex app on your iPad.
Tap on the icon to open up your exercises.
Each exercise has written instructions including number and frequency. There is a video
demonstrating the exercise attached to each. You can watch this video by tapping the white
triangle. You can scroll down the page to see more exercises.
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Patient User guide for iPad
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Information and Communications Technology
Resources
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VidyoDesktop User Guide
Installing VidyoDesktop
1. Navigate to the Vidyo portal in a web browser
Example: http://fthp.vidyo.flinders.edu.au
2. Click Download VidyoDesktop and run the installation file
3. Follow the on-screen instructions
4. Login with your username and password
VidyoDesktop: Pre-Call Interface
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1) Search Contacts: Enter a name in this text box to search for a contact.
As soon as you begin typing, search results appear.
2) Contact Status: The status and name of the contact or room.
Click to view information about the contact or room, place a direct call to the contact, join
the contact’s room, or join a public room.
3) Room Information: Click to invite guests to a Vidyo meeting.
When you do so, the meeting invitation automatically opens using your default desktop mail
application, and pre-fills with your personal Vidyo room information. You can enter the email
addresses of the guests you want to invite to the meeting or edit the email content before
sending.
4) Settings: Click to open the Configuration and Status screen.
Participant Status Icons:
Icon
Description
The contact is online and available to receive a direct call or to join a
room.
The contact is online but is currently in a call or conference. You cannot
make a direct call to this contact; however, you can join the contact’s
The contact is offline (not logged into the VidyoPortal). You cannot
make a direct call to this contact; however, you can join the contact’s
Room Status Icons:
Icon
Description
The room is available and empty, so you can enter the room.
The room is available and PIN-protected. If you attempt to join the room, you
will be asked to enter a PIN.
The room is occupied but available to enter.
The room is locked, so you cannot enter it.
The room is full, so you cannot enter it.
VidyoDesktop: Taskbar In-Call
The VidyoTask bar is accessable by moving your mouse over the VidyoDesktop screen.
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1) Click
to view a list of the conference participants and chat with them, invite
participants to the conference (via the contact list or by email), and launch the
Control Meeting panel which provides access to the conference moderation options.
2) Click
to chat with all participants as part of the conference group chat.
3) Click
to select how to view the participants’ video windows during the
conference, and control the maximum number of windows.
4) Click to select which application or screen you wish to share in the conference.
5) Click
to toggle among the applications or screens that are being shared during
the conference.
6) Click
to toggle your self-view preference.
7) Click
to show or hide the video feed from your camera.
8) Click
to mute, unmute, and control your microphone volume.
9) Click
to mute, unmute, and control your speakerphone volume.
10) Click
to open the Configuration and Status screen.
For more information, see “Using the Configuration and Status Screen” on page 12.
11) Click
to toggle between the conference time and a clock.
12) Click
to end the conference.
Direct Call (Point to Point)
Open Vidyo by double clicking on the Vidyo
screen near the date and time)
icon in the system tray (bottom right of
1) Enter the contacts user ID into the Search field and click on the result
2) Check the status of the user
3) Click Connect with contact directly
4) Click
to end the conference
This will discannect the call for all participants
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Direct Call to External Participant (Point to Point)
Note: Vidyo uses a VidyoGateway to connect to standards based Video Conferencing unit like
Cisco and Polycom. The gateway uses a prefix to the dial string to identify an external
connection, much like the PABX phone systems.Most system will connect using the 04 prefix,
however please contact support should this not work.
Open Vidyo by double clicking on the Vidyo
screen near the date and time)
icon in the system tray (bottom right of
1) Enter the contacts dial string into the Search field and click on the result
2) Click Call a non-Vidyo system
3) Click
to end the conference
Case Conference (Multi-Site)
Open Vidyo by double clicking on the Vidyo
screen near the date and time)
icon in the system tray (bottom right of
1) Click on your name (top of contacts list)
2) Click Connect to your Room
3) Bring the Taskbar up (page 3)
4) Click on the
5) Click on the
icon to bring up with participants list
right of the window
Control Meeting button located towards the bottom
6) Your default internet browser will open to a meeting control page
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Meeting controls are performed through the browser as the VidyoDesktop controls don’t
provide a way to disconnect participants of the conference; this is particularly useful for
assisting patients to end their conference.
7) Click the Add Participant
button, located at the top right of the browser.
8) The Add Participants window will pop up
9) Type the contact into the Search field
10) Click on the participant you wish to call
Tip: you can create a list of participants to invite by repeating steps 9-10, rather than invite
each participant individually.
11) Click Invite
12) To invite a non-vidyo user into a case conference, repeat steps 9-10, using the nonvidyo dialling string (example: 0454157@vc.sahealth.sa.gov.au)
Controlling a case conference (Multi-Site)
1) List of participants in the case conference
2) Click
to add a participant to your room.
3) Click
to invite a participant to your room via email.
4) Click
to toggle between locking and unlocking your room.
Once locked, no one will be able to connect to your room, even if invited
5) Allows you to search for participants connected to the case conference
6) Click
enable it.
to disable video on all participants’ cameras without allowing them to re-
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7) Click
enable it.
to disable video on all participants’ cameras while allowing them to re-
8) Click
to mute audio on all participants’ microphones without allowing them to
re- enable it.
9) Click
to mute audio on all participants’ microphones while allowing them to re-
10) Click
to disconnect all participants from your meeting room.
enable it.
11) Click
to disable video on the selected participant’s camera without allowing
that participant to re-enable it.
12) Click
to mute audio on the selected participant’s microphone without allowing
that participant to re-enable it.
13) Click
to disconnect the selected participant from your meeting room.
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T-Rex – Installation onto iPad
Overview:
To make access to the T-Rex website as easy as possible for the patients, we use the Web
Clip feature within Meraki to assist in setup and access to the T-Rex exercise list.
For T-Rex to appear as an application we have used the Full Screen option of the web clip
which hides the address bar at the top of Safari.
To enable the patient to automatically login, we are required to include another web clip to
the login page – this is because Safari uses a separate engine/database for the full screen
mode, meaning saved settings in the standard mode aren’t available in full screen mode.
This guide will include:
• Creating a profile and applying to device
• Adding T-Rex to the Meraki Web Clips
• Adding an exercise to T-Rex
• Logging into T-Rex on the device
Creating a profile and applying to device
1. Log into Meraki
2. Click the MDM menu heading
3. Click on Profiles
4. Click on “Add new”, located at the top right of the screen.
5. Click on “New mobile profile”
6. Complete the Mobile Profile information
a. Configuration: Choose “Use the Meraki Dashboard…”
b. Name: RITHOM_FTHPxxxx (where xxxx is the asset number)
c. Description: Can be left blank
d. Removal Policy: Change to require password (this can be anything)
e. Scope: Change to “with ANY of the following tags”
i. Enter the asset number and click “Add Option”
7. Click Save
8. Click on “Monitor” from the left hand menu of the Meraki dashboard
9. Click on “Clients”
10. Check the box of the device you wish to apply a tag to
11. Click the “Tag” button, towards the top left of screen
12. Type fthpxxxx (where xxxx is the asset number)
13. Add
Adding T-Rex to the Meraki Web Clips:
1. Log into the Meraki dashboard
2. Click on MDM from the left hand dashboard menu
3. Choose the profile from the dropdown box (rihtom_fthpxxxx)
4. Click on Settings
5. Click on Web Clips
6. Click “Create a Web Clip”
7. Label: Login (We have left T-Rex off to avoid confusion)
8. URL: http://t-rex.net.au/wp-login.php
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9. Check Full Screen
10. Click “Save Changes”
11. Click “Add a new Web Clip”
12. Label: T-Rex
13. URL: http://t-rex.net.au/exercise-plan/fthpxxxx (change xxxx to device asset number)
14. Check Full Screen
15. Click “Save Changes”
Adding an exercise to T-Rex
If the URL http://t-rex.net.au/exercise-plan/fthpxxxx is not found, you will need to create a
blank exercise plan for the device.
1. Log into T-Rex http://t-rex.net.au
2. Click the Start Button to go to the log in page
3. Input your Username and Password and tick both the “I do agree to Terms and
Conditions” and the “Remember Me” boxes
4. After you login, the first screen you are presented with is the Exercise Plans page
5. Click “Add New” towards the top of screen
6. Enter the following into the fields
i. Client First Name: asset number
ii. Client Last Name: asset number
iii. Client Username: asset number
iv. Client Password: Telehealth01
v. Exercise Label: asset number
vi. Internal-Use Label: asset number
7. Click “Save Exercise Plan” and Click “Publish”
8. Repeat the above step (Click Save and Update)
Logging into T-Rex on the device
When the device checks into Meraki it should pick up the 2 Web Clips, which will appear as 2
white icons on the iPad labelled, Login and T-Rex.
1. Tap on the “Login” icon
2. Enter the username and password (asset and Telehealth01)
3. Check both the boxes
4. Save the username and password for auto-fill
5. Press the home button on the iPad
6. Tap on the “T-rex” icon to test
a. You will notice the icons change to the T-Rex dino
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Telehealth Room Setup
Purpose:
This document has been designed to provide an overview and step by step setup procedure
of the standard Telehealth consultation room that was utilised in the Flinders Telehealth in
the Home Project.
Overview:
WebCam - Logitech BCC950
Main Screen
Computer – NUC
Software
Windows OS
Office 2010
VidyoDesktop
ManyCam – Virtual Camera
BandiCam – Recording of video
2nd Screen
Document Camera
Equipment:
2 Monitors/Screens
One for main VidyoConferencing window
One to control the Vidyo Conference and share content to far end
HD WebCam - Logitech BCC950, C920 or similar
Computer
Keyboard and Mouse
Software:
Windows OS – Required for software compatibility
VidyoDesktop – Video Conferencing software
ManyCam – Virtual Camera
BandiCam – Recording of video
Office 2010
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Adobe Acrobat
Setup
Computer
We are using a Windows computer running the Windows 7 Operating System, the computer
uses a local login and no patient related data is stored on the video conferencing computer.
Dual monitors are connected to the computer, with one acting as the main Video
Conferencing display and the other being used to control the video conference and share
content to the fat end.
2 USB cameras are utilised; 1x WebCam for portrait and 1x Document camera for showing
material to far end.
Software
ManyCam – Virtual Camera
This software allows for the therapists to easily switch between different camera sources,
play back video and sound to the remote end.
1. Install the ManyCam software (http://manycam.com/)
*On the 2nd and 3rd screens, ensure to click the Decline button
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2. Once installed, open ManyCams
3. Click the ManyCam menu (Top left hand of window) and select Activate
ManyCam Pro
4. Input the activation code and click activate
(Licencing information can be found \\sharefiles\share\RESTRICTED - Telehealth Project\07Support\Documents\ManyCam)
5.
VidyoDesktop:
1. Install VidyoDesktop, instructions and install file can be found at
http://fthp.vidyo.flinders.edu.au
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2. Login to VidyoDesktop (details will be specific to the user or consultation room –
See Vidyo user management guide)
Portal = fthp.vidyo.flinders.edu.au
Username = VCCS1 (example)
Password = Telehealth01 (example)
3. Select peripherals through the VidyoDesktop settings
a. Click on the settings icon to the top right of the VidyoDesktops contacts
window
b. Select Devices from the left hand menu ensure the following devices are
highlighted:
i. Microphone (ManyCam Virtual Microphone)
ii. Main speakers
iii. ManyCan Virtual Webcam
BandiCam – Recording of video
BandiCam is a screen capture program that provides the therapist with the ability to record
a patient’s Telehealth session and replay it to provide visual feedback on their rehabilitation
program.
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1. Install the BandiCam software - http://www.bandicam.com/downloads/
2. Accept all defaults and run BandiCam
3. Register BandiCam by clicking on the ‘key’ icon on the right hand side of the
window
(Licencing information can be found \\sharefiles\share\RESTRICTED - Telehealth Project\07Support\Documents\BandiCam)
4. Click General and change the output folder to the desktop
5. Click Start Bandicam minimized to tray
6. Click Start Bandicam on Windows startup
7. Click Video
8. Click Settings
9. Check Record Sound
10. Choose Win 7 Sound (WASAPI) as the primary sound device
11. Choose the microphone as the secondary sound device
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Vidyo Troubleshooting Guide – Tele-Rehabilitation Rooms
Issue
No Video from
patient
• Black
screen
Troubleshooting
Tele-Health Room
• Check that both monitors have
power going to them
• Check that the power is turned
on
Patient:
• Check the patient has Vidyo
‘maximised’
• Check the patient hasn’t disabled
Video in the settings of Vidyo
No Audio from
patient
Unable to call
Patient
Patient can’t
see me
Patient can’t
hear me
Tele-Health Room
• Check that computer volume
isn’t muted
• Check that the correct audio
device is selected in Vidyo
settings under ‘Devices’
• Check that the Volume level
through Vidyo is at an
appropriate level
Patient:
• Check that patient hasn’t
disabled Microphone in the
settings of Vidyo
Tele-Health Room
• Check that the user is online
(green)
• Check that you have the correct
details for the far end
Patient:
• Ensure patient has iPad turned
on and is logged into Vidyo
• Check your camera is plugged in
• Check you haven’t ‘muted’ your
Camera
• Check that ManyCam is open
and the correct source is the
selected live stream
•
•
•
Check your microphone is
plugged in
Check you haven’t muted your
microphone
Check that ManyCam is open
and a microphone appears under
the audio tab
Actions
Tele-Health Room
• Reboot the computer
Patient:
• Call patient on phone and end Vidyo
call
Ask patient to go to Vidyo settings
Ask patient to confirm Video is turned
• Ask patient to reboot iPad
Tele-Health Room
• Reboot computer
Patient:
• Call patient on phone and end Vidyo
call
Ask patient to go to Vidyo settings
Ask patient to confirm Microphone is turned
on
• Ask patient to reboot iPad
Patient:
• Ask patient to reboot iPad and log
back into Vidyo
•
Confirm that you can view yourself
in self-view.
• Confirm that the correct ManyCam
is selected under the Vidyo Settings
and Devices options.
Engage your IT support for Vidyo
•
Confirm that your microphone isn’t
muted.
• Confirm that the correct camera is
selected under the Vidyo Settings
and Devices options.
Engage your IT support for Vidyo
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Meraki – Mobile Device Manager
Overview:
Meraki is a cloud based Mobile Device Manager which allows you to remotely manage the
settings, profiles and applications of a mobile device fleet. There are different offerings for
support, although the project has opted for the free/basic service offering which only
provides support via the only knowledge database.
Account Registration:
1. Create a free meraki account, click on the following link and click “Create an
account”: https://account.meraki.com/secure/login/dashboard_login
2. Complete the details, click “Create account”. You will now be sent a confirmation
email with an activate link – you will need to click this link to complete registration.
3. Once you have confirmed your account, login to the Meraki Dashboard using the
following link: https://n85.meraki.com/login/dashboard_login
Configuring your MDM environment:
When logging in for the first time you will be prompted to create a new network.
1.
2.
3.
4.
Click “create a new network”
Type in a meaningful name into the “Name” text field.
Select MDM from the options
Click “Create Network”
5. Click on “Organizations” on the left hand menu, and then click “MDM”
6. Click on Meraki_Apple_CSR.csr and save the file to your computer
7. Click “Apple Push Certificate Portal”
8. Login with your/organisations Apple ID
9. Click “Create a Certificate”
10. Tick the “I have read and agree to these terms and conditions.” Box and click
“Accept”
11. Click “Browse”
12. Located the Meraki_Apple_CSR.csr file from step 6 and click “Open”
13. Click “Upload”
14. Click “Download” and save the file to your computer
15. Go back to the Meraki Dashboard webpage (Organisations and MDM)
16. Enter the Apple ID you used to log into the Apple Push Certificate Portal
17. Click “Browse” and locate the “MDM_ Meraki Inc._Certificate.pem” file and click
“Open”
18. Click “Save Changes” by scrolling to the bottom of the page
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19. The push certificate will need to be renewed every 365 days, if the email linked to
the Apple ID isn’t monitored; it is advisable to set a reminder.
Creating Profiles
A Profile can be applied to a single or group of iPads and will allow you to configure the
settings and applications a device has access to.
14. Click the MDM menu heading
15. Click on Profiles
16. Click on “Add new”, located at the top right of the screen.
17. Click on “New mobile profile”
18. Complete the Mobile Profile information
a. Configuration: Choose “Use the Meraki Dashboard…”
b. Name: Provide a meaning full name. Example, rithom_profile, staff_profile,
patients_profile, law_students_profile, etc.
c. Description: Can be left blank
d. Removal Policy: Change to require password (this can be anything)
e. Scope: Change to “with ANY of the following tags”
i. Just type a meaningful scope name and
click the “Add option” link in the popup
19. Click Save
Settings
Before applying the profile to a device, which will enforce your settings and restrictions,
you’ll need to adjust the settings of the profile.
1. Click the MDM menu heading
2. Click on Settings
3. Select the profile you wish to edit from the drop down box
a. There are a number of settings you can adjust; although for the purposes of
this guide we will only look at restrictions. The settings mentioned would be
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fairly common across most environments where the device is loaned out to a
customer. Most are self-explanatory
4. Check the “Enforce Restrictions Box”
Device functionality
a. Allow installing apps – True – this is required for application management
b. Allow screen capture – False – Isn’t required
c. Allow voice dialling – False – Isn’t required
d. Allow automatic sync when roaming – False – Isn’t required
e. Allow Siri – False – isn’t required, can be a security risk
f. Allow Passbook notifications while locked – False – Isn’t required
g. Allow in-app purchases – False – can be changed if utilising applications with
in-app feature that require unlocking
h. Force user to enter iTunes Store password for all purchases – True – if deselected, users have 15min after a password has been entered to download
additional application without requiring authentication.
i. Allow multiplayer gaming – False – isn’t required
j. Allow adding Game Centre friends - – False – isn’t required
k. Show control centre in lock Screen – False – Just adds a layer of complexity for
end users
l. Show notification Centre in lock screen – Flase – Adds a layer of complexity for
end users
m. Show Today view in lock screen – False – Adds a layer of complexity for end
users
n. Allow documents from managed apps in unmanaged apps – False – isn’t
required
o. Allow documents from unmanaged apps in managed apps – False – isn’t
required
Applications
a. Allow use of YouTube – False – can impact on data usage costs
b. Allow use of iTunes store – False – can impact on data usage costs
c. Allow use of Safari – False – Can impact on data usage costs
iCloud
a. Allow Backup – False – isn’t required
b. Allow Document Sync – False – Isn’t required
c. Allow photo stream – False – Isn’t required
d. Allow cloud Keychain sync – False – Isn’t required
Security and privacy
a. Allow diagnostic data to be sent to Apple – False – Isn’t required
b. Allow user to accept untrusted TLS certificates - False – Isn’t required
c. Force encrypted backup – True
d. Allow automatic updates to certificate trust settings – True – iPad will
automatically update trusted certificates
e. Force limited ad tracking – True
Content ratings
a. Allow explicit music and podcasts - False
Ratings region
a. Australia
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Allowed Content ratings
a. Movies: Don’t Allow Movies
b. TV Shows: Don’t Allow TV Shows
c. Apps: Allow All Apps
iOS supervised restrictions
The following are only available if you supervise your devices with Apple Configurator, this is
advisable and setup procedure can be found in this in the apple configurator setup guide.
a. Allow iMessage - False
b. Allow App Removal - False
c. Allow Game Centre - False
d. Allow Bookstore - False
e. Allow Bookstore erotica - False
f. Allow UI configuration profile installation - False
g. Allow modifying account settings – False
h. Allow AirDrop – False
i. Allow changes to cellular data usage for apps – False
j. Allow use-generated content in Siri – False
k. Allow modifying Find My Friends settings – False
l. Allow host pairing – False
5. Click “Save Changes”
Applying profiles to a device
To apply a profile it a device, you just the relevant tag/s to the device.
1. Click on “Monitor” from the left hand menu of the Meraki dashboard
2. Click on “Clients”
3. Check the box of the clients you wish to apply a tag to
4. Click the “Tag” button, towards the top left of screen
5. Type and select the wanted tags
6. Add
The next time the device ‘checks in’, the profile/s will be applied.
Adding Free Applications to Meraki
1. Click on “MDM” from the left hand menu of the Meraki dashboard
2. Click on “Apps”
3. Click on “Add new” near the top right of the dashboard
4. Click on “iOS app”
5. Enter the title of the application in the text field
6. Change the Country to Australia
7. Click search
*You may need to choose the iPhone tab if you can’t find the application in the iPad results.
8. Click the “Add” button to the right of the application icon/image
*For paid applications, view “Adding paid Application to Meraki”
9. Add
10. From the “Scope” dropdown, choose “with and of the following tags”
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11. Enter the TAG you wish the application to installed on, or if you are going to target
individual devices, enter “App_ApplicationName” and click the “Add” button.
12. Tick Prevent backup
13. Click “Save Changes”
14. If you created a new Tag to target individual devices, apply the tag to the device as
outlined in “Applying profiles to a device”
Adding Paid Applications to Meraki
1. Login to the Apple VVP store http://vpp.itunes.apple.com/au/store
2. Search for the application you are and purchase
http://vpp.itunes.apple.com/au/store
3. Click on the Application you are searching for
4. Check “Redeemable codes”
5. Enter the number you wish to purchase in the “Quantity” field
6. Click “Review Order”
7. Click “Place Order”
8. Wait to receive an email from the VPP store with your licence codes
9. Open the email and the attachment
10. Copy the Codes from the excel document – this is the 12 character code
Click on “MDM” from the left hand menu of the Meraki dashboard
Click on “Apps”
Click on “Add new” near the top right of the dashboard
Click on “iOS app”
Enter the title of the application in the text field
Change the Country to Australia
Click search
*You may need to choose the iPhone tab if you can’t find the application in the iPad results.
18. Click the “Add” button to the right of the application icon/image
*For paid applications, view “Adding paid Application to Meraki”
19. Add
20. From the “Scope” dropdown, choose “with and of the following tags”
21. Enter the TAG you wish the application to installed on, or if you are going to target
individual devices, enter “App_ApplicationName” and click the “Add” button.
22. “Purchase method” is “VPP Codes”
23. Paste the VPP codes into the “Redemption Codes” text field
11.
12.
13.
14.
15.
16.
17.
24. Tick “Remove with MDM”
25. Tick Prevent backup
26. Click “Save Changes”
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27. If you created a new Tag to target individual devices, apply the tag to the device as
outlined in “Applying profiles to a device”
Adding Enterprise Applications to Meraki
1. Click on “MDM” from the left hand menu of the Meraki dashboard
2. Click on “Apps”
3. Click on “Add new” near the top right of the dashboard
4. Click on “iOS enterprise app”
5. App Location is dependent on the size of the application:
If the application is under 64MB you will be able to upload the IPA directly to Meraki, if it is
over this you will need to host the IPA and .plist file on a server – the developers of the
application should be able to provide you with both the files.
6. From the “Scope” dropdown, choose “with and of the following tags”
7. Enter the TAG you wish the application to installed on, or if you are going to target
individual devices, enter “App_ApplicationName” and click the “Add” button.
8. Tick “Remove with MDM”
9. Tick Prevent backup
10. Click “Save Changes”
11. If you created a new Tag to target individual devices, apply the tag to the device as
outlined in “Applying profiles to a device”
Applying tags as default
You may wish to apply a Tag to every device that joins your MDM, this could be to push
out a minimal security profile, application or network settings.
1. Click on “Configure” from the left hand menu of the Meraki Dashboard
2. Click on “General”
3. Scroll down to “Enrolment Settings”
4. Add the tags you require to “Default Tags”
Updating Applications
Unfortunately the only way to update a particular application on multiple devices is to
reinstall it of all devices, which can result in some devices not updating if they don’t ‘checkin’ for a while, or the application can occasionally not install completely when updating.
1. Click on “MDM” from the left hand menu of the Meraki dashboard
2. Click on “Apps”
3. Click on the Application you wish to update
4. Click on “Re-push to all”
MDM Commands
Meraki provides you with some addition commands that can be accessed via the Clients
details.
1. Click on “monitor” from the left hand menu of the Meraki Dashboard
2. Click on “Clients”
3. Click on one of the clients
4. About a quarter way down the page you can see the MDM commands
• Mobile Security
i. Clear Passcode: Clears the passcode in the event a user can’t log into
the iPad
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•
•
•
ii. Lock Device: Will put the device back to the lock screen – only
effective with a passcode
iii. Selective wipe: Will delete all application and profiles installed by
Meraki, but the device will remain enrolled in Meraki
iv. Erase Device: Will erase the device back to a new state
Data Settings – disable data roaming (doesn’t work)
Send notification – allows you to send a message through Meraki using
Apples notification system
GPS Location – this requires a user open Meraki
Additional Features
The settings of the profile also provide you with a couple of additional features which you
may find useful:
• Passcode – Used to enforce a passcode when unlocking the device, typically used for
staff devices.
• WiFi – Used to push out a wireless profile to your managed devices.
• VPN – Used to push out pre-configured VPN settings to allow end users to tunnel
back to a secured LAN.
• Web Clips – Used to push out a URL to a devices home screen, can be used to
provide access to Web Apps, mobileconfig files, enterprise application installs, etc.
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Asset Management Database - Basics
Purpose:
This document is intended to be a resource in the use of the Telehealth database. The
intended audience are those individuals that need to manage the assets and resources of
the Telehealth system.
Introduction:
Filemaker Pro is a cross-platform, multi-user, rapid deployment environment, relational
database. In simple terms it is quick, easy flexible and versatile.
Prerequisites:
To use the Telehealth database, you need a copy of FileMaker Pro or FileMaker Advanced
v13 installed on your Mac or Windows PC.
User Access:
The Telehealth database supports multiple user accounts, including Administrator and Data
Entry Only privilege sets, as well as others.
Each user has their own login credentials and these should not be shared with anyone else.
Accessing the Telehealth database:
There are two scenarios for accessing the Telehealth database.
1 The Telehealth database file is stored on your local hard drive. You double-click on this
file and authenticate to it, or, launch FileMaker and navigate to the file from the Open
dialog box. Alternatively, launch FileMaker, then from the File Menu, open the file.
2
The Telehealth database file is served by FileMaker Server, or another user has opened
the file locally and is sharing the file. Launch FileMaker, then from the File Menu, click
Remote. Within the Open Remote File dialog, choose your host and the Telehealth file
and click Open.
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3
Authenticate when prompted and you will see the AssetV2 layout. If your layout
resembles this one, you need to enlarge your window until the full layout is visible as
shown on the following page.
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Database Schema:
The primary table for the Telehealth database is the Asset table shown in the layout
AssetV2. Each record in this table relates to one Asset.
A related table is Asset Allocation, shown in the layout AssetV2 as a portal named Allocation
History. This table has entries for each time an asset has been deployed, a loan history in
effect.
Another related table is Note of Asset, shown in the layout AssetV2 as simply Note. This is a
log of any pertinent notes for this asset, such as when an asset has been sent in for repair,
for example.
The AssetV2 layout:
1
Asset Nº: is a unique identifier. Each asset has a sticker on it that has the asset number
shown (except for some very small devices that have it written on in texta or not at all).
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2
Custodian: is the responsible person that currently has the asset. This field may contain
the identifier for a patient, or it may contain the real name for a non-patient.
Note: you cannot enter data into this field unless you are performing a Find.
3 Entity: is the entity associated with the custodian. This could be RITHOM or Palliative
Care, or even ICT Stock (meaning it is in our inventory cupboard).
4 Tag: you can select multiple choices in this field. These entries are used in searches to
select products that are in certain groups. For instance if you tag an asset as Not iOS, it
will be excluded from searches that are not related to iPods and iPads. If it is tagged as
decommissioned, it will not appear in searches for available items, etc.
5 Flag: this field is used to identify groups of assets that are of interest. Before using this
field, you should Show All records, clear the current entry in this field, then from the
Records Menu, select Replace Field Contents. This will clear this field for all records. The
way to use this field is to use a combination of Find and/or manual selection until you
have the desired Found Set that you want. You then place a value in the Fag field, such
as 1, then use Replace Field Contents again to flag all entries in the found set. At any
time you can perform a simple Find for 1 in the Flag field to find the same Found Set.
You can also use any combination of Finds to add or remove assets from that set by
setting the Flag to 1 or by clearing it.
6 Equipment: is a description of the Asset, often with some specifications to differentiate
it.
7 SerialNº: is the serial number that the manufacturer has applied to the Asset.
8 Manufacturer: is the name of the manufacturer of the Asset.
9 InvoiceNº: is a two part field, the upper line is the Invoice number that the equipment
was purchased under, the lower line is the Date of that Invoice.
Portal to the Asset Allocation table
10 Custodian: is the responsible person that currently has the asset. This field may contain
the identifier for a patient, or it may contain the real name for a non-patient. To enter a
new Custodian, enter them in the next available blank field in the Custodian column,
then click out of the portal (say on the word Custodian) so that the entry is saved. This
field has a script trigger on it that executes a script as soon as you leave the field. That
script updates the previously mentioned Custodian field in the Asset table. This
arrangement has some advantages. If you want to find the current custodian, search the
field at the top of this layout. If you want to find any instance of a custodian, search the
portal entry from the Asset Allocation table.
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11 Entity: is the entity associated with the custodian. This portal entry field also has a script
trigger on it that updates the Asset table with the latest custodian when you exit that
field.
12 Tag: is an additional status field for the particular allocation. If the Asset is loaned to a
Staff member, check the Staff box. If it is on loan to another non-patient individual or
entity, check the Loan box. The buttons for finding groups of devices (and the scripts
behind the buttons) take into account the Staff and Loan tags, so as not to include them
in the Found set of Assets that are currently out with patients etc.
13 Del (button): deletes the portal row in which it lives.
14 Move To Stock (button): auto populates the End, Custodian and Entity fields for an
Asset coming back into stock.
15 IMEI: International Mobile Station Equipment Identity. This applies only to cellular
capable Assets and is usually written on the device near where the SIM socket is. It is
also usually on the serial number sticker of the box. On iOS devices it is accessible via
the Settings.
16 Anna Cares: if the device has the Anna Cares software installed or not (there were only
10 devices we could install on at the time of writing this).
17 SIM ID: this is written on the SIM. Needed to manage the SIMs.
18 ID Asset: is the database key for this Asset. It is used for all relationships with other
tables.
19 FaceTime: is the identity used by FaceTime to call this Asset.
Note: the Asset needs to be logged in to FaceTime using this identity to be able to
receive a call.
20 Vidyo String: is the identity used by Vidyo to call this Asset.
Note: the Asset needs to be logged in to Vidyo using this identity to be able to receive a
call.
21 Form Factor: of the SIM. Standard, Micro or Nano.
22 Cell Phone Nº: of the SIM. Needed to manage the SIMs.
23 Service Provider: of the SIM/Cellular service.
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24 Move To Stock (Button): deassigns the SIM from the current Asset and puts it into the
SIM Stock portal as an available stock item.
25 SIM ID: of in-stock SIMs.
26 Form Factor: of in-stock SIMs.
27 Cell Phone Nº: of in-stock SIMS.
28 Service Provider: of in-stock SIMS.
29 In-stock Flag: this field needs a 1 in it for a SIM to appear in the SIM Stock portal.
30 -> Device (Button): assigns the SIM to the current Asset and removes the in-stock flag,
effectively moving the SIM to the device.
31 Del: does not actually delete the SIM, rather it removes the in-stock flag without
assigning it to a device, so the SIM disappears from the in-stock list and remains in the
SIM table for reference only.
32 Slider: allows you to scroll the list of in-stock SIMs when there are too many to display
in the portal.
33 Note: any text you want to record against the Asset.
34 Delete: removes the Note entry.
35
36
37
38
Client: is for whom the Job was performed.
KeyWord: is used for grouping/finding Jobs.
Category: is used for grouping/finding Jobs
-> (Button): this button opens a new window of the job within the Job table. Here you
can edit the Job or create a new Job.
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In the graphic above, the Sort buttons sort the corresponding column. A
second click on the Sort button reverses the sort order.
The records (rows) each correspond to one Asset in the table. Clicking
on an Asset in a record causes all of the information for that Asset to be
shown in the aforementioned area above the records. This enables you
to scroll through the Assets and select one.
The Sidebar consists of a column of buttons to automate regular tasks.
Under Navigation:
The Asset button does nothing as we are already in the Asset
•
table.
The Job button opens a new window into the Job table.
•
The SIM button opens a new window into the SIM table.
•
Under Find iOS Devices:
The Available button finds all of "our" iOS devices that are in
•
stock and available, where "our" means the Asset is owned by the
Telehealth Project. (Some Assets in the Telehealth database are
owned by other parties. They appear in the Telehealth database as the
Assets were on the same invoices that some of the Telehealth Project
assets were purchased on).
The Ours button finds all of the Telehealth Project's iOS Assets.
•
The Patient & Carer button finds all iOS Assets that are currently
•
assigned to Patients and Carers
The Pall Care P & C button finds iOS Assets that are currently
•
assigned to Pall Care patients and carers.
The Rehab P & C button finds iOS Assets that are currently
•
assigned to Rehab patients and carers.
Under Find Items:
The Flagged button finds any Asset that has the Flag field set to Yes.
•
The All button finds every Asset.
•
The
This Custodian button finds all Assets assigned to the current Custodian.
•
The Not iOS button finds all Assets that are not iOS devices, such as stands, modems,
•
WiFi access points etc.
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iPad setup – Complete guide
Procedure
• Obtain the items from the appropriate checklist below
• Check that the items are in the Asset database, if not, add them in.
• Fit the micro-SIM or SIM
• Ensure the iPad has the correct Device Name and image installed.
• Login to Admin, delete the old Vidyo user and add the new Vidyo user
• Setup the Fitbit on the iPad
• Register the user in Fitabase
• Setup Rehab Tools, Patient and Nurse
• Ensure that all the required apps have been installed from Meraki.
Checklist for Rehabilitation in the Home (RITHOM)
□ TR Nº from service manager
□ Stylus pen (Optional, ask service manager)
□ iPad stand Mophie (deluxe) with Power Adapter and Asset Nº sticker
□ Fitbit Zip (Asset Nº written on with texta) (configured on iPad and in Fitabase)
□ iPad power adapter (Optional)
□ iPad lightning cable (Optional)
□ iPad (3G/4G with Telstra micro-SIM) with Asset Nº sticker
o Re-image with the latest Base Image and the FTHP - WiFi Payload (eduroam)
o All RITHOM tagged Apps from Meraki
o VidyoMobile (configured to login using the AssetNº device name)
o FaceTime (configured to login with the Apple ID: AssetNº@icloud.com)
o Fitbit (configured on the iPad and in fitabase, zip paired to iPad)
o Rehab Tools (configured with Clinician and Patient authentications: see
lastpass)
o Exercise Website “App” (with client registration on the T-Rex site).
o CARE with registration (Care For Stroke patients only)
Setting Up an iPad – Required Items
4 Required items: You will need the Telehealth Apple MacBook, the power adapter for
the MacBook Pro, the iPad you wish to setup and the lightning (USB to iPad) cable
5
Ensure that the iPad has been entered into the Asset Database and has an Asset Nº
sticker on it. The sticker should display the FTHP Nº
6
7
If the iPad is connected to the MacBook Pro, disconnect it
Plug the MagSafe power adapter (for the MacBook Pro) into a power outlet and the
MagSafe connector into the left hand side socket.
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•
•
An amber dot in the plug indicates that the battery is charging.
A green dot indicates that full charge has ben reached.
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Setting Up an iPad - Imaging with Apple Configurator
1. Turn on the MacBook Pro
2. At the Login prompt, click on FTHP0001 User Account icon
and authenticate with the Password: Fl1nders
3. Warning: Ensure that any iOS devices, iPhone, iPod and iPads
are disconnected before launching Apple Configurator, as they
may be automatically erased.
4. Launch Apple Configurator
5. Click on Prepare
6. Check that the name is correct, use the Asset Nº for the iPad, example: FTHP0020
7. Tick the profile named: FTHP - WiF Payload (eduroam)
8. Select Restore: BaseImage_Patients_iOS7_1.7 (or newer version if available)
9. Turn on the iPad.
10. Connect the iPad using the lightning cable to the MacBook Pro
11. If the iPad is not seen by Apple Configurator - within say 30 seconds of connection
a. Click the Stop button at the bottom of the Prepare window
b. Click on the Supervise button
c. Click on USB Connected under the Supervised Devices sidebar
d. Click on your USB-connected supervised device and select Unsupervise from
the Devices Menu. (This wipes the device and sets it back to factory defaults.)
e. Once the device restarts and displays the white apple, disconnect its USB
connector and wait for it to finish starting up.
f. Click on the Prepare button and check that the settings you require are
correct.
g. Reconnect the iPad - preparation will begin.
12. To see the progress of the preparation of your device, click on the disclosure triangle
for your device.
13. When "Update Completed" is presented, click Continue
Setting Up an iPad – Connecting to the WiFi network
1. When the iPad has restarted, login by sliding to the right
2. When "Choose a Wifi Network" is presented, click Next.
3. When “Continue without WiFi?” is presented, tap Continue.
4. When "Location Services" is presented, click "Enable Location Services".
5. When “Welcome to iPad” is presented, tap Get Started.
6. Go to Settings and click Wi-Fi, select eduroam
7. When asked to accept the flinders certificate, click Accept.
Setting Up an iPad – Installing Apps with Meraki Mobile Device Manager (MDM)
1. Go to your computer and login to the Meraki site
(https://account.meraki.com/login/dashboard_login?go=). (Use the authentication
provided to you by the Project ICT Support Team.)
2. Click MDM (Mobile Device Manager) in the sidebar, then Add devices.
3. Scroll down so that the QR code is fully visible
4. Go to the iPad
5. Launch Meraki Systems Manager App
6. When “Meraki SM” Would Like to Send You Push Notifications is presented, click OK
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7. When Error Could not connect to the host… is presented, click OK
8. Click Use QR Code and point the camera at the QR code from the Meraki web page.
The iPad will recognise the QR Code and return you
to the Custom Enrolment window. The code "025961-2777" should be displayed.
9. Click enrol.
10. When "Profile Installation" is presented, click OK
11. When "Install Profile" is presented, click Install.
12. When "Profile Installed" is presented, click "Done".
13. When “Meraki MDM Would Like to Use Your
Current Location", click OK
14. When "Enrolled in FTHP" is presented, click the home button at the bottom of the
iPad to back out of Meraki MDM.
15. Go to your computer and the Meraki site:
https://account.meraki.com/login/dashboard_login?go=
16. From the sidebar click Monitor, then click Clients
17. Click the checkbox next to your iPad in the list. The name will
18. match the Asset Nº of your iPad.(The iPad will be tagged
with "recently added".)
Setting Up an iPad – Applying Tags
• Click the Tag tab
• Click in the Add field
• For a Rehab device, enter "r" and select RITHOM_Patient or RITHOM_Clinician as
appropriate, then click "Add". Tab out of the field or click outside the field.
• Click on the Quarantine tab and select Authorize
• Click on the device in the list.
• A new view will be presented showing the detail for the device.
• Scroll down to the "Apps" section and click
"Missing".
• At the bottom of the list, select "All".
• Go to the "Actions" column at the right hand
side of the list. For each item in the list, click
"Install" and click "OK" when prompted.
• Go to the iPad
Note: If this is a new iPad being commissioned (or it
has been re-imaged), you will need to login to the
iTunes Store once. To do this:
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Launch the "iTunes Store", then tap the "Purchased" button at the bottom of the screen and
enter the password: Fl1nders. (This password uses a "one" instead of an 'i".)
• Navigate to the Home Screen and wait for the Apps to appear and start downloading. If
the Apps do not start appearing within a minute or two, reboot the iPad and wait again. If
they still do not begin downloading, ensure you are connected to wifi. If they still do not
download, escalate the issue to your technical support person.
Setting Up an iPad - Setup Telstra Dongle - 3G/4G Cellular card with WiFi Access Point
1. Swap out the Telstra Pre-Paid SIM with a Telstra MonthlyAccount SIM.
2. Record the IMEI, serial Nº, Phone Nº, etc. into the Telehealth
FileMaker database.
3. Plug the dongle into a power socket.
4. Join the WiFi network (See the Wireless Security Card provided
or inside the case of the modem for the SSID and the WPA key).
5. Launch Safari and go to the address 192.168.1.1
6. Enter the PIN (found under a scratch-to-reveal panel on the card
the SIM came in) and select “Disable PIN” and click "Apply".
7. Click “Settings” and authenticate with username: admin,
password: admin
8. If presented with a dialog indicating a weak password, tick "Do
not remind me again" and proceed.
9. Go to "System -> Modify Admin Password" and Change the
Admin authentication to username: admin, password: Telehealth01
10.
Go to Settings
11.
Authenticate with the new credentials
12.
Go to WLAN -> WLAN Basic Settings
13.
Change the SSID to: FTHP1, with the following parameters:
•
802.11 authentication: WPA/WPA2-PSK
•
Encryption: AES
•
Pre-shared key:
KC7fHdX6cwp4HifZuF5qJyUqAgKExEwNncdB7fuai65IDsR3ZgXKuDvxr
•
SSID: enable
•
Click “Apply”
Setting Up an iPad - Setting up a Fitbit Scale
1. Plug in a wireless access point that is configured as FTHP1.
2. Join the FTHP1 network from your computer with the password:
KC7fHdX6cwp4HifZuF5qJyUqAgKExEwNncdB7fuai65IDsR3ZgXKuDvxr
3. Remove the battery blocking strip from the Fitbit Aria Scale
4. Launch the Fitbit WiFi Scale Setup application
5. Click Get Started
6. Click Login to your account
7. For the Email placeholder, enter the Patient
Identifier email address. For example,
pc018@caresearch.com.au for a Palliative Care
patient. (NOTE: For Palliative Care patients, the
numbers are sequential. For Rehabilitation
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patients, ask Claire for the Patient Identifier as these numbers are issued from her
contact in Europe.)
8. For the Password placeholder, enter: Telehealth01 (NOTE: Get it right first time as
you only get one chance to enter it).
9. Click Enter
10.
At the Personal Info window, click Next
11.
At the Scale Info window, click Next
12.
At the Would you like to use FTHP1 to connect to your scale, click Yes.
13.
Wait while the scale joins the network. If you have problems at this stage,
manually configure the IP settings for the scale's network and try again. Often the
Mac will join the wrong network because it is stronger. The config process often fails
because of not being able to switch to the correct network at the appropriate time.
14.
At the Success window, click Done.
15.
Ensure the Fitbit Aria Scale is entered into the Assets FileMaker database.
16.
Print an Asset label and apply it inside the battery compartment.
Setting Up an iPad - Setting up a Fitbit Zip
1. Fitbit Zip
2. Setting up the Fitbit Zip
3. Unpack the Fitbit Zip
4. Test the battery with a battery tester or voltage meter.
The battery is a 3V Lithium disc (2025) type and should be
at least 3V when new. It will need replacement if it is less
than around 2V. Many of our Fitbits have flat batteries out of the box and those
batteries will need to be replaced.
5. Fit the battery to the Fitbit Zip (while taking care to insert it the correct way around)
using the supplied tool (or a coin) to remove/replace the cover on the back.
6. Tap the Fitbit Zip with your finger and the display should change to a smile.
7. Setting up the iPad for your Fitbit Zip
8. Ensure that you have the Fitbit App installed on your iPad. If not, do that and return.
9. Launch the Fitbit App.
10.
If the Fitbit App has been setup with another user, tap on account, swipe up
from the bottom of the screen and tap log out.
11.
Tap "Join Fitbit"
12.
Tap "Setup Your Zip"
13.
Tap "Let's Go"
14.
When presented with "How tall are you?", slide the scale to 165 cm,then tap
"Next Step".
15.
When presented with "What's your gender?", tap on the female form, then
tap "Next Step".
16.
When presented with "What is your weight?", slide the scale to 32, then tap
"Next Step".
17.
When presented with "What is your birthday?", slide to 1 Jan 1951, then tap
"Next Step".
18.
For the Email placeholder, enter the Patient/Carer Identifier email address.
For example, pc018@caresearch.com.au for a Palliative Care patient. (NOTE: For
Palliative Care patients, the numbers are sequential. For Rehabilitation patients, ask
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Claire for the Patient Identifier as these numbers are issued from her contact in
Europe.)
19.
For the Password placeholder, enter: Telehealth01 (NOTE: Get it right first
time as you only get one chance to enter it).
20.
Click Return
21.
At the “Before you start setup” dialog, click Start.
22.
At the Looking for your Zip dialog, tap your Zip to wake it up.
23.
At the We found a Zip dialog, click Next.
24.
At the Please enter the number on the display of your Zip., enter the number
displayed on your Zip.
25.
Click Next
26.
Click Done
27.
At the “Fitbit would like to send you push notifications dialog”:
27.1.
For Palliative Care patient, click Don’t Allow
27.2.
For Rehabilitation patient, click Allow
28.
At the Setup screen, click Edit:
28.1.
For Palliative Care patient, keep steps, weight and distance, remove others
(Click the "✓” button to toggle between ticked and not ticked).
28.2.
For Rehabilitation patient, keep steps and distance, remove others (Click the "
✓” button to toggle between ticked and not ticked).
28.3.
Click Done.
29.
Click Account.
30.
If you do not see Fitness Goals, click the back arrow at the top LHS of the
screen.
31.
Click Fitness Goals and set the following:
31.1.
Steps: 1000
31.2.
Distance: 1 km
32.
Click Account at the top LHS of the screen
33.
Click Zip
34.
If Zip Update Available is shown, click on it.
35.
The “A few things to know before updating your Fitbit Zip” dialog appears.
36.
Drag up and click Next.
37.
Place your Zip near the iPad (and tap it to wake it up if necessary).
38.
The “Updating your Zip” dialog appears. A progress bar appears on your Zip.
39.
Wait for completion (up to 10 minutes). If there is a problem resulting in an
unsuccessful or incomplete update, you can quit the Fitbit App, relaunch it and run the
update process again. If it did not complete, it will resume.
40.
When the “Your update was successful” dialog appears, click Done.
41.
Ensure the Fitbit Zip is entered into the Assets FileMaker database.
1.
2.
3.
4.
Click on Flinders Telehealth
On the RHS sidebar, look for User Invitations and click Add/Edit.
Click Manually Connect Device.
Fields
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Setting Up an iPad - Vidyo App (on the iPad)
1. Open Vidyo Mobile
2. Enter the Vidyo credentials and click login:
• Portal: asset#.vidyo.flinders.edu.au (example: fthp0037.vidyo.flinders.edu.au)
• Username: asset# (example: fthp0037)
• Password: Telehealth01
3. Click on the settings icon at the bottom right of screen and enable Always use
VidyoProxy.
4. Click Contacts
Setting Up an iPad – Configure Facetime
1. Open Settings
2. Tap on iCloud
3. Tap “Get a free Apple ID”
4. Enter 01/Jan/1951 as the date of birth and tap Next
5. First name: fthp
6. Last name: the 4 digits on at the end of the asset number (example: 0037)
7. Tap Get a free iCloud email address, then tap Next
8. Email: fthpxxxx@icloud.com, where xxxx is the 4 digits on at the end of the asset
number (example: fthp0037@icloud.com), then tap Next
9. Check that you have typed it correctly and tap Create
10.
Password: Telehealth01
11.
Verify: Telehealth01 and Next
12.
Security Questions - select and complete as follows:
• Question 1: What is the first name of your best friend in high school?
• Answer 1: Flinders
• Question 2: What was your childhood nickname?
• Answer 2: Telehealth
• Question 3: What is the name of your favorite sports team?
• Answer 3: Project
13.
Rescue Email: fthp@flinders.edu.au
14.
Disable Email Updates.
15.
Agree to the EULA.
16.
Agree to the Terms and Conditions
17.
Don't Merge with iCloud
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18.
OK to Allow iCloud to use your location.
19.
Turn off syncing for all items.
20.
Tap on Photos and turn off Photo Syncing.
21.
When launching FaceTime, login using the newly created AppleID credentials:
<AssetNº>@icloud.com and password Telehealth01.
22.
Once the Facetime account is verified, close settings.
Adding a User to the T-Rex Exercise Web Site
1. In a web browser, go to t-rex.net.au
2. Authenticate as Username: servicemanager, Password: ServiceM101!
3. Click "I agree to Terms & Conditions".
4. Click "Log In".
5. Go to the Exercise Plans area.
6. Click "Add New"
7. If you know the client's name, populate the Client First Name and Client Last Name
fields appropriately, otherwise user the Asset Nº for both fields.
8. For the Client Username placeholder, enter: the Asset Nº. For example, FTHP0116
etc.
9. For the Password placeholder, enter: Telehealth01
10.
For Exercise Label, enter: None
11.
For Internal-Use Label, enter:None
12.
Click "Save Exercise Plan".
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13.
14.
15.
Click "Publish".
Repeat step 12, Click “Save Exercise Plan”
Click “Update”
Setting up the Exercise "App" on an iPad
1. Go to your computer and login to the Meraki site
(https://account.meraki.com/login/dashboard_login?go=). (Use the authentication
provided to you by the Project ICT Support Team.)
2. Click MDM (Mobile Device Manager) in the sidebar, then Profiles.
3. Click “Add New” towards the top right of windows and then “New Mobile Profile”
4. Create a new mobile profile with the following information and click “Save New
Profile”
• Configuration: “Use the Meraki Dashboard to create a conf…”
• Name: RITHOM_Asset# of Device (example: RITHOM_FTHP0037)
Removal Policy: “Require password to remove this profile”
• Password: 1937
• Scope: Apply to devices “with ANY of the following tags”
• Use the Asset number of the device for the tag – Click “Add option” if there
are no results
5. Click MDM (Mobile Device Manager) in the sidebar, then Setting.
6. Select the profile from the dropdown box towards the top left of window.
7. Click on Web Clips
8. Click “Create a Web Clip” and enter the following information;
Label: Login
URL: http://t-rex.net.au/wp-login.php
Removable: Blank/Not ticked
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Full screen: Ticked
Precomposed: Blank/Not ticked
9. Click “Save Changes”
10. Click “Add a new Web Clip” towards the bottom left of window and enter the
following information;
Label: T-Rex
URL: http://t-rex.net.au/exercise-plan/asset# (example: http://t-rex.net.au/exerciseplan/fthp0307/)
Removable: Blank/Not ticked
Full screen: Ticked
Precomposed: Blank/Not ticked
11. Click “Save Changes”
12. To push the web clip out to the device you will need to assign the tag to the device;
13. From the sidebar click Monitor, then click Clients
14. Click “Edit details”, just below the device name
15. In the tags field, type in the asset# and click on it to select
16. Click “Save”
17. The web clip will be pushed out to the device when it next check’s in.
Note: You can force the profile to be pushed out to the device by clicking on “Install
missing/updated profiles” which is located approximately ½ way down under the Profiles
heading.
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