We sat down on and reviewed the current state of things in the Tele-Rehab 2.0 project. This helped us to understand where things stand, the timeline we are working on, some of the roadblocks we are facing, and how to continue forward. We have a lot of work to do before we start community trials in March 2020.
Let’s start with a WIN: We have finally completed all the milestones for Phase 1 - Engagement with Communities and Formation of Working Groups!
We also have a solid team dedicated to the project!
Martin Ferguson-Pell - Leading strategic planning and coordinating technical development Courtenay Badran - Overseeing operations, coordinating clinical leads Emily Armstrong - Administrative and communications support Sydney Hampshire - RA, guiding the ethics application process Zosia Czarnecka - RA, directing community engagement and site selection Andrew Vonow - RA, developing mobile EMG technology Emmanuella Osuji - RA, overseeing PROMs/PREMs research and development
Molly Henneberry - RA, exploring novel research in the area of vestibular/ balance
Since the last progress update, we have made progress in all areas of the project: technology, clinical, operational, ethics, PROMs/PREMs, community engagement, and strategic.
Technology:
We have two streams of technology development underway: (1) Kinetisense markerless motion capture for wheelchair, shoulder, hip & knee arthroplasty and (2) Mobile EMG sensor and software development.
The challenges have mostly come from the complexity of the project. We are trying to direct novel technology development for 4 complex rehabilitation assessments that are being conducted remotely. It is novelty on top of complexity on top of novelty. Not to mention the time constraint and sizeable financial commitment.
We are developing a novel mobile EMG technology for this project, inspired by the work Kaitlyn did last year. There are several elements of this project, including validating the relationship between EMG and force, software and hardware development, and developing the calibration protocol. This work requires Andrew and Michel to work together, and the current priority is to outline and illustrate the goal for the final product. Then we can solidify the expectations, requirements, and milestones.
Clinical:
We have scheduled in-house trials with our clinical leads for vestibular/balance and wheelchair seating.
For the first vestibular/balance trial, Sheelah will be coming to the lab to oversee the “remote” assessment of a mock patient. Emmanuella will be the mock generalist, and she will review the storyboard beforehand and familiarize herself with using the infrared goggles and other technology.
For the first wheelchair seating trial, Genevieve is coming to the lab to oversee the “remote” assessment of a mock patient. One of her colleagues will be the mock generalist and is already familiar with the standard EZSS - Assessment process.
For both trials, the focus will be on how well the technology can support a remote assessment. This exercise will help us revise the storyboard, evaluate tech needs, determine educational needs, and identify process issues for both modules.
After these are completed, we will be able to schedule trials for hip & knee replacement and shoulder pain as well.
Operational:
We’ve had all these conversations with our lead clinical and stakeholders about what will be involved in completing the pilot project (i.e. implement their clinical pathway with 5-10 patient assessment and treatments to demonstrate proof of concept). These conversations generated a lot of operational questions about how exactly these remote assessments and treatments will be carried out.
We are going to compile all the questions collected from these meetings and organize them into a single word document. This way, we can effectively crowdsource assistance and/or answers from our Operations Advisory Group.
The Operations Advisory Group will include members from AHS (ex. Virtual Health), ethics, Lifemark, clinical leads, Elaine Finseth, Katie Churchill, Todd Farrell, Giselle Tupper etc. We will also include the generalist clinicians we are going to be working with to get a clearer idea of how we are going to do this in the specific community/clinic.
Initial individual conversations with this group have already been held with strong senior AHS involvement.
Ethics:
Ethics applications for each module are being developed. I realize now that we could not have really started the ethics applications much earlier in the project because we needed time to think through and set up the different project components.
We can reach out to Virtual Health if any support is needed with ethics or NACTRAC.
PROMs/PREMs:
We have started working on Patient-Reported Outcome Measures (PROMs), and Patient-Reported Experience Measures (PREMs). We are leaning towards utilizing standard PROMs tools for each of the clinical focus areas and developing a specific tele-rehab experience survey that could be conducted through interviews with patients to collect qualitative information on the tele-rehab experience.
Emmanuella has been reviewing PROMs that apply to the delivery of Tele-Rehabilitation assessment. She has also been developing the PREMs that can assess patients’ experience when participating in Tele-Rehabilitation assessments.
PROMs are based on the objectives and goals of the patient. This is standard practice and not specific to Tele-Rehab 2.0 (i.e. they do not contribute to our project goals). The PROMs for the 4 clinical focus areas were specified by the clinical leads.
Shoulder: EQ-5D
Hip/Knee: EQ-5D-5L / WOMAC
Vestibular: Dizziness handicap inventory
Wheelchair: WAT-LX
We now need to outline 3 processes for PROMs collection:
How is info collected?
When is info collected?
Where is info stored (privacy/security)
PREMs are based on the experience of the patient. Typically they are questionnaires. We are using the PDSA method so we will be incorporating changes after each patient interaction based on their feedback. We also need to outline the same 3 processes for PREMs collection:
How is info collected?
When is info collected?
Where is info stored (privacy/security)
The information we are gathering from the PREMs will ultimately guide the focus groups that will occur at the end of the project.
Facilitators guide will be based on feedback from PREMs
Bringing together clinical leads, generalist clinicians, patients
Gathering feedback, building consensus on the path forward
Future study/improvements
Overall, it fees like the PROMs/PREMs component of the project is pretty straight forward. We just need to figure out how they will be integrated into the assessment protocol.
Community Engagement and Site Selection:
We have had a productive conversation with Zosia about community engagement and how we want to go about it. Our goal for right now is to come up with a strategy for community engagement and then begin that process.
The main priority of community engagement is to find engaged clinicians who want to participate in this project. Currently, we are looking at having sites in Wetaskiwin, Grande Prairie, Peace River, Fort Chipewyan.
We had our vestibular/balance specialist reach out to a Lifemark clinic in Grande Prairie, to ask about completing our pilot project with them, and their response was: "I guess it ultimately comes down to costs/benefits. Are they just looking for space to provide these services? Or is there a component of PT attached to all of them? I am not sure that we have the extra space to set up any sort of permanent telehealth room, we were just going to use our one private PT treatment room. With a lot of new WCB projects going on, space is at a premium here. Also, I do need to be a little cautious, as my PT situation is never very stable, and I am often bringing in new services, then due to staffing, are shutting them down within a year."
This response highlighted the need to have specific asks for our community partners and materials that explain the why, what and how of the project. We also need to think about how we will be doing patient recruitment.
A secondary goal of this is that we need to be raising awareness. At the end of the project, we need people to know about this project so that we have champions or advocates for the continuation of tele-rehab. If we get to the end of the project, and nobody knows what we have been doing, it is going to be even more difficult to secure additional funding to keep it going, especially if we are going to be making the case to AHS to incorporate this into their services.
Strategic
We are always thinking about how to support the long-term sustainability of this program.
We are initiating this engagement process by having a Tele-Rehab 2.0 Co-investigators meeting/info session on Thursday, September 26, via webinar. This is intended to share updates on the project and to gauge interest in being part of the SAG.
The first meeting of the SAG will happen after the co-investigators meeting/info session.
Conclusion: So as you can see, all roads lead to Rome. We need to take our assumptions and start testing them, and have faith that all the hard work we've put into the project so far will set us up for success!
-Courtenay