The core of the workshop consisted of four panels—each featuring two or three speakers and a respondent—on applications of technology in different areas of personal and community life. The next four chapters summarize the formal presentations made during each of these panels. The reflections of the respondents appear in Chapter 7 as part of the summary of the discussions that took place throughout the workshop.
In the panel on technologies to promote activities of daily living and independence, Rory Cooper, FISA and Paralyzed Veterans of America chair and distinguished professor at the University of Pittsburgh, described some of the ways in which wheelchairs can overcome mobility limitations, along with mobility challenges still to be overcome. Then Gregory Wellems, chief operating officer at Imagine!, described how universal design can help make smart-home features widespread and familiar.
Rory A. Cooper, Ph.D.
University of Pittsburgh
Assistive technology needs to be delivered through a team approach, but that rarely happens. In America, most assistive technology is simply purchased from a retail outlet such as Walmart, Costco, or Home Depot. In addition, rehabilitation technology suppliers are loosely regulated and not highly trained.
New technologies are also slow to emerge because of insufficient fund-
ing for research and development, especially for translational research and technology. SBIR funding is available, but a technology needs to be developed to the point that it is eligible for SBIR funding. Such funding also requires working with a small business rather than with large companies that can more easily bring a technology to market.
Finally, reimbursement for assistive technology is inadequate. Cooper is a veteran, which made him eligible for the kind of wheelchair he uses, but it is not covered by most insurance. Without his wheelchair, Cooper would have to stay wherever he was. Similarly, without a communication device, someone who cannot communicate otherwise transitions from being an independent person to a dependent person. Assistive technologies can be expensive. A sampling of mobility devices that Cooper showed for use in communities (e.g., robotic exoskeletons, prosthetic limbs) cost between $90,000 and $120,000. These devices, some of which are covered by insurance but some of which are not, challenge current reimbursement systems.
Many people in the world who need a wheelchair do not have access to one. Cooper asserted that only about 6 million wheelchairs are produced each year, and about 4 million Americans use wheelchairs, with an average wheelchair lasting 3 years. Ten years ago the average wheelchair lasted 5 years, Cooper said, but because of pressure from reimbursement, manufacturers have moved to cheaper technologies, a change that has reduced the lifetime of wheelchairs.
Wheelchairs are designed to help prevent pressure ulcers or alleviate pain, but people do not use them as prescribed. As a result, an insurance company may wonder why it spent $35,000 or $40,000 on a piece of equipment that is not treating the problem. Monitoring systems can help determine whether a chair is being used as prescribed. For example, chairs can provide information about configurations to relieve pressure ulcers, with the data being transmitted to a clinician as well so that the issue can be discussed with the patient. Most individuals do not need such a system for the long term, but it enables them to make adjustments that they then can internalize into their routine activities. Cooper also showed a technology that addresses such problems as whether a chair is tilted back too far to go up a ramp safely. The chair provides information about the angle to tilt the chair to compensate for the ramp.
Transfers from a wheelchair to another seated location are a critical aspect of accessibility. Cooper has been involved in a study to look at the heights and gaps that can be managed independently during transfers; the study found that most people can easily handle only about 2 inches of horizontal or vertical difference during a move.
Sports and Recreation
Sports and recreation are important modalities of rehabilitation, but the U.S. Department of Veterans Affairs and U.S. Department of Defense are the only agencies that cover sports and recreation equipment today. Activities such as bicycling, quad rugby, and wheelchair basketball provide both wheelchair skills and community integration. People typically cover about 2,500 meters of community-based activity per day, which is about the same as it has been in the past. But sports participants in wheelchairs can cover about the same amount of distance in a 1-hour game.
Wheelchairs and other devices providing robotic manipulation are becoming available to help with activities of daily living. Cooper showed a person using voice control and a tablet to control a wheelchair as well as two manipulators (arm-like mechanisms which grasp and move objects) in an office supply store. Nevertheless, many places remain inaccessible to people in wheelchairs, changes in the physical infrastructure remain slow, and the kinds of wheelchairs needed to access some locations are typically not covered by insurance.
Technology for amputees is also making rapid advances. For example, virtual reality devices can help an amputee improve balance on a prosthetic. Powered ankles and knees are now on the market and will become more sophisticated over time.
Cooper described a simple magnetic device called Path Lock, which converts a wheelchair to a one-arm drive, so a user can hold something with one hand and push with the other. In addition, hybrid systems can work partly with human and partly with mechanical propulsion to increase mobility. And technologies are providing information about how wheelchairs function, which can be used to improve their functionality and reduce risk for outcomes such as carpal tunnel syndrome or rotator cuff injuries.
Wounded Warrior Home1
Cooper’s group has been working with several companies to create accessible housing for military personnel who continue on active duty. He showed two finished houses at Fort Belvoir, Virginia, where 120 more are planned. The homes feature keyless entry; a security system; floor surfaces that help with visual guidance; accessible tubs and showers that look more like those in a standard bathroom; technology closets in which to keep
wheelchairs and prosthetics; high and low sinks and appliances in the bathroom and kitchen; an indoor room for home therapy with a door to the outside; temperature control for every room in the house; high-filtration systems for people with allergies or sensitivities to smell; turning space in all the rooms; and other features for military personnel with disabilities.
Universal design, in which all homes include the features needed to accommodate limitations, is the key, Cooper said. As people get older, they are able to use such features. When they have children, they will use these features. When people who have disabilities come to a home built using universal design, they will use those features. Such homes can be used by everyone.
Imagine!, which is a private, not-for-profit organization in Colorado that provided support to 2,800 people in 2011, largely assists people on Medicaid who have relatively few assets.2 Imagine! therefore focuses on technology because technology will be essential to overcome the barriers to care faced by those without extensive resources on which they can draw.
Providers tend to throw technology at problems, technologies such as an online learning system, an online management system, an enterprise application, and a remote monitoring system. But unless these systems are tied together, they will not interrelate and work together. In addition, when smart homes or smart services are developed in universities, the people who test technologies tend to be college students pretending to have a disability, said Wellems. But the best way to develop technologies is to have people with cognitive and developmental disabilities use technologies to figure out what works and to determine where changes are needed.
Service providers need to have a strategic process to prioritize and analyze organizational “pain points.” For example, a 6-inch binder full of paper is a pain point because it is static information, whereas dynamic information is needed to plan for change. Technology produces change in services and caregiver dynamics, and organizations need to plan for such change.
Universal design has to encompass technology, Wellems observed. A house can have an outlet near the top of the door so that an automatic door opener can be added at some point. Ceilings can be reinforced to accom-
modate a barrier-free lift. Walls can be reinforced with particleboard or plywood so that a robotic arm can be added, and countertops can be adjusted up or down. Control panels can allow complete access to any outlet or device in the home so that doors or windows can be opened or closed and televisions and radios can be turned on or off. Energy use can be monitored to increase efficiency, and other kinds of dashboard systems can capture and analyze data and present that information in a meaningful way to an end user. Wellems emphasized the value and importance for these homes to be “green” because energy efficient homes save on ongoing operating costs. Additionally because these homes are typically funded through grants and private donations, green building techniques help to attract funders.
Imagine! uses a radio-frequency identification system in its homes to provide services to occupants as well as to inform caregivers and managers. The same system can be used to understand health care needs and how they change over time. For example, it can monitor the amount of time a caregiver spends with a client and how the amount changes over time. Remote monitoring systems can detect falls or proximity, provide for remote health monitoring, and compile other kinds of data. Cognitive support technology can work in any location, whether a home or the community.
Wellems pointed to a particular example of “low-hanging fruit” for promoting independence in the environment. The expertise of most corporations, he said, is in information technology, not in managing remote monitoring systems. Such expertise is increasing in some companies, but service providers are looking for more. For example, radio-frequency identification technology needs to be more reliable to use with confidence in smart homes.
Wellems also cited the success of social media, which has redefined community for people with disabilities. Social media do not recognize disabilities, he said.
Finally, he emphasized the importance of personnel. A particular caregiver may understand a particular technology, but then a new caregiver arrives who does not. Service companies will need to do a better job of writing job descriptions, recruiting employees, and training them for their positions to provide support.
The goal is not just to create smart home after smart home, said Wellems. Families are waiting, and some individuals will not become eligible for Medicaid. Technologies need to be developed and widely implemented so that smart-home concepts become familiar and common.