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    100-Overview

    Abstract

    Communication network for 30 residents of a VA Spinal Cord Impairment Community Living Center, accommodating disabilities ranging from up to eyeblink only. Provides communication including internet access, single/multiparty telephony, mail and instant messaging with a secure server. Augmented Communication interfaces include voice recognition, head control, and eye-gaze control. This will enhance communication among residents, and give all residents access to telecommunications and cyberspace.

    Problem Statement


    The Veterans Millennium Health Care and Benefits Act directed the VA to provide long-term care to eligible veterans, including those with Spinal Cord Impairment (SCI). The Joint Commission requires that long-term care provide a home-like atmosphere, with the long-term care recipients termed “residents”, not “patients.” The James A. Haley Veterans Hospital (Tampa) has one of the largest SCI Centers in the country with 100 beds and 1500 outpatients. Thirty beds are located in a new (June 2008) long-term care facility, known as a Community Living Center (CLC). Ten of these beds are dedicated to ventilator-dependent residents. This is the only SCI Vent CLC in the country. Residents comprise a mix of paraplegics (intact manual dexterity), non-vent tetraplegics (impaired dexterity but intact head movement and voice), vent-dependent tetraplegics (impairment of head motion and voice) and ALS (Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s disease, limited to eye motion only). In the non-vent side of the CLC (SCI-F), communication among residents is self-directed, as they move around in their wheelchairs, congregate in public areas, make conversations with each other. There is an internet café, stocked with a few old donated computers that are used by residents possessing manual dexterity. In the vent-side (SCI-FV), communication among residents is almost non-existent. These residents stay in their room most of the time, connected to ventilators unless the staff gets them up into wheelchairs equipped with portable ventilators. The non-ALS residents can talk for only some portions of the day, when the staff partially deflates the cuffs of their tracheostomy tubes. Their speech pattern is still highly abnormal, and in general is not suitable for controlling a computer through voice recognition software. They can, however, control a computer, either by mouth-driven joystick, or by their head position, using a reflective spot on their glasses and a camera integral to the computer. The ALS residents need a special Augmentative and Alternative Communication (AAC) device that monitors eye position to control a cursor. Problem Statement. Communication is important to quality of life and for delivery of health care. In this CLC, the 10 vent-dependent residents have severe difficulty just communicating with the health care staff, and do not communicate amongst each other at all. Of the 20 non-vent residents, communication outside the hospital, either by phones or through cyberspace, is limited to those with manual dexterity to operate the telephones computers in the internet café. While communication to the nursing station is facilitated with a call bell, room-to-room communication is not facilitated, and is limited to knowing others’ telephone numbers and using a phone. At times, some residents are restricted to their rooms due to fractures or infections, and during this period they are socially isolated.


    Solution

    The solution must: a. Allow non-verbal residents to communicate directly with peers, medical staff, etc. b. Allow both verbal and non-verbal residents to communicate with speech via a telephone call, regardless of motor skills. c. Create a uniform system for all residents to aid in the training of the medical staff and the upkeep of the system. d. Improve the sense of community of the residents, by creating a special online meeting place that includes a message board and other items in which all residents can interact, regardless of verbal and motor abilities. e. Allow the ability to send email, text messages, and securely access the internet. We propose to design and demonstrate the use of a networked communications system which will allow residents of the SCI CLC to talk to, instant message, or email each other and outsiders, and to access the internet. Individual stations would be customized to the match the disability of the user. These stations would network to a communication server which would securely manage communication among stations and outside the network. Customized software, such as an adapted message board to allow users with different communication speeds and schedules to communicate. In order to accomplish these objectives, we propose using the software and hardware platforms of a single AAC company. This will allow uniformity throughout the CLC. We have classified our residents into three groups based on their disabilities and have identified a different communication strategy for each. Group 1: Reliable motor control of head and arms. Portable communication devices can be operated by touch, and can be carried around the campus facilitating communication. Group 2: Reliable motor control of head, but not arms. A large touch-screen which can be operated by a head-controlled cursor with the use of a head tracking device, or by a caregiver’s touch of the screen. Group 3: Reliable motor control of eyes only (those diagnosed with ALS). An Eye-controlled communication system will allow the resident to select communication words and phrases by using the motion of their eyes. An online Message Board will be created specifically for the residents. The AAC Company will provide customized software to allow all residents to access, read, and use the Message Board. The four leading commercially-available devices were reviewed, and the two leading ones in terms of capability were determined to be DynaVox and Tobii. The DynaVox system was chosen based on its customizability, and also due to long length of association between the Speech-Language Pathology (SLP) staff at the hospital and the DynaVox customer service representatives. Also, DynaVox is a US-Based company and has a GSA contract (V797P4811A), whereas Tobii is Swedish. Wireless issues. Currently, the hospital uses a Wireless-G system for Computers on Wheels and Bar Code Medical Administration devices. It is critical to design the proposed system to not interfere with the hospital’s established system. To this end, we propose to use the newest standard, 802.11n (Wireless-N). This uses the wide open, interference-free spaces of the 5GHz band. There are 24 channels there, compared to WirelessG, which uses the 2.4 GHz band and only three channels. Other features of this standard include beam-forming, a technique that focuses radio signals directly on the target antenna, thereby improving range and performance by limiting interference, and a protocol whereby transmitters only use the minimum power necessary to maintain the connection, instead of transmitting full power all the time. The N standard also allows superior security to WPA2 by using AES to prevent wireless data frame eavesdropping, forgery and replay. If the hospital decides to expand in the future to N, there will be plenty of capacity for both the hospital and the user networks to run simultaneously without interference.

    Impact

    This system will improve patient care and quality of life in multiple arenas: 1. Residents with varying disability will have equal access to communications. 2. Bedridden tetraplegics can only call the nursing station; this will allow them to call each other as well, facilitating forming a community identity and reducing social isolation. 3. Empower all residents to call outside the CLC, to improve communication between residents and their families; 4. Provide residents who cannot read books the ability to read for pleasure or information; an improvement over passively watching television all day; 5. Allow access to sites for Health Promotion such as My HealtheVet, to social networking sites such as MySpace or Facebook, and to therapeutic escape in a virtual world/MultiUserDomain such as Second Life, where they, through their avatar, can be seen without handicaps. 6. Allow a measure of their socialization and rehabilitation through metrics such as number of messages originated; 7. When a visitor or staff member wants to find a resident they may be difficult to locate. This will improve finding them. This system would have broad impact: -Improve patient care access by removing barriers to communication between residents and nursing staff. -Improve efficiency by reducing the time it takes caregivers to receive information from speech-limited residents. -After demonstration of its utility in this CLC, similar systems could be deployed to other group living centers such as geriatrics; to ICU's; and to acute rehabilitation wards for Wounded Warriors with spinal cord injury and traumatic brain injury/polytrauma. -There is nothing like this now, so this would meet an unmet need instead of being an incremental improvement. -This helps meet the need of the mandate for VA Community Living Centers to have a 'Cultural Transformation” by becoming more home-like.


    Technical Approach

    1. System requirements. The communications system must: - Be independent of the hospital information system (CPRS) for security issues. -Protect privacy and promote autonomy by allowing each resident to control whether they are able to be reached by the clinical staff or other residents. -Be HIPAA compliant. -Allow residents to access the internet and receive email. -Allow residents to call to the nursing station and to each other. -Allow multilateral communication, both in real time, like a chat room, and in a send-and-store format like a message board. 2. System Design. 2.1 LAN using Wireless-N eventually connecting all 30 residents, the VA-café, the nursing station, the nurse manager, and the physician. 2.2 Secure communication server will manage the network and connect to the Internet through use of a leased line that does not go through the hospital IT system. 2.3 Oversight and management of communication by the VA IT staff in conjunction with the CLC Medical Director, to prevent viewing of inappropriate websites, to intercede if one resident harasses another, and other security/privacy issues that arise. 2.4 Communication devices usable either at bedside or on wheelchairs using chair-mounting hardware and docking stations. 3. Hardware: 3.1 Computers: 3.1.1 Resident Nodes 3.1.1.1 XP or Vista Tablet computers (3). Option of touch screen where appropriate. 3.1.1.2Wheelchair mounting hardware and docking stations on bedside carts 3.1.2 Stationary Nodes. XP or Vista Desktop computers (3) ( Doctor’s office, Nurses station and VA-Café) 3.2 AAC devices (7). For demonstration purposes, AAC devices will only be required on the 3 Nodes for those requiring Eye Gaze tracking, and on the 3 for those that must use head motion. There will also be one for staff training and backup 3.3 Wireless Network. 3.3.1 Wireless access point/Switch 3.3.2 Wireless-N repeaters (4) 4. Software: 4.1 Text to Speech and voice recognition 4.2 Communications server Function: Email, IM/chat, secure storage. The Communications Server provides the following security functions, which the installation can use to protect communications in a network: a. Overall Access control for the IP stack, ports, and port ranges. b. Application Transparent Transport Layer Security (AT-TLS), to set up a trusted channel to another trusted IT product through a potentially insecure network. c. Private Mail application. This application keeps the messages and all other information used by the application (e.g. the address book entries) in a protected storage area where they are kept in encrypted format at all times. d. IM specific functions. The server stores and delivers offline messages, users never lose information they are supposed to receive. Messaging encrypted with strong algorithms so personal and group conversations are safe and secure even if messages are sent via the Internet. 5. Monitoring and metrics 5.1 Software allows monitoring and control by IT staff, without providing a portal into the hospital system which could be a portal for a security breech 5.2 Internet filter configurable 5.3 Communication system configurable to allow call blocking and its equivalent initiated by residents, and also by IT or clinical staff. 5.4 Summary metrics, including number and length of calls/use, typing speed, etc, which could be useful to Clinical Staff (nursing, SLP, psychology).

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