2001 Conference Proceedings

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Cheryl Trepagnier
John Noiseux
Elizabeth Greene
Rehabilitation Engineering Service
National Rehabilitation Hospital
102 Irving Street NW, Washington DC 20010 length
David Wachter
Rock Creek Foundation
700 Roeder Road, Silver Spring MD, 20910


A recent review of patient satisfaction with telemedicine calls for large-scale, randomized-assignment controlled studies, since available research fails to provide satisfactory explanations of the underlying reasons for patient satisfaction or dissatisfaction and to explore issues of communication (Mair & Whitten, 2000). It can also be argued that in-depth case studies are valuable avenues to generating hypotheses regarding the sources of satisfaction or lack of it with the use of distance communication techniques as a channel of rehabilitation service provision.

We offer a descriptive account of two trials of videotelephone use by vocational service providers and their clients in supported employment contexts (Wehman & Revell, 1996). Both sites were selected with the help of one of the authors (DW), an experienced vocational counselor, and the supervisor of the counselors who participated in the study. He selected both sites based on an expectation that, while both sites were functioning at a highly satisfactory level, use of videophone communication had the potential to add value to the service being provided to the clients.

In-depth structured interview of the vocational service providers was the only data for Case 2. Case 1data included a weekly log of ‘actual’ and video contacts and monthly client interviews, in addition to the counselor interview. These cases are offered as an illustration of the variety of factors that need to be taken into account in the design of a study of the utility of videophones in vocational rehabilitation.

Case 1 The client, an individual with developmental disability and mental illness, aged 44, worked as part of the two-person mailroom staff of an educational institution, under the supervision of the senior mailroom clerk. A vocational support provider met twice weekly with the worker, once at the job site, and once at the agency, when the worker went there to attend psychotherapy sessions. The counselor was a 40-year-old, foreign-born man with a BA in Communications, a former television commentator in his home country, who had worked in vocational rehabilitation for 6 years. The worker had held his position for 9 years. Crises requiring the counselor to make unscheduled trips to the job site occurred no more than two or three times per year. The relationship between the counselor and the worker was of one year’s standing, and was a close and successful one. The counselor had first become aware of the videophone project when a focus group was conducted by project staff at his agency (Trepagnier, et al., 1999).

While the employer’s representative expressed support for his employee’s participation in the study, his actions communicated ambivalence. The institution had the study’s informed consent documents reviewed by its legal department. Once it was approved, the employer’s representative agreed to proceed only if the project bore the cost of installing an additional analog telephone line.

Once informed consent procedures were completed both with the worker and the counselor, two Aiptek Hyper AVP 2000T videophones were installed, one at the job site and the other in the counselor’s office. These were standard-phone-line-based video conferencing units, combining camera, display screen, audio-video coder/decoder (codec), and a telephone with speaker-phone, in one package. System set-up consists of plugging in the power cord and the telephone line. The counselor logged frequency and duration of visits and video contacts, and carried out a brief monthly interview of the worker every four weeks. Reports were e-mailed to the project weekly.

Case 2 This was an enclave of individuals performing janitorial work in the evenings at a federal courthouse, under a subcontract between the vocational service agency and an employment agency, so that the employment agency could meet the ratio of persons with and without disabilities (75:25) required under NISH regulations. (NISH is a national nonprofit agency that facilitates employment of persons with disabilities by federal agencies.) These workers had mental illness diagnoses, and approximately half also had had minor forensic involvement or substance abuse history. The group of 9 workers included both men and women, ranging in age from 20 to 55, of diverse racial backgrounds. The senior vocational service provider was a 60-year-old man with a Master’s degree in education, who had spent 15 years in the vocational rehabilitation field. The other job coach, new to the field, was a 42 year-old woman with a Master’s degree in history, a former substitute teacher, who was assigned to this site during the second month of the study. The enclave had been in existence for 6 months when the study began. Both counselors were on site three out of five evenings, and at least one was present on the remaining two evenings. Two representatives of the employment agency were also present, one who was on site most of the time and one who departed once the workers had checked in. As in Case 1, the senior vocational service provider had a close and trusting relationship with the workers.

Like the educational institution in Case 1, the employment agency (the direct employer) in Case 2 had the consent form reviewed by their legal department. In contrast to the Case 1 employer, the employment agency was highly enthusiastic about incorporating the technology, and indeed took the initiative to become involved in the study.

The project was introduced to the counselors and employer’s representatives by project staff and representatives of the employment agency and informed consent was obtained. At that time, the senior service provider expressed concern about use of the videophone, since regulations allowed him to bill only for services provided on site.

The equipment consisted of a GE speaker-phone with speed-dial buttons connected to an 8x8 desktop videophone. This unit included a camera, display screen, and audio-video codec. Availability of both a speaker-phone option and speed-dial function allowed users to make hands-free calls once they had pressed two buttons. To reduce inadvertent pressing of other buttons, a plastic cover was fabricated to block all except the speaker-phone and speed-dial buttons. One videophone was installed at the work site, in the office used by the vocational support staff. The second videophone was installed at the home of the senior vocational support provider, so that he could be reached on his off-site evenings. The on-site system shared the available analog phone line with a fax machine, and an A/B switch was installed to allow the user to switch the phone line between the videophone and the fax machine.

Results Case 1 * Mean number of visits before videophone installation is based on retrospective report. Figure 1. Frequency of contacts before and after videophone installation The data reported here were gathered over a 20-week period. While actual baseline data were not acquired, the counselor’s customary practice had been twice-weekly meetings, one on site and one at the agency offices, so that meeting time plus provider travel time (a 1-hour round-trip) was typically 3 hours/ week. Figure 1displays mean weekly number of ‘actual’ contacts before and after installation of the videophone, and mean weekly number of ‘videophone contacts during the 20 weeks of the study.

Both participants reported a high degree of satisfaction with this communication mode. The service provider reported that the worker seemed to gain a feeling of security and confidence from the video contacts and the knowledge that he could initiate them if he felt the need to. The worker consistently reported satisfaction with the device. According to the counselor, the client’s supervisor was pleased with the client’s improved performance. While the study period was not long relative to the worker’s previous low incidence of crises, the absence of any crises since installation of the videophone was consistent with the positive reports. It should also be noted that during the last weeks of the study, there was a new source of stress, as the counselor was preparing the client for his departure due to promotion.

Relative to the previous routine of regular meetings, frequency of visits involving travel decreased, and the length of these visits was reduced. Comparison between month 1 of the study and the subsequent months showed a decrease in counselor travel and contact time of over 1.5 hours per week on average. This contact included 2 to 4 videophone calls per week, averaging about 8 minutes’ duration (range 3 to 23 minutes). In summary, while number and duration of ‘actual’ contacts, and overall time required from the counselor to meet the needs of this client decreased, the frequency of contacts, due to use of the videophones, increased. Interestingly, use of the videophones was not one-sided. Both the counselor and the worker took the initiative to place calls, as shown in Figure 2. * Data on call-initiation are available only for weeks 12 through 20 Figure 2. Initiation of video contacts by counselor and client Case 2 As in Case 1, the workers were very receptive to the prospect of using the equipment. In marked contrast to Case 1, the videophones were on site for several weeks before they were tried out by the vocational service providers. During the 5 months that the videotelephones were in place, they were almost never used.


It is evident that we cannot conclude any causal relationships between characteristics of these two sets of circumstances and the adoption and use of videophone communication. It is nevertheless interesting to point out circumstances which were contrary to expectations: the employer’s lack of enthusiasm, in Case 1, and the Case 2 employer’s pro-active involvement, did not carry the day in either case. The fact that the Case 1 counselor and worker were of quite different cultural backgrounds was not at all a detriment to their therapeutic relationship, and their mutual adoption and successful use of the technology. At both sites, clients were pleased with the videophone and interested in its use.

There were many differences that may have contributed to the contrasting outcomes. The Site 1 counselor was younger than the main counselor at Site 2. The Site 1 client knew when his counselor could be reached at the agency office. Site 2 clients worked during the evening, and the counselor was not always at home, where the other videophone was installed, when he was not on site. The counselor at Site 1 had a videophone in his office at the agency, and became the videophone ‘guru’ for his colleagues. His participation in the project was featured in a company newsletter. The other counselor received no such peer support.

An important factor in willingness to use the technology at one site and not at the other appears to have been funding policy. The worker at Site 1 is served through the state Developmental Disabilities Administration (DDA). DDA funding is set in advance. In contrast, funding for clients at Site 2was provided through the Mental Health Administration (MHA), on an as-needed basis. If a client required more hours of service, these were provided, billed for, and reimbursed. As a result, the job coach at Site 2 had a disincentive to reducing his or her in-person hours of service. The DDA-funded client’s provider was able to save time otherwise spent in travel and put it to more fulfilling and effective use, without detriment to and, as it appears, to the benefit of, his client. It may have been possible for the clients at Site 2 to be served with less intensive on-site staffing; however the regulatory and funding structure removed any incentive for exploring this.

The counselor reported that initially the employer’s representative perceived a threat to privacy. Eventually he came to like having the videophone because he knew the worker could be in touch with his counselor as needed, with the result that there was increased confidence that work would not be impeded by crises. Both the client and the provider reported that the client felt more connected to the provider by virtue of using the videophone. Videophone contact with his counselor made the worker feel “as if he is right there with me”. The worker used the videophone to talk about problems he was experiencing, and the counselor used it as a channel for reminding the worker of his goals and providing encouragement. On some occasions the calls were primarily social (e.g., talking about vacation plans). The mailroom supervisor reported that the worker was more productive and had fewer difficulties during this period than before.

It is interesting to note that the videophone was mutually adopted. Both parties originated videophone calls. The presence of the videophone made it possible for the worker to take the initiative and request support when he perceived a need. This may have contributed to a feeling of control.

Because of the success of the videophone link in this case, another installation is being planned, and the supported employment agency is considering eventually purchasing videophones to serve appropriately selected clients. In keeping with the client’s request, the existing videophones are being left with him and his counselor. Because of the modest amount of time spent using the videophone, the agency is negotiating with the employer to drop the requirement of an additional telephone line, so that the analog line used for the fax machine will be shared, by means of an A/B switch, as described above.

Opinions elicited from a focus group held at the service provider agency prior to the installation of videophones had supported the likelihood that videotelephones would be helpful in achieving vocational goals (Trepagnier, et al., 1999). Among perceived advantages were marketing appeal for job development, expected increase in employer confidence, ability to respond in a timely manner to needs and prevent crises, ability to monitor and anticipate sources of difficulty or danger, and ability to assess workers’ dress and hygiene, and to provide reassurance and instruction. Potential drawbacks were seen as employer technophobia, concerns about security of the equipment , and for some clients, possible aggravation of paranoia. Image quality, due to low bandwidth, was not perceived as problematic. Video was expected to be more useful for communicating with clients with cognitive impairments than audio alone. It was also noted that video at the service provision center would allow for coverage when needed even when the assigned counselor was unavailable. These expectations were for the most part borne out in the experiences reported here. The employer who was hesitant in prospect came to find videophone use valuable in practice. Videophones proved especially useful in the hands of a talented support provider who used the technology to enable his client to benefit from frequent brief contacts for problem-solving, encouragement and reassurance.

Despite high demand for workers in the current economy, employment success of persons with disabilities continues to be limited, for numerous reasons. One is the limited amount of funding available to provide vocational support personnel. We have seen that apparently superior benefit resulted from addition of videophone contact, despite a net reduction in counselor time commitment. If the amount of counselor time needed to serve each client was reduced as it was in the case of this client, the counselor might be able to serve more clients as effectively, if not more so. As the costs of equipment decrease (from the current $550 for an Aiptek videophone), and the costs of vocational staff rise, it is possible that availability of videotelephones will not only add value but will at the same time reduce costs of providing effective vocational support. If the funding structures and policies permit, this could open the door to more individuals who are waiting for such supports in order to have access to employment. It remains to determine under what circumstances videophone-enhanced job coaching can be helpful, and how big an impact this technology can have on the quality of clients’ and service providers’ working life. Further study is underway, using single-subject experimental design to allow for the range of dimensions along which individuals and their work contexts can differ.


F. Mair, P. Whitten (2000). Systematic review of studies of patient satisfaction with telemedicine. British Medical Journal 320 (1517 – 1520).C. Trepagnier, J. Noiseux, & M. Glenshaw. (1999). Video communication for vocational support. Presented at the Biomedical Engineering Society / Engineering in Medicine and Biology Society Joint Meeting. Atlanta GA, October 13, 1999. P. Wehman, W. G. Revell (1996). Supported employment from 1986 to 1993: A national program that works. Focus on Autism and Other Developmental Disabilities 11(4), 235-242.


This is a publication of the Rehabilitation Engineering Research Center on Telerehabilitation, which is funded by the National Institute on Disability and Rehabilitation Research of the U.S. Department of Education under grant # H133E980025. The opinions contained in this publication are those of the grantee and do not necessarily reflect those of the Department of Education.

We would like to thank staff and consumers at the Rock Creek Foundation and CHIMES, International for their invaluable contributions.

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