OpenTeleRehab

According to the WHO, globally, an estimated 2.4 billion people are currently living with a health condition that may benefit from rehabilitation. The need for rehabilitation worldwide is predicted to increase due to changes in the health and characteristics of the population. In some low- and middle-income countries, more than 50% of people do not receive the rehabilitation services they require. Emergencies – including conflicts, disasters and outbreaks – create enormous surges in rehabilitation needs, disrupt existing rehabilitation services, and have the greatest impact on the most vulnerable populations and the weakest health systems.

Rehabilitation helps to prevent, reduce or manage complications associated with many health conditions, including diseases (acute or chronic), illnesses or injuries. It complements other health interventions, such as medical and surgical interventions, helping to facilitate recovery and achieve the best outcome possible. Rehabilitation is an investment, with cost benefits for both the individuals and society. It can help to avoid costly hospitalization, reduce hospital length of stay, and prevent re-admissions. As rehabilitation also enables individuals to engage in or return to work and employment or to remain independent at home, it minimizes the need for financial or caregiver support.

Since 2016, Humanity & Inclusion (HI) has been researching and testing the use of information and communication technologies in remote service provision, particularly for low- and middle-income countries and complex situations. Based on findings from research, we are working on improving access to rehabilitation services through an innovative service delivery model that combines the existing delivery setup in a given context with the use of digital technologies.

OpenTeleRehab is an innovative, open source, multidisciplinary telerehabilitation software, recognized as Digital Public Good and which has been designed and developed following the Principles for Digital Development.

OpenTeleRehab connects rehabilitation professionals with service users to improve access to rehabilitation services and contribute to universal health coverage by facilitating discharge, transition of care and community-based follow-up. OpenTeleRehab allows its users to access tailormade rehabilitation treatment plans adapted to a variety of health conditions. The software contains four different platforms:

1) An admin web portal to manage content, users and system settings

2) A therapist web portal to manage patients accounts, design treatment plans, set up appointments, and exchange with patients via chat, audio, video communication and SMS

3) A patient mobile app to access treatment plans online and offline, provide feedback, request appointments and exchange with therapist

4) An open access library web portal allowing the rehabilitation community and peers to access and contribute to a global telerehabilitation clinical library. Additional information can be found on our Wiki Space: https://hidsi.atlassian.net/wiki/spaces/OpenTeleRehab/overview

Rehabilitation helps a child, adult or older person to be as independent as possible in everyday activities and enables participation in education, work, recreation and meaningful life roles such as taking care of family.

So far, OpenTeleRehab has mostly been used with children, adults and older persons with neurological conditions, such as stroke, traumatic brain injury, cerebral palsy or developmental delays. In the near future, additional clinical content (exercises, information and education material, questionnaire) will be added for trauma conditions, such as fracture, burn, amputation, peripheral nerve injury or spinal cord injury.

Recent scientific evidence suggest that telerehabilitation would have at least similar effects to traditional rehabilitation on long-term pain, on short and long-term physical function and on short and long-term quality of life (Dias et al. 2021). The advantages of telerehabilitation are numerous, such as limiting travel, reducing health care related costs and allowing continuity of care. This can be particularly helpful in contexts where rehabilitation is not available at primary health care level or in the aftermath of emergencies or disasters.

While telerehabilitation has advantages, it also has limitations, such as skepticism or resistance to using new technologies, lack of digital skills, challenging digital environment and limited available workforce. Appropriate design and implementation of telerehabilitation interventions can help to ensure these interventions are effective, equitable, and accessible to all who need them.

Since 1982, HI has been providing rehabilitation services to help people with disabilities, injuries, trauma or other health conditions reach and maintain a maximum level of functioning. Enshrined within the core humanitarian standards of accountability to affected populations (AAP), our activities take into account the personal and contextual resources and barriers to accessing and benefiting from rehabilitation and related services, paying specific attention to the role of caregivers and communities in the rehabilitation process.

Since 2016, HI has been researching and testing the use of information and communication technologies in remote service provision, particularly for low- and middle-income countries and complex situations. Based on our findings, we are working on improving access to rehabilitation services through an innovative service delivery model that combines the existing delivery setup in a given context with the use of digital technologies. In underserved areas, the provision of services can be supported by HI remotely and implemented by local partners.

More specifically, HI conducted a study, “Barriers and levers for the use of telerehabilitation through experimentation in three countries”. The aim of this study was to identify, through quantitative and qualitative data, the barriers and levers for the use of telerehabilitation by professionals and beneficiaries, based on experiences in three countries (Haiti, Madagascar and Colombia). The barriers and levers were classified according to human factors, technological factors and organizational factors.

The initial software development and following improvements of OpenTeleRehab were done by complying with the Principles for Digital Development, namely “Design with the User” and “Understand the Existing Ecosystem” by integrating the different stakeholders, including service users, service providers and authorities from the design phase. Early user acceptance tests were organized with during development stage. Since deployment, user satisfaction surveys have been implemented, which informed successive product improvement.

OpenTeleRehab was officially launched in January 2022. To date the software is used:

- in 2 countries (Cambodia and Vietnam)

- by 110 rehabilitation professionals

- in 14 rehabilitation services

- by 150 service users having received one or multiple rehabilitation treatment plans in the two countries covered.

OpenTeleRehab would welcome:

• Critical opinions, strategic advice and technical guidance about alternative pathways to scale and strengthening of business model
• Networking opportunities in the Information and Communication Technologies for Development community
• Networking opportunities with academics active in the field of digital health to learn and demonstrate the impact of OpenTeleRehab
• Financial support and funding opportunities

While several commercial telerehabilitation software are already available on the market, the uniqueness of OpenTeleRehab lies in the fact that it:

• Targets specific and relevant health conditions encountered in fragile contexts
• Integrates offline mode and SMS capability
• Is available/can be made available quickly in local language or dialect
• Was designed to strengthen health systems, with the potential to integrate with other health information systems
• Was developed in accordance with Web Content Accessibility Guidelines (level A/AA)
• Was developed using a micro services architecture to facilitate localization, technology transfer and sustainability
• Includes a dedicated administration application allowing for a decentralized management of users and settings

Our ambition is to leverage ICT opportunities to contribute to improved access to rehabilitation services worldwide and contribute to universal health coverage. Our main impact goal for the next five years is to have the software deployed in 10 countries, serving 500 rehabilitation professionals and positively impacting 5000 rehabilitation service users.

To do so, our plans for scale are to focus on:

- Scalability: Increase the user base across different regions by translating the software in relevant languages and diversifying the clinical library

- Usability: Increase user experience by improving performance and user friendliness of the software

- Interoperability, Privacy and Security: Interoperate with digital health ecosystem in security and privacy

- Data: Increase data collection and analysis by integrating business intelligence tools

- Advocacy: undertake evidence-based advocacy at local, regional, national and international levels.

Impact can be measured through:

- the number of beneficiaries using OpenTeleRehab

- the adherence of beneficiaries to the rehabilitation plans provided

- the satisfaction of beneficiaries on Goal Achievement Scale

- the number of health and rehabilitation services using OpenTeleRehab - the number of countries where OpenTeleRehab has been deployed to

OpenTeleRehab currently integrates a basic dashboard for admin and therapist users. We plan to integrate additional analytics and business intelligence features to support better monitoring, evaluation, monitoring and learning.

Specific research on cost-effectiveness is expected to take place in 2023 and beyond.

Access to Services is a systemic analytical framework developed by HI to implement adapted responses in the form of concrete actions to ensure full and effective participation in community life by everyone, with specific attention paid to people with disabilities and vulnerable populations who are the most excluded. This theory of change also applies to OpenTeleRehab. HI has identified the following main barriers and expected intermediate changes to ensure access to services for people with disabilities or vulnerable populations:

1. Inadequate policies > Fair and relevant policies are defined, funded, implemented and monitored in order to guarantee access to all services for all vulnerable populations and people with disabilities.
2. Inadequate services > Nature and quality of services, including service provider and professional capacities, satisfy the needs and priorities of people with disabilities and vulnerable populations.
3. Insufficient implication and participatory approach > Active participation of people with disabilities and vulnerable populations in decisions concerning them is ensured, including via their representative organizations.
4. Negative attitudes > Stereotypes and discrimination in attitudes and practices towards people with disabilities and vulnerable populations are reduced.
5. Insufficient and inadequate funding > Sufficient funding is allocated to programs, policies, services and measures that enable a response to the needs and priorities of people with disabilities and vulnerable populations and the improvement of their participation in community life.
6. Insufficient data > The situation of people with disabilities and vulnerable populations and their access to services is fully understood and monitored through systems of collection and analysis of data that takes inequality factors into account.
7. Lack of individual opportunities > People with disabilities and vulnerable populations have access to the opportunities empowering them to be actors of change.

OpenTeleRehab was designed and implemented based on the following guiding principles:

1. A future system must be conceptualized and implemented with the needs of the end-users in mind. This means actors have the chance to participate in the design phase, test early, providing valuable feedbacks for definition and refinement.
2. The system should use a modular system design and micro-services architecture to make it easier to implement changes in the future
3. A thorough and stable implementation and early piloting are achieved incrementally through agile development. It assures strict orientation at business value and improves quality through regular development, validation and learning cycles
4. The information must be integrated and centralized ideally, in the cloud. This decreases vulnerability to local system failure, increases scalability and allows for wider access, process improvement and automation

Micro-Services Architecture 

Micro-services, also known as the micro-services architecture, is an architectural style that structures an application as a collection of services that are highly maintainable and testable, loosely coupled, independently deployable and organized around business capabilities.

OpenTeleRehab Modules 

OpenTeleRehab is a combination of 3 different modules that interact with each other. The first module is a web application for administrators to manage content, users and system settings. The second module is a web application for therapists to manage patient accounts, design treatment plans, set up appointments and organize communication. The third module is a mobile application for patients to access tailor-made treatment plans and get in contact with therapists.

A satellite open access web app, OpenTeleRehab Library, allows the public to access, review and contribute to a global telerehabilitation clinical library of contents (Exercises, Information and Education Materials and Questionnaires).

Admin Portal and Therapist Portal 

These are web applications. The frontend is developed using ReactJS and Google Material Design. The backend of the portals is developed separately and follow the micro-services architecture mentioned above that allows all three modules to connect to these micro-services independently. These micro-services use technologies like Laravel framework, Restful APIs, Identity and Access Management systems and other open-sourced third-party systems that can easily be integrated as a micro-service using Restful APIs.

Patient Mobile App 

The mobile app was developed using ReactNative and Google Material Design. Chosen technologies are all rooted in free Open Source projects and the components are popular and widely used in Android and iOS. Choosing ReactNative means that the system can be developed and compiled for both iOS and Android instead of being built separately.

Technology stacks

• Operating System and webserver: Ubuntu
• Programming language and framework: Laravel 
• PHP 
• Databases: MySQL 
• Identity and authentication management: Keycloak
• Hosting: Amazon Web Services – supporting Kubernetes and Docker

Full detail is available on our Wiki Space: https://hidsi.atlassian.net/wiki/spaces/OpenTeleRehab

Diversity, equity, and inclusion is built into the HI mission and identity as the leading international aid organization promoting the rights of persons with disabilities and the inclusion of persons with disabilities across all levels of society. With hundreds of active projects in more than 50 low- and middle-income countries worldwide, HI raises awareness on disability inclusion among the public; engages with local, national, and multinational authorities to develop and implement disability inclusive policies; and collaborates with local partners in implementing initiatives that create opportunities for persons with disabilities to get vital health care, get an education, earn a livelihood, and advocate on their own behalf.

HI has developed a number of institutional policies which provide an essential reference framework for our statutory mission. These policies apply first and foremost to HI staff. However, they also include provisions that apply to the other stakeholders in our activities, especially our public, private or associative partners, and companies that provide us with goods and services.

The list and content of each policy can be found here: https://www.hi.org/en/institutional-policies  

It includes:

- HI’s policy on Disability, Gender and Age. This policy sets forth HI’s different levels of commitment with regard to Disability, Gender & Age, and the changes to be made in how the organization works, including with its partners. These commitments apply to the whole HI network and are to be taken into account at operational, technical and advocacy levels, and notably in technical and operational strategies and programming policies.

- Be Hinclusive, an internal project aiming at making HI an organization recognized for its inclusiveness in terms of employment of persons with disabilities.

Consistent with our vision of positive social impact and powerful partnerships, our business model is based on open licensing. As part of our rehabilitation, licenses are granted to rehabilitation service providers. Rehabilitation service providers are able to invite service users after account creation.

Our current revenue model is based on cost recovery through projects. To become financially sustainable, intended revenue model is hybrid and includes:

- Software as a Service

- Technical Assistance

- Grants

- Contribution from the open source community

Current model has allowed to share different running costs between several projects and make economies of scale. Beyond initial software development cost, funded through specific grants from USAID and the Fondation Botnar, the software running costs are kept as low as possible (< $30,000 USD/year). Hosting and maintenance are provider by a third-party service provider. Human resources are funded through projects and own funds. It is expected to provide the Software as a Service to large organizations as of 2024. This will allow to share software running costs and investments. Deployment is funded through specific projects at country level. As per our social mission, we do not intend to make financial profit.