BIOFEEDBACK continued...
How does one go about setting up a remote biofeedback system?

There are two primary components to the system. The first establishes the video and audio communication between patient and provider. 

The second component allows the provider to control the biofeedback system at the remote site and 'see' the remote site biofeedback computer display. All this must happen in 'real time', which can present a challenge, given that many remote sites do not have a well-developed communication infrastructure.

Often, the only telecommunications available remotely are the "plain old telephone service" (POTS) lines. This is certainly true for most of our sites in the Pacific. Fortunately, realtime simulateous visual and audio communications have recently undergone major technological advancement, to the point that excellent audio and acceptable video signals can be sent over POTS.  To establish the video/audio connection, we utilize H.324-compatible videophones, of which many are available commercially for as low as $450 per unit. (A web search under 'H.324' will easily locate the vendors). All are designed to work over a single phone line.

To establish a videophone call, the sender and receiver must have their videophone units turned on at their respective site.

One party then dials the other using a standard phone attached to the videophone.

Once a connection is established, one party presses a key on the phone and the two videophones link up.

While picture quality is not up to broadcast standards, we have found it to be very adequate for the job.

The biofeedback system is set up at the remote site. The clinician controls the remote computer using commercially available 'remote control' software.  This allows for all computer-intensive activities (signal acquisition, signal processing, data collection and visual display) to occur at the remote site.  The clinician is able to control the remote computer (keyboard and mouse) as well as view an exact image of the remote computer display.  To properly maintain remote control of the biofeedback equipment, we found it necessary to use 100% Windows - based biofeedback software. 

For a number of technical reasons biofeedback systems that were DOS - based were found to be completely incompatible with the remote control software.  This was also true for DOS - based biofeedback programs running in a Windows environment.  The system we used that met our project's requirements was the ProComp+/BioGraph system.

What applications and conditions are you using this for at Tripler?

We have utilized the above system with a number of patients and have now established remote stations 

at U.S. Army 121 General Hospital in Seoul, Korea, the U.S. Navy General Hospital in Yokosuka, Japan, and the U.S. Navy General Hopital in Guam.  In each location, connectivity has proved to be very reliable and patients are currently receiving biofeedback services for a variety of conditions, including migraine headache, irritable bowel syndrome, temporomandibular joint disorders and chronic pain. 

What is the "approximate" total cost of a telehealth system such as the one you use?

There is a tendency for clinicians when considering telehealth, to think that 'more is better'.  This is often not the best choice as a high-end telehealth systems can cost from $20-100 thousand and have high infrastructure requirements (technician support, ISDN phone lines, etc.).  The system we developed, including all biofeedback and telecommunications equipment, cost approximately $9000.  The equipment was designed to have minimum installation requirements - two phone lines and an electrical outlet.  The video/audio connection is established with a videophone ($450), good speakerphone ($200), and 20" TV ($300) on each end. The biofeedback connection consists of remote control software ($100) and a Pentium computer ($1000) on each end and biofeedback equipment and software ($5000) at the remote site.


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