>> Hello, thank you for tuning in. Today we will be talking about electronic aids to daily living. My name is Brian Burkhardt, on a clinical rehabilitation engineer at the Maguire VA in Richmond, Virginia.
>> Most of my experiences with CA that I try to structure and talk about things in this presentation more broadly so it is not just focus on VA clinicians, but there is a lot of information to cover and this is intended as an overview and to give someone who was not  is not familiar with electronic aids to daily living a good jumping off point to dive deeper.
>> Again, I am Brian Burkhardt and there is my contact information. I have no conflicts of interest of anything I mentioned this presentation. I want to start with some definitions or semantics. Some of these might seem basic but I we use a lot of these terms interchangeably throughout the presentation. Electronic aids to daily living, EADL, ECU is a little older term for environmental control unit and both of those are synonymous with smart home in the context of this presentation which is also synonymous with home automation. We would talk a bit about mobile devices, smart phones and tablets. Again in the context of this conversation. We would talk a little bit about AAC and if you're wondering what the square root of that big number is it is 543. 
>> What are our objectives? I'd like for you to identify one characteristic of an appropriate user for mobile devices using EADLs. This to couple of components of EADL systems and understand some of the cost associated with using assistive technology solutions for EADLs versus consumer solutions.
>> Like I mentioned in the beginning, this is kind of like drinking from a firehose.There is a lot of things c overed. There are many simple solutions, they just don't fit everyone. There is lots of options.Because everything is changing, we are talking about technology, cell phones come out every year with variations, we are definitely moving with the moving target so this represents a snapshot especially with specific examples of what is available today.
>> We would do a bit of an overview of what EADLs are and in that context talk about who, what and where related to EADLs. We will talk a little bit about the evaluation process, this is a Lake evaluation process, it is things to go out.Go over a bunch of examples of different products that are out there and some quick reference guides as well that should be available.
>> EADL basically provide some method for users who can't access their environment in traditional methods to access their environment. That is typically things like the television or lights or fans, thermostats, telephones, the list goes on and on. You can summon up by things that are electronic or mechanical.
>> This is a diagram of the components in a ECU system. This is an oversimplification but you have the user which is the center of this system and there is an interface that interacts with kind of the electronic portion of the EADL and it has to communicate with all these things the user wants to control. We will talk about each one of those components. 
>> This is a, slide to show him HAAT presentations but it is the HAAT model that applies well to EADLs because you are not just giving someone a device or an app, you have to think about what this person wants, where and how they are going to use it to find the right solution.
>> Talking about the patient or the user, if anyone needs an alternate axis two things you would use in your daily life and the television is theis the one -- TV lights or fans and that independence can really change how they feel and increase their quality of life but it doesn't just affect the user. It also affects caregivers. As a caregiver you don't have to come in every couple minutes to change the channel or move the hospital bed, that takes the burden off you so you can focus on other things.
>> Focusing on the patient, physical ability is one of the first things you were going to look at as far as what they can do to determine access method. I like to start simple, even if it is just a switch and not even bring the EADL into this picture, can they access the switch or something different? Cognitive ability please especially how complex or simple the interface to the EADL needs to be. There mental status, if they get frustrated quickly, you don't want to pick something that is going to break down or difficult to use. There home environment certainly determines different types of systems you would want to use especially when it comes to a home environment or long-term care facility.
>> Focusing more on the environment, single room or multi room especially when we talk about the home. If it is a single room you have to think of things like how does this EADL system need to be mounted?It is simple installation if you are doing a single room but it's not usually that typical. Usually they are using systems in multiple rooms of their house say have to think about how it's going to be mobile, is it on their wheelchair or different base stations in different r ooms? Certainly the access method and type of system it takes a lot of your options in these areas.
>> In the hospital it is a little bit different. We typically will do a temporary installation, a lot of times  if someone is here for a week or couple weeks, we keep the installations simple. Maybe TV and nurse call but it's important if you are installing something like this in a hospital edge of educate the caregiver staff and nursing staff so they are able to reposition things.If it is in a hospital, it needs to be durable because the hospital can be a rough environment. It's a little different if you are doing a long-term installation like a long-term care facility, you might do just more than the TV and nurse call, you might incorporate other things like the bed or lights or fans. Again, we covered the home area but in the home it is ideal if you can go out and do a home visit. At the VA where I work, we aren't able to do home visits so we do a lot  of questions to try to nail down what the patient wants and what their home environment is like. Sometimes we have vendors go out which is the best at getting that home visit.
>> Jumping into the interface, how does this person interact with there EADL? I have broken the standby access method and these are, access methods for all assistive technology. Direct access is the best. If your patient can directly control what they want access, that is the quickest and most efficient.Things like keyboards, masses, touch screens, Joyce  -- joysticks. Voice control can be tricky because there is hands-free switch initiated a different types of voice control with menu structures and complexity l evels. You have to think about someone's voice and can they maintain a good voice all day long? May be patient with ALS has a good voice in the morning and we voice good afternoon. When I do voice control I like to have a backup access method.
>> Indirect assess  -- access methods, scanning can be a hard sell to patients. It is basically the most simple way to do it is one switch and that's scanning your options and you press it again and it selects your option. It is not the most efficient the people who use it regularly can get really fast especially when patients use it when they are young.There is the double switch would does it do auto scanning which allows you to implement but it can require more energy because you're hitting the button more often.There are types of things like directed scanning that more complex EADL systems have that can increase or decrease the amount of time to get to certain areas of the screen. I don't know if this exists anymore, but there were some systems that would allow you to use Morse code. Apparently it is really fast but I have ever seen it in person.
>> Moving to the actual EADL hardware itself.They can be mobile or s tationary. Mobile is nice if you are using it on a wheelchair or multi room but stationary systems can be used that way, too with some sort of wireless access. They can be battery-powered or off-the-wall. I like it when they have a battery backup in case the power goes out. If the power goes out and the EADL is still running because it has a battery and you have a battery backup door opener, the patient can't open the door and get out of the house if they needed to. Differences said different mounting requirements. Most of the time it is something you can sell the bedside table you can put it on a wheelchair in different ways to mount them and mounting can be a presentation on its own.
>> We have covered the patient, interface and control unit so how is the control unit talking to these devices?Infrared is common. Is your team you are  teeny typically uses. The important thing to know and line of sight. You are shooting light to the receiver of the television so if someone stands the way that could make it not work.It is calm and easy to use.There is different radio frequency type communication for things like remotes that turn on and off lights or garage door openers.Those are simple things. We talk about more house controlled there is a slew of other communication methods. The old stuff used to be powerline -based and it would communicate two different things like through your power wiring in your house. That is still used with some of the assistive technology systems that more, home automation systems are using Wi-Fi or Z wave or Bluetooth or different wireless communication standards and consumer devices are using that and is very common these days. 
>> The evaluation process, I really like this cartoon because it can show sometimes doing something simple like wiping a napkin on your mustache, if you can't directly do it it can become very complicated. 
>> One of the things I do in my position is power wheelchair evaluations. I feel like the EADLs are similar to that because you are dealing with a complex system with lots of different things and pulling you in different directions and lots of pros and cons, and they can be very expensive.I think collaboration is important. Of course the patient is the center of having caregivers or family members is important. As a rehab engineer, I love having clinical staff present. That is not always possible but the more viewpoints offered, especially with complex access cases, it is beneficial. The basic evaluation for us typically consists of a few sessions, maybe an hour each. It could be longer the more complex it is. The first thing is determining what the patient wants to do and what they want to control.In conjunction with that, what are there abilities? Determining access methods based on those abilities.
>> Normally we would do an initial session, it could be one or two hours and it depends on the person how long it takes. Sometimes would go longer, but I think it is too much after that. After finding out what the patient once and what their abilities are, I like to demonstrate access methods and different EADL systems based upon that initial conversation.Once I have demonstrated, the patient can decide, I want to try to actually use a couple of systems. If we can do that in the first session, great, if not we have following sessions. They can try these systems. This can be hard if you don't have access to everything. Fortunately we have a good library but especially with voice control I think it is important. If possible especially when we have in place is in the hospital or multiple outpatient sessions to do a more long-term trial to let the person use a system or access method to see if they like it. A lot of times these systems are expensive and you don't want to have a problem. Once you go to these demonstrations and trials, you can sit with the patient and they can make an informed decision on what they want to use then you can talk about how we are going to implement this. In the VA we use contractors to do a home installation but if it is something simple maybe the patient's family can help set it up or if you are in private practice you can set it up yourself.
>> This is the map I like, mounting, access and power.We talk about the clinical side but these are some logistics to think about to make sure you get a good implementation.Your integrating a lot of different things in someone's home potentially. If you think about mounting and access and power, that covers a lot of the basis, if you don't get these right, things don't work well. Do you need movable mounts? That is something I think about. Kenda device be moved from one place to another and you need multiple mounting locations. Does the patient want to access the system all the time without help or is it okay if someone puts a microphone in front of them or a switch in their hand. Cable management is huge. Sometimes you have a lot of cables and sometimes you don't but when you do, it's important to make sure cables aren't getting pulled or crushed. The better they are organized, the longer it is going to last and the less headaches the patient is going to have. Thinking about the map can ensure success.
>> I'm going to renter  ton of devices. As I said this is a moving target. Some of the slides has some devices you can still buy that aren't made anymore and in a week there will be new devices. I have not covered everything because that would take years to talk about. These are devices I have had personal experience with. It is grouped into AT products, products designed specifically for the population that uses AT. That is what I considered traditional EADLs but were going to talk about landline access, integration with wheelchairs and communication devices and home automation  products. I like to break that down into standalone devices and professional or home c ontrollers.
>> Speaking of assistive technology products, they are intended for specific populations. The companies making these aren't making times because it is not for the general population. They have really good alternative access  methods and they are customizable with auditory will and visual feedback. It is intended for access so scanning is probably built in. Oftentimes technology can be dated and expensive and not always local vendors who know how to do an install or comfortable with the systems.
>> These devices don't really fit, these are really consumer products but for the sake of organizing to access methods I put it here but there are lots of remotes. If you're patient can press the button but maybe they can't lift their arm to reach a light switch, there are lots of remotes out there they can use. The one on the right is from Lowes or Home Depot that is like $20 and can turn off three different lights.
>> Getting back to assistive technology devices, the remotes on the previous slide were direct access. If you are doing indirect access and switch scanning, the relax 2 is being made anymore. It looks a little different and can't control as many devices but it works the same.It is switch input and you have visual and audio feedback to very limited. It is an LED turning off so you have to see this to use it. It is essentially a universal remote control so it can learn commands from different devices like a TV or blue Ray player. It is battery-powered. You can do other stuff if you like a converter that will allow you to turn off things like lights. Saje technology pocket mate is better. It is better visual feedback in the form of text but it basically does the same thing. A universal remote control. They have a version that does voice control.
>> A little more complex is the primo. It has a screen that is a touch screen that you can configure icons. If you can't use a touch screen you can do switch scanning. You have to be able to see it. It also comes out-of-the-box where can interface to an IR phone for telephone access. Other devices can do the same thing that require little or set up and this is also battery-powered so what mounts nicely on a bed or wheelchair. 
>> The pilot one, this slide covers voice control devices. The pilot one is a type I don't use that much, but it has got a switch as a backup which as I mentioned is very important. It does auditory feedback and does really good auditory feedback because it reads out the different things like light or television so you don't have to see the device if you are doing switch scanning.The voice control is trained to your voice. That can cause problems. If someone's voice changes throughout the day it may work in the beginning of the day or not work the end of the day. It is kind of universal remote control back into IR but with adapters can do things like lights.Voice IR is similar.It is voice control been trained to your voice. You have two commands, like television and channel up. You have to say television every time you do a command. The voice-recognition algorithm isn't that great but it is pretty inexpensive for this field and can work well.
>> Quartet simplicity is what I like to call Old Faithful because it is built like a tank. It can do voice access and switch control and has a ton of features. It is dated, it still has VCR on the menu. If the user is willing to call things like you save VCR that mean blue Ray, it gets tricky if you are navigating like a cable box menu where you are doing up and down and left and right and enter. It is like the others are universal remote. It is the built-in ability to do X10 or Insteon which are powerline interfaced to control things like lights. I use it a lot of times in the hospital because it is very bulletproof. The voice control is dated and trained to your voice, but the microphone they use is very sensitive when you are close to it so it works good in a noisy environment. Most other voice-recognition systems have trouble in a noisy environment. And it has a built-in telephone so you don't have to have a separate telephone.The Saje roommate is similar in that it does voice control and switch as an option.It is not trained to the users voice so it works with anybody which is nice but you have to hit a switch to initiate a voice command.That it is only one command whereas with the quartet you have to wake it up with a name. The one I call here is how and then I say how, television and channel and up. There are pros and cons I like to describe to patients because they in one way or the other.
>> There is a lot of computer-based EADLs coming out now. Many are based on the smart box grid software and others have proprietary software. The ones I'm going to talk about are based on the Windows tablet. That opens up a lot of options especially with the grid software. You can do switch access or voice control or any can pewter access you want so that is nice from an access point. Audio and visual feedback, you can do whatever you want. You can never read out commands like -- you can also do magnifiers so the screen enlarges for people with low vision. In addition, because it is a computer it opens up different things like it can function as a communication device or for doing computer access to do games or e-books.Because it is a computer most of the companies that sell these will remote into your devices to provide technical support if you have Internet access. One of the drawbacks is that it is Windows and if you use Windows for any length of time you know it can lock up at times and that's not a good thing. If you are using it on the Internet, you are susceptible to viruses. That is something I think patients should know before selecting a device.
>> A couple examples, these are ones I have used but there are others out there. The ASI autonomy, they are little different. The Reach has its own proprietary software but for voice-recognition, they either use the built-in Microsoft voice-recognition or Dragon. Dragon tends to be better in my experience when someone has a low voice or maybe slurs their words whereas Microsoft works just as well for just the normal voice. Both of them can be trained to the user.There are different options. These are. Typically similar priced traditional systems like the quartet. They are in the $5000 to $10,000 range.
>> Stepping back. These complex systems there is bold axis. If someone wants to access landline phones, there is been a lot of options that have come and gone especially in the voice access area. The Able phone 5000, it is under different names, there are couple different distributors in the U.S.. It is a voice controlled dialer and you basically trained it to your voice and when you pick up the phone or time on the speakerphone  it says name to dial and that you say what they you want to dial. Able phone makes a switch phone which basically you hit a switch and it picks up the phone so if you combine that with the voice dialer you have almost hands-free access.The Sero phone is an infrared controlled phone and it also has some interesting communication device features like premade messages that say I am using a communication device so I speak slowly and please be patient. It can be used with anything that can control IR devices.The talk IR is similar to the Sero phone. It is basically a conference room phone that can be controlled by IR. The RC X 1000 is a switch that says accessible phone. There is a lot of visual or auditory feedback that is pretty basic. It also has a remote you can plug a switch into see you don't have to be right on the phone. There used to be a bunch of options that have come out, some were really nice and for whatever reason that got away.
>> For door access, open Sesame is one we use a lot. I liked that it has a battery backup but we have had good success with those so somebody wants to open a door, into VA we justify that is a safety thing so maybe letting and caregivers are giving access to a door if somebody's to exit their house in an emergency, they can do that independently. If someone is using a power wheelchair, we will put it on a door that has a ramp so in the event of an emergency that open the door and exit the house safely.
>> Communication devices, any of the complex ones can function as ECUs or EADLs. Almost have all built-in IR to control things like TVs but a lot of the newer ones have options to do things like Z wave to do things like lights and other home automation products.
>> Also wheelchairs, all the big manufacturers of power wheelchairs have controllers that can do at least IR like things like TVs, but also Bluetooth and mouse control.A Bluetooth switch for phones and mouse for computer-controlled can be beneficial if you are accessing like a Windows-based EADL.
>> I am kind of moving to mobile devices.I like this, this is back in 2012, if you look at this 9% of people are using their phones for actually a phone and the Internet is the biggest. We can leverage that for EADLs. Mobile devices can do anything the assistive technologies can do like communication, environmental control or cognitive aid. The difference is it gets a little more clunky when you getting to access and changing feedback options. They typically aren't as flexible although it is getting better all the time.
>> Using a little biased  of life as our EADL was the time requires Wi-Fi an Internet access.The idiosyncrasies of the system differs between what device  you are using. I really focus on Apple and android phones but you can certainly do plenty with Microsoft phones as well.
>> Why would you use a mobile device as the EADL? The two biggest things I can see is that can be very cost effective and kind of a social aspect, everyone has a cell phone or tablet. A lot of our younger patients like that. It is not something extra they carry around that people wonder what it is.That is kind of my target that it think of using mobile devices. When I has the person that likes to use a cell phone I start thinking this is where we can go with the EADLs. There are lots of access options and as I said it's always getting better. Apple has really robust and powerful switch scanning interface. It is intimidating for people to learn it. When you have somebody who maybe doesn't like cell phones or technology or doesn't have Internet access is used to interacting with the touch interface do have to start thinking about whether or not it is the right option.
>> I broke this down, using an app on your mobile device to control things, there are standalone interfaces. Some electronic product that control one or two things.Maybe something that can turn on and off lights. These are typically pretty cheap. You can buy them in many places. A lot of times they are very easy to install and a lot can be controlled by bigger automation home systems. The biggest drawback is if you're trained to control a lot of different things, like an app for controlling air lights, and app for controlling your TV and an app for your thermostat, that is a lot of apps and it can be clunky.Some people might like that but typically that is not the best. If you're using all these apps you have to think about axis. If your patient can't access the touch screen, are the apps compatible with like Apple switch control.
>> The other pieces is going to do the install. The VA would like to use it because there is some went to provide support after the fact that it outside the VA, you might have a family member do the install or pay an outside vendor as well.
>> With these devices they are consumer devices so it is hard to know who is able or willing to do the install.Some examples are door locks that are Bluetooth or Wi-Fi. You can interface these -- I would touch on that later. You can control your garage d oor. There lots of security cameras you can use. I think the importance of security cameras is if you're giving some access to open their door or unlock their door, it is nice for them to see who was there. Having a camera or an intercom, and the camera is ideal, if I can do it I like to have a camera and an intercom. Having that makes it safe so they are not letting in someone they don't know.
>> There is also the thermostat and lots of ways to control lights.There is one where you plug into a module into the wall and you plug your light into that. There actual lightbulbs you can plug in.
>> IR for controlling TV is popular.The Logitech Harmony hub is something we use a lot.Again all these things have separate apps. There lots of devices you by like a lot of the newer Samsung TVs you can control from an app and cable boxes and home theater systems are doing that often as well.
>> Some hospital beds, apparently there is an interface that control a hospital bed from a phone and there are consumer pays that use Bluetooth to control that functions. 
>> Those are all standalone devices. Thinking up more on controllers, these are things that are Holthouse home automation systems meant to control many things. They are competitively priced when it comes to the comparable assistive technology products. They are typically more expensive than the standalone devices that they have the ability to do more. One nice thing is one app does typically control everything and you can integrate a lot of the standalone devices into that a pp.They can be easy to install and there are professional ones which we would touch on at the same things for the apps that have limited accessibility features and some require a subscription fee and there are some issues when you want to do IR.In the realm of controllers there are do-it-yourself and  it to yourself professional install systems. Do-it-yourselfers almost always less expensive. There is the question of who is going to do the installation if your patient doesn't have family and who is going to support it. Are you going to support it or are they going to have to call Amazon Echo tech support?Apps are hit or miss. Some are great, some are not. It is nice you can purchase them at places like Lowe's and Best Buy and sometimes some don't do IR and TV is a pretty popular control option. The professional systems are more expensive than do it yourself but less expensive than the assistive but still pretty cost competitive. You get a really good install typically because you have this installed on and then you have a company that is going to provide training and support. The systems we use, the apps have been around a while and pretty well developed.I am really doing a lot of these professional systems because  the kind of bridges the gap between assistive technology products and the do-it-yourself home automation products. It all depends, in the VA, we can fund these things so it's a little different in the outside world if you have to worry about cost.
>> Home controllers. Smart things has been around for a while and pretty inexpensive. It can do voice control. I have shortcut and  -- that Amazon echo pretty much works with all the things I'm going to talk about. It gets on your Wi-Fi network and communicates to your phone and can control everything from lights and doors. It doesn't do IR, you have to buy an additional thing that interfaces, although it is a little bit clunky. The -- from Lowe's works with Amazon echo and you can even pay a service fee to have voice access and extra features.They are actually doing it for the elderly population to kind of monitor, is my dad moving around and can send you a text alert. That is a fee service you pay for monthly. The thing about Iris, you can pay Lowe's to do an install.
>> Amazon echo, it is hard to know where to put it. I'm sure everyone has heard a lot about the echo and may even have one and they are pricing been very competitively.It is really a voice control. Google home is very similar.It is voice control for your home so it has all the things but it is a lot more and what is promising about the echo in particular is Amazon has worked hard to integrate to a lot of different home automation systems. It works with almost everything. The voice access or voice recognition is really good. The one thing I will say about the Amazon echo, in an allowed environment, I had patient last week was very hard of hearing so when he turns on the TV, it is loud.Echo could not function in that environment.
>> The last thing about Google home or echo is they aren't actually home controllers.They interface through your Wi-Fi to other things like the home controller like the echo interfacing with Iris or the echo interfacing with one of the standalone devices like your thermostat.You have to buy multiple components to do that.
>> Professional install examples, control 4 is what we use the most. It is not the newest for the fanciest and it works very well. I would bet money almost in any town however small it is within a 50-mile radius there is a home theater company that also is a distributor for control 4. I haven't found a place that doesn't have somebody close by.It can do voice control for Amazon echo but with echo, and this applies to everything echo can control, a lot of it is pretty new and doesn't have full functionality as an example with control 4. You can use echo to do a lot of things but the TV control is not quite there yet. You can do neat things like a macro  for you say to turn on HBO and it would turn on your TV, and your stereo and cable box and make sure TV is on the right input and change the channel to HBO. To change the channel up one or the volume, it can't do that. It used to be the same way for the Logitech Harmony which had the IR interface I mentioned, but those have already changed. Is actually have more functionality with echo. All of this is in flux so I think they are viable options. The nice thing about using these is when they get upgraded it is probably just a software update.These installations depending on how much you do can be pretty inexpensive or at least the entry-level is pretty low for having something professionally installed.
>> The voice control like it mentioned is not as good. Switch access isn't as good as the assistive technology p roduct.You have to think about the patient when you look at these different systems to decide what is going to be best for them.
>> A lot of cable companies and home security companies do home automation but most of them require a fee. I have recommended this to anyone because I don't like subscription fees for products like DirecTV and Apple are including voice access their apps.There is some functionality there, but the problem is, and this same problem for like doing telephone access on your cell phone, even though you have voice access it is not intended to be hands-free. On your telephone if you want to make a call, you start up the voice access by saying Suri, call mom. If you want to hang up when so-called, you are out of luck. Little details like that play into it so that is why it can get complicated.
>> How do you pick the right solution?There is not necessarily an easy answer. The short answer is it depends on your user. You have to match their abilities with an access method and match what they want to control with different devices.I really am a fan of identifying a champion or the coup group for whatever system you get. That could be a family member or caregiver but that helps prevent the system not being used.
>> 
>> And basically going to hit a bunch of things to think about.How do you currently access or your practice that can be big help you understand we need to go. What do they want to control? Where will it be used?Really assessing the access method relative to their abilities. Do they have a mobile device and what type is it? Is just a dial phone or smartphone? How do they use it and how motivated are the team is it? Do they have Wi-Fi and Internet. We rented out all the time with patients in rural areas. This is not champion, is there someone in their life that is motivated to be part of this EADL process.
>> Assistive technology products I think are best used when you need a customized user i nterface, whether or not that is access method for the feedback. Those devices are going to have the most flexibility. The standalone consumer electronic products, if someone was to turn on a light or a lock your front door, maybe that is right way to go. The home controllers are when someone was to control a lot of things in the house and maybe they don't like the assistive technology products that can do that. Maybe they have a cell phone and that's all they want to use but that is a lot of times when you go in that direction.Do-it-yourself versus professional home controllers, that depends on the situation the patient.Maybe they have a daughter or son that is a tech do room and was to  once installed the stuff, I can be a cost effective way to do i t.
>> I am at the expanded using consumer products because it is cost effective and you get the latest in technology.Some of the neat things, they can be so much more integrated. A lot of times you can control things when you are not physically in the area which can be good and bad. For voice control I do think the consumer products especially if you're using Microsoft Word Dragon voice-recognition you don't get better voice control than that in the same is true for the Amazon echo. They really lead compared to some of the assistive technology products in those areas however, it really is the wild West of home automation. Actually put that bullet on a presentation four years ago and it is only worse now. I can't dictate how many products I have purchased that are no longer made say have to be careful what you pick. I like to stick with the big-name companies. I feel like Amazon is pretty invested in their echo and Logitech is invested in their Harmony product so those will probably be around a while. Certainly the access methods are constantly maturing and getting better both invoice and switch access.When you start doing these things, let's take the example of the Amazon echo controlling smart things and controlling Logitech Harmony. I don't think you have to do it that way now that six months ago that is the way you would have to control if you wanted to do IR control to do the Amazon echo or at least one of the ways to do it. You have three or four product companies talking to each other. They are going up into the cloud in talking to different accounts and coming back to your house and turning on the lights so a lot goes on behind the scenes which is pretty cool from a technology standpoint but as we all know, things don't always work so that can be a major problem for these products. Things like standing and voice access aren't always as streamlined because again they are intended for the general population so they are not putting in those little details that help when you can't physically touch or device. If you don't have family members or you are not doing the installation for the patient, who is going to do it? Finding people to do consumer products, they used to not have anybody to do that. There are companies and that is all they do is install things like the Nest thermostat so that is a market niche you can use and what is great is they can't provide support if you are not providing that support. 
>> Just a few examples, these are all based on patients we have worked with. This is using a mobile device. This patient is a great example of who is a good candidate for consumer electronics. He is a 30 -year-old male with the spinal cord injury. UBS in his own home and has the power wheelchair. He uses an android cell phone for telephone access and e-mail and he doesn't with touch a ccess. This guy uses his knuckles to access the touch screen. All he wanted to do was to unlock his front door and controllers thermostat is both of those things are difficult. He couldn't reach the thermostat because he didn't have the motor to  raise up his upper extremities. The TV remote he felt pretty easily. The questions we think about, what do we go with? Like I said he was a perfect example of somebody who would be good for these consumer electronic products because he said I don't want anything extra, I just want to use my phone. Then we have to decide if we get a standalone or do-it-yourself product which would've worked or do we get a professional install? In this case we went with a professional install, having that  support. It kind of work to meet. We were able to get one of our local home automation in theater companies talking to one of our AT companies and they worked together to make sure the patient got what he needed.This was a controlled 4 system installed. You can see it has a pretty simple interface with icons on the screen. That worked so well that we actually go straight to the home automation company now. Will almost converted one of their sales reps to being a AT vendor for us so it has worked out really well so I encourage you to reach out if you're interested.
>> Another example and this is as simple, and inpatient in our hospital, this patient has a spinal cord injury in using three different -- if you can't move around a whole lot and you basically have to have these -- in your mouth and every two hours you are being rotated and then you're having to move these things to do treatments, it is really frustrating, one, to have those things in your mouth and have the caregivers reposition these things so we used in this case a primo and used one sip and puff to do access. Then just one straw has to be repositioned. Initially we mounted everything on this arm for the TV so that was for caregivers and not so much the patient.We didn't give him a lot of extra functionality but we did help with the quality of life I think for him and the c aregivers.
>> This is an example, and this actually isn't with the real patient, comparing traditional or assistive technology solutions with mobile device solutions.This is just to show you there is a cost difference and that is something to be thought about. We have a patient with good vision, limited motor in his upper extremities but he wants to access lights, TV and landline and does well with switch scanning.
>> These costs might be a little bit off, and actually the picture on the left is covering up our number little bit but if we look at the traditional system, one option would be the primo, it is about $2000 that you buy a primo and a couple of switches and by the Sero phone and some lighting modules so that gets you into the $4000 range.It is pretty typical of assistive technology systems. The mobile device, let's say the patient already has an iPhone. You by a switch interface with switches on it that will connect to an iPhone.You get a Logitech Harmony hub and some white modules so you are in the $400 range. If you had to buy the phone or the  tablet, you can add another $5 to $1000 that you are still considerably cheaper and cheaper. When someone still purchasing that is a really good option however like I mentioned before the switch scanning on a primo is a lot simpler than on and I was device but there is a cost difference so it is something to take note of.Hopefully I would have said reference cards for you to download. The initial contention was to give an overview of all the different devices both the consumer and the AT world.As it turns out there is a lot of information so I don't know how quick these guides are however, they can be helpful to get an idea of what is out there.
>> That about wraps it up. I feel like I have covered a lot of information so if there are any questions, please let me know.
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