When the Office of Technology Assessment was eliminated by the
104th Congress, it had been preparing a major report on policy
issues concerning technology and people with disabilities. 
Evidently, an official version was not published, so I am sharing
the latest draft I obtained.  Although a couple of years old,
most of its analysis remains useful today (policies don't change
that quickly!).

Jamal Mazrui
National Council on Disability
Email: 74444.1076@compuserve.com

----------
Technology
and
People with Disabilities


Draft
September 1995


Report Prepared For

U.S. Congress
Office of Technology Assessment
Contents


Chapter 1 Introduction
     Jan C. Galvin

Chapter 2 Disability Demographics
     Mitchell P. LaPlante

Chapter 3 Assistive Technology: Public Policy and Financing
Steven Mendelsohn

Chapter 4 Consumer-Responsiveness in Assistive Technology
Service   Delivery
     Jan C. Galvin

Chapter 5 Education and Training of Individuals Involved in
Delivery of    Assistive Technology Devices
     Marvin G. Fifield, Ed.D. and Bryce Fifield, Ph.D.

Chapter 6 The Importance of Outcome Measures for Assistive
Technology     Service Delivery Systems
     Frank DeRuyter, Ph.D.

Chapter 7 Technology and Aging
     William C. Mann, OTR, Ph.D.

Chapter 8 Development, Evaluation and Marketing of Assistive
Devices
     Joseph P. Lane, MBPA

----------
Introduction

Jan C. Galvin

I.   Background

In 1982 the Office of Technology Assessment published a landmark
report entitled Technology and Handicapped People.  This report
contained many important recommendations, but as important as its
recommendations, the report focused attention on the connection
between our technological revolution and the interests and
concerns of Americans with disabilities.  As such, the report
raised the subject of technology and disability to a position of
visibility in the formulation of public policy.

In the wake of the OTA report, technology has emerged as a
discreet and conscious element in many legislative enactments
dealing with services, civil rights or other matters of concern
to America's estimated 49 million citizens with disabilities. As
they relate to research, service delivery and financing of
assistive technology, these enactments bear upon the subject in a
number of different ways, impacting the process at many points:
from research and development to distribution to end-users. 
Table 1 summarizes policy developments improving AT access for
persons with disabilities from 1986-1994.

[Insert Table 1 about here]

The present moment marks an auspicious time for evaluating what
we have done and for analyzing options for the future. 
Monumental changes have occurred since the publication of the
original OTA report.  While these changes are most obvious and
dramatic on the level of technology itself, they include profound
legal and attitudinal developments as well.  These changes are
reflected in the passage of the Americans with Disabilities Act
of 1990 (ADA), the incorporation of the values of
consumer-control into a variety of traditional human services
programs and in the rise of the independent living philosophy.
Indeed, evidence of this attitudinal change can be found here in
the fact that a report entitled Technology and Handicapped People
will be updated under the title Technology And People With
Disabilities.

An entirely new paradigm for understanding disability and
disability-related services has developed, based on the
independent living philosophy and the recognition of the
importance of technology in the lives of individuals with
disabilities. This "Technology/Ecology" paradigm (Daniels, 1990)
suggests that disability is a result of a lack of fit between a
person's goals, capacities and environmental resources rather
than a defect in the person. The characteristics of these
paradigms are compared in Table 2.  In the new paradigm,
disability can be addressed through access to an appropriate
system of resources, of which assistive technology (including
environmental modifications) is often a solution of choice.

[Insert Table 2 about here]

We revisit the subject of assistive technology and people with
disabilities at a time of far reaching political change when many
of the ideas and assumptions that have shaped the development of
public policy over the past generation are being subjected to the
most fundamental scrutiny and reassessment. It is interesting to
note that in the Introduction to the 1982 report it is stated
that...."this report is prepared during a time of uncertainty
regarding Federal block grants to the States for disability and
other social programs." Yet again, thirteen years later we are
facing this same uncertainty, but with less assurance that the
development, delivery and funding of assistive technology will
not be greatly affected.

This 1995 update, Technology and People with Disabilities,
highlights those areas of assistive technology where there has
been the most change since 1982 and where there is the most
concern. It includes policy changes; financing of assistive
technology; service delivery issues, including outreach,
training, information collection and dissemination, outcomes
development and management; aging; and, technology development,
evaluation
and marketing.

II.  Evolution of the Term Assistive Technology

While the concept of technology for people with disabilities was
recognized in a number of major legislative enactments during the
mid-1980s (e.g., The Rehabilitation Act Amendments of 1986
"rehabilitation engineering services") no consistent or
standardized nomenclature emerged until passage of The
Technology-Related Assistance for Individuals with Disabilities
Act (The Tech Act) of 1988.  Adopting the terms assistive
technology devices and assistive technology services, the statute
defined them as follows:

Assistive technology device means any item, piece of equipment,
or product system, whether acquired commercially off-the-shelf,
modified, or customized, that is used to increase, maintain, or
improve the functional capabilities of an individual with a
disability.

Assistive technology service means any service that directly
assists an individual with a disability in the selection,
acquisition, or use of an assistive technology device,
including...evaluation of the needs of an individual...;
Purchasing, leasing, or otherwise providing for the acquisition
by an individual with a disability of an assistive technology
device; selecting, designing, fitting, customizing, adapting,
applying, maintaining, repairing, or replacing assistive
technology devices;...Training and technical assistance...  (29
USC Sec. 2201).

Since 1988 the assistive technology (AT) terminology has been
incorporated into a succession of federal statutes (including the
Individuals with Disabilities Education Act, The Rehabilitation
Act Amendments of 1992, and The Developmental Disabilities and
Bill of Rights Act Amendments) as they were enacted or
reauthorized.

Utilization of this more uniform wording in a succession of
statutory frameworks has contributed to greater clarity in the
understanding and awareness of what we mean when we speak of AT.
This uniformity has also facilitated comparing various funding
streams and strategies, as well as contrasting various
administrative models in terms of their responsiveness to and
utilization of AT.

As this report goes to print a National Classification System for
Assistive Technology Devices and Services is being developed
under a grant from NIDRR with the goal of obtaining uniform data
through such a system on assistive technology devices and
services across public programs and information and referral
networks. At the present time inconsistencies among existing
lists of assistive technology devices and services, make it
burdensome, if not impossible, for publicly-funded programs to
communicate effectively about technology-related assistance.

III. New and Emerging Technologies

It is important as we look at the changes in policy over the past
13 years that we also understand the changing nature of the
technology that surrounds us. For example, the origins of E-mail
go back to the 1960's when Western Union developed their
Computerbased Messaging System. However, it is only in the past
seven years that E-mail has blossomed. When the first OTA report
was issued in 1982 very few of us were using computers at work,
let alone at home. Today about 20 million people are on E-Mail.
Two million members of the American Association of Retired
Persons have personal computers with modems. The number of Email
users increases at a rate of 500,000 per month coming onto
on-line services such as Internet, CompuServe, and Prodigy.

Thousands of discussion groups are available on these services on
a host of subjects of interest to individuals with disabilities,
researchers and providers. Individuals who access discussion
groups can read various notes from others on the list, receive
regular newsletters, keep up with the latest in medical
breakthroughs, experimental drug treatments, consumer evaluations
of products, conference agendas, Federal government requests for
proposals, research papers and reports.

Children in early intervention programs are accessing computers
at eighteen months old through simple switches. By kindergarten
they are accessing VCRs and computer games.  Students at schools
and universities are able to learn and research more easily,
quickly, and comprehensively than ever before. No longer do we
need the Encyclopedia Britannica filling all our book shelves, it
is on disc.

Technology, especially computer technology, can enhance or
amplify different human abilities: text processing systems, for
example, allow us to explore enormous volumes of written material
very quickly. And, because computer technologies can work with
visual, auditory, or tactile output, they can equalize
information-processing opportunities for people with sensory
limitations. But other technologies, such as graphical user
interface, rely heavily on a particular modality - vision in this
case. These make it hard for people with visual disabilities to
use computers. Meanwhile specific assistive technologies are
being developed to enable persons with disabilities to
effectively deal with the new digital environments. Looking to
the future involves understanding basic computers and related
infrastructure; powerful tool-level developments, such as
object-oriented technology, knowledge- based systems, and neural
networks; virtual reality and nanotechnology (Galvin & Scherer,
1995).

Information is the currency of the 21st century. The Information
Superhighway brings together interactive multimedia (phone, TV,
computer, video - a marriage of text, pictures and sound) in
digital form (letters, numbers, sounds, and images reduced to a
sequence of zeros and ones), traveling over fiber optic cables in
order to provide information to people in their homes, at
schools, and at work. The full potential of the Information
Highway is still in the future. However, all the pieces are in
place and efforts are being made through mergers of phone, cable
and entertainment companies to capitalize on both the process and
the product that will move along it. It is important that
individuals with disabilities are actively involved in
influencing the direction of the highway, to ensure the on-
ramps, highways and byways are accessible to all.

The advent of comprehensive computerization in the business world
bodes well for people with disabilities. The more sophisticated
the computers, the more extensive the networks, the more easily
they will accommodate adaptive devices and programs.

Color printing and faxing will be common. Within five years the
fax will be totally integrated with more completely electronic
communications. OCR (optical character recognition) programs will
not only read machine-generated text perfectly, it will
"understand" page layout as well.  This is of particular
importance for those with a visual impairment.

By the year 2000, speaker-independent voice recognition systems
at reasonable prices will be available. Speech will replace pens
and keyboards as the main form of interaction with computers.
Language translation programs will have also improved.

Wireless communication will be everywhere. It is already possible
to hook a portable computer's modem into the airplane's telephone
system. By 1999, even the connection to the airplane's switch
will be wireless. A simple device worn on the wrist or carried in
the pocket will allow our computers in the home, car, office and
airplane to talk to each other. They will also deal with
environmental functions such as controlling lighting, air
conditioning and heating.

Software and hardware will be easier to install. By 1999, the
Compaq/Microsoft "Plug 'n' Play" standard will be in widespread
use, so that Intel machines and clones will allow their users the
same kind of simple peripheral software installation enjoyed by
"Mac" owners since 1984. Video input will be everywhere, and most
machines will either have video cameras built in or available as
inexpensive options.

Multimedia will become part of all computing. Most new PC's are
already shipped with CD-ROM drives and sound boards.  Animations,
video, hypertext and stereo sound will become standard.

Perhaps the most striking impact of technology on the "office" is
that it will obviate the need for a physical gathering place.
This will have major importance for individuals with
disabilities. By some estimates, as many as 40 million Americans
now work either full-time or part-time at home, many of these by
telecommuting. Already telephone, videoconferencing, e-mail and
voice mail are replacing face- to-face meetings. As imaging and
OCR systems improve, the need for physical access to files goes
away (Galvin & Scherer, 1995).

Distance Learning, as defined by the U.S. Office of Technology
Assessment is the "linking of a teacher and students in several
geographical locations via technology that allows for
interaction." Since no one has to be in the same place at the
same time to participate in the lecture or conference, distance
learning provides a maximum of schedule flexibility for students
and teachers alike. An added benefit of distance learning is that
students are more likely to have greater self-confidence and not
worry about stereotypes, of ethnicity, appearance or disability
(Coombs, 1988).

Virtual reality will obviate the need for a person in a
wheelchair to get his/her wheelchair onto a factory floor or go
without sight into dangerous environments. Instead, through
modeling and simulation those environments can be created and
experiments run on the computer.

Computers may well be the most important ally of the individual
with a disability in tomorrow's world. Computer technology will
bring about environments tailored to individuals, in which the
significance of their particular disability is diminished or
neutralized.

This changing face of technology and the need to ensure that new
and emerging technologies are accessible to all is an important
aspect of policy development and implementation.

IV.  Major Issues in Assistive Technology

Technology is recognized as a powerful force in the lives of most
U.S. residents, providing tools to make performing tasks quicker
and easier. This is especially true for individuals with
disabilities. However, major barriers to accessing assistive
technology still remain.

     The Tech Act Amendments of 1994

In congressional hearings prior to the Technology-Related
Assistance for Individuals with Disabilities Act Amendments of
1994 (P.L. 103-218) several key issues were raised. Most states
have technology-related assistance programs carried out under the
Tech Act. In spite of their efforts, there remains a need to
support systems change and advocacy activities to assist States
to develop and implement consumer-responsive, comprehensive
state-wide programs of technology-related assistance for
individuals with disabilities of all ages. Notwithstanding the
effort of such State-technology assistance programs there is
still a lack of:

� resources to pay for assistive devices

     � trained personnel to assist individuals with
disabilities to use such devices and services

     � information among individuals with disabilities
     and other related persons about the availability
and potential of technology for individuals with disabilities

� aggressive outreach to underrepresented and rural populations

� systems that ensure timely acquisition and delivery of
assistive technology devices and services, particularly with
respect to children and the elderly

� coordination among State human services programs, and between
such programs and private entities, particularly with respect to
transitions between such programs and entities

� capacity in such programs to provide the necessary technology-
related assistance

In addition, several other problems were identified. First, many
individuals with disabilities cannot access existing
telecommunications and information technologies and are at risk
of not being able to access developing technologies.  Second,
there are insufficient incentives for commercial pursuit of the
application of devices because of limited markets. And third,
there is a lack of coordination among agencies at the Federal
level that provide or pay for the provision of assistive
technology devices and services.

In addition to the definition of assistive technology devices and
services from the original "Tech Act" four new terms were
defined. These clarifications reflect the intention of Congress
to redirect the focus of the state Tech Act programs to
ameliorate important identified barriers.

Systems Change and Advocacy Services

"efforts that result in laws, regulations, policies, practices,
or organizational structures that promote consumer-responsive
programs or entities and that facilitate and increase access to,
provision of, and funding for, assistive technology devices and
assistive technology services on a permanent basis, in order to
empower individuals with disabilities to achieve greater
independence, productivity, and integration and inclusion within
the community and the work force."

Consumer-Responsive

"easily accessible to, and usable by, individuals with
disabilities and, when appropriate their family members,
guardians, advocates, or authorized representatives;

responds to the needs of individuals with disabilities in a
timely and appropriate manner; and

facilitates the full and meaningful participation of individuals
with disabilities (including individuals from underrepresented
populations and rural populations) and their family members,
guardians, advocates and authorized representatives in: 1)
decisions relating to the provision of assistive technology
devices and services; and 2) the planning, development,
implementation, and evaluation of the comprehensive statewide
programs of technology- related services."

Advocacy Services

"services provided to assist individuals with disabilities and
their family members, guardians, advocates and authorized
representatives in accessing assistive technology devices and
assistive technology services; and provided through: 1)
individual case management for individuals with disabilities; 2)
representation of individuals with disabilities (other than
representation within the definition of protection and advocacy
services); 3) training of individuals with disabilities and their
family members, guardians, advocates and authorized
representatives to successfully conduct advocacy for themselves;
or 4) dissemination of information."

Underrepresented Population

"a population such as minorities, the poor, and persons with
limited English proficiency."

     Financing

There are numerous sources of financing for assistive technology
in the U.S. Federal programs such as vocational rehabilitation,
special education and Medicaid are sources of direct consumer
acquisition support. IRS codes and Social Security work
incentives are sources of indirect consumer acquisition support.
The major shortcoming of all of these programs are that their
primary focus is not assistive technology.  AT is one service or
option available.  As such, AT funding is limited and often
administratively difficult to obtain.

Some new leveraged funding sources are now available through the
ADA and federal statutes coordinating or establishing the use of
accessible design standards.  The ADA may be a source of AT
funding as the law requires employers to provide "reasonable
accommodations" and businesses to furnish "auxiliary aids and
services" in certain situations.  Assistive technology may be
used to meet these requirements, and the employers and businesses
would be covering the expenses.  Several federal laws promote the
general availability of accessible technology by requiring
manufacturers to include certain features in their products.  How
useful these mechanisms will be depends on the level of
compliance and enforcement of these laws.

While there are a variety of potential resources for funding
assistive technology for individuals with disabilities (described
fully in Chapter 3), lack of funding is consistently cited as a
barrier to obtaining assistive technology devices and services. 
Three major problems exist
-    internal problems plaguing the AT delivery system, policies
founded on the deficit model, and the lack of public sector
resources to meet the need and demand for assistive technology
services.

     Service Delivery

Assistive technology is a young field and provision of services
seems simple on its face.  However, the AT service delivery
system is quite complex and fraught with problems (Smith, 1987).
As outlined in Chapter 4, there are many AT service delivery
models which make the system fragmented and compartmentalized. 
There is little coordination among agencies which leads to
duplicative services, delays in getting devices, and interrupted
services when transitioning from one agency to another (Phillips,
Bennett & Galvin, 1993).  There is also a lack of services
provided to traditionally underrepresented populations resulting
in underutilization of AT. These problems have a negative effect
on the ability of service systems to effectively involve and meet
the needs of consumers with disabilities.

Access to information about assistive technology continues to be
a problem. Once someone becomes aware that AT exists, they do not
know how to find out more about it. This is true for both service
providers and consumers. There are sources of information, but
there is no central point of contact at present.  When
information is found, there is no assurance that it is accurate
or up-to-date (CDD, 1993). This situation is a major obstacle to
achieving consumer- responsive services.

There is a scarcity of qualified assistive technology service
providers and they are difficult to identify because they come
from different disciplines and work in different settings. There
are few training programs available to develop high-level AT
skills.  There are no certification or licensure standards for
professionals who provide AT services except for occupational
therapists.  While efforts to develop such standards are
underway, it will be some time before they are implemented.  As
the quality of AT services received depends on the quality of the
individual(s) providing the service, these training needs impact
the level of consumer-responsiveness of the service system
(Fifield, 1988).

There have been gaps in the development of mechanisms for quality
assurance for AT service delivery. There are no standards for
delivering services or requirements for assessing outcomes of
services.  Some voluntary standards exist for service delivery,
but they only serve as guidelines (Phillips, Bennett & Galvin,
1993). The demand for a comprehensive system of objective
measures of service delivery abounds. Due to the complexity of
assistive technology service delivery, it will be challenging to
develop a system that takes into account the interests of the
various stakeholders. Initial efforts have begun, but more work
remains to be done to identify a viable system (DeRuyter, 1994).

     Development, Evaluation and Marketing

Much progress has been made since 1982 in the development,
evaluation and marketing of assistive devices.  Federal support
for various types of university research and development, small
business development, public-private technology transfer civil
rights for people with disabilities combined to improve supply of
and increase demand for AT.  However, this convergence was
largely due to chance. There are still many issues that need to
be addressed directly such as the lack of market data, liability
issue, and the lack of comparative product data. A coordinated
Federal initiative, involving the private sector and consumers
with disabilities, is needed to further expand the availability
of quality AT devices (Lane, 1994).

V.   Systems Change

Disability service systems and the communities in which they
operate are changing constantly. New legislation, emerging
consumer priorities, shifting resources and advances in assistive
technology are just a few of the sources of change. And it all
occurs in the larger context of many changes in health and social
services, and in society at large (the emerging information
highway, impact of the Federal deficit, and so forth). Managers
in disability service systems, consumers and their advocates and
others with responsibilities for these systems must respond to a
bewildering array of changes at all these levels. For those
involved there are significant challenges in bringing about
effective change, such as resistance of both people and
organizations to new ideas and new behaviors. But they also have
many opportunities to guide and facilitate systems change using
their knowledge and positions proactively both in the disability
service system and in the community.

Many of the changes facing disability and rehabilitation related
organizations and agencies in the United States today, public and
private, are not welcome. They constitute important challenges to
providing effective services for individuals with disabilities.
Continuing fiscal austerity is perhaps the most compelling of
these challenges. Almost all of the 50 states currently have
budget crises, and Federal support for disability and
rehabilitation related services, especially assistive technology
services is limited, making it an absolute requirement to "do
more with less."

Organizations and agencies have other challenges to confront as
well. These include significant growth in the number of
individuals with disabilities needing services, including recent
mandates for reaching out to currently unserved and underserved
populations, pressures to enhance efficiency, changing
technological and labor force requirements, and demands for
heightened consumer and family involvement in the service
delivery process. In a larger context, the overhaul of America's
health care system is a significant factor. Managed care, the
increasingly popular approach to health care cost containment
will affect the amount of rehabilitative services available for
individuals with disabilities.
References

Center for Developmental Disabilities, The Feasibility and
Desirability of Establishing a National Information and Program
Referral Network for Assistive Technology: Final Report
(University of South Carolina: 1993).

Coombs, N. R., "Using Distance Education Technologies to Overcome
Physical Disabilities," Mindwave, (New York:  Pergamon Press,
1988).

Daniels, S.M., "The Meaning of Disability: Evolving Concepts," AT
Quarterly
Fall, 1990.

DeRuyter, F., "Assistive Technology Usage Outcomes: A Preliminary
Report," RESNA Annual Conference (Washington, DC: RESNA, 1994).

Fifield, M. G., The Need for Training in Assistive Technology,
hearing before the Subcommittee on the Handicapped of the
Committee on Labor and Human Resources, United States Senate, May
19, 1988 (Washington, DC: U.S.  Government Printing Office,
1988).

Lane, J.P., "Toward a Single Global Market in Assistive
Technology," Computers for Handicapped Persons, 4th ICCHP
Conference (Berlin: Springer-Verlag, 1994).

Galvin, J. and Scherer, M., "Technologies of the Future,"
Evaluating, Selecting and Using Appropriate Assistive Technology,
J. Orr (ed.) (Rockville, MD: Aspen Publishing Co., 1995).

Phillips, B., Bennett, J. and Galvin, J., Assistive Technology:
Practical Intervention Strategies (Washington, DC: Consumer
Satisfaction with Assistive Technology Project, Assistive
Technology/Rehabilitation Engineering Program, National
Rehabilitation Hospital, 1993).

Smith, R.O., "Models of Service Delivery in Rehabilitation
Technology," Rehabilitation Technology Service Delivery: A
Practical Guide (Washington, DC: RESNA, 1987).

U.S. Congress, Office of Technology Assessment, Technology and
Handicapped People (Washington, DC: U.S. Government Printing
Office, May 1982).

----------
Table 1.  Policy Developments Contributing to AT Access
for Persons with Disabilities (1986-1994)

198
     6    Action: Amendments to    Contribution: Clarified
     Rehabilitation Act.  Added and expanded program
     definition, expanded     benefit of major public
     program requirement.     program.

     Action: Early  Contribution: Established
intervention. Created new new major public program.  entitlement,
expanded
     program benefits.

     Action: Section 508,     Contribution: Changed
     Rehabilitation Act  procurement practices,
     Amendments. New guidelines impacted manufacturer
     for federal procurement of expectations of accessible
computers.     design standards at lower cost.

     Action: Social Security Contribution: Permitted
Amendments.    tax sheltering of income to purchase technology.

Action: Temporary Child Contribution: Provided Care for Children
with grants to states for Disabilities and Crisis respite,
emergency or
Nurseries Act. planned supports for families of children with
disabilities including assistance in accessing AT resources.
198
     7    Action: Amendments to    Contribution: New priority
     Developmental Disabilities within existing public
     Act. Expanded program    program.
     requirements.

Action: Older Americans Contribution: Expanded Act Amendments.
Created program benefit.  new provision of AT within
     existing program; defined
     AT.
198
     8    Action: Medicaid    Contribution: Clarified
     Amendments. Clarified    and expanded existing
     funding options and program benefit.
     mandates.

     Action: Tech Act. Created Contribution: Created new
     statewide systems of     funding, new public
     technology assistance.  program.

Action: Telecommunications Contribution:  Established Devices for
the Deaf Act.  new telecommunications law
with access requirement within federal agencies.
199
     0 Action: Americans with Contribution: New access
     Disabilities Act.   requirements of private
     Employment,    sector, access technology
     transportation, public by expanding concept of
     accommodations,     civil rights.
     telecommunications.

     Action:  ADA Tax Credit Contribution: Created tax
for Small Businesses.    incentives to expand access to AT.

Action: Decoder Circuitry Contribution: Required new Act. Design
standard for manufacturer standard for
     televisions.   access.

     Action: Policy Letter- Contribution: Clarified
Special Education.  rights under existing major public program.

     Action: Policy Memo-     Contribution: Clarified
     Vocational Rehabilitation. rights under existing
     major public program.

     Action: Amendments to    Contribution: Clarified
IDEA. Added definitions of rights under existing AT devices and
services.  major public program.

     Action: Amendments to    Contribution: States must
Vocational Education Act.  provide special population Created
integrated quality students (including and equity requirements. 
students with
disabilities) with equal access to vocational programs and
provide AT.
199
     1 Action: Amendment to Part Contribution: Clarified
     H of IDEA. Added    rights under existing
definitions of AT services public program.  and devices.

Action: Policy Letter- Contribution: Clarified Special Education
(Schrag right to take technology
     Letter).  home from school.
199
     2 Action: Rehabilitation Act Contribution: Expanded use
Amendments of 1992. of rehabilitation technology; widened scope
of services and allowed choice of provider, including those for
AT.
199
     3    Action: National and     Contribution: Included a
     Community Service Trust set-aside of $5-8 million
Act of 1993.   to make necessary accommodations including AT.

Action: New rules for Part Contribution: Ensured 1308 of the Head
Start Act coordination of AT
     for children with   provisions in children's
disabilities.  IFSPs are carried over into IEPs.
199
     4    Action: National    Contribution: Industrial
Information Infrastructure leaders must review Advisory Council
formed by legislative and regulatory
     U.S. Secretary of   reforms impacting the
     Commerce. Includes  electronic communications
     national disability industry including
advocate. disability access provisions.

     Action: Reauthorization of Contribution: Included set-
the Tech Act.  aside and focus on AT advocacy.

Action: Human Services Contribution: Ensured Reauthorization Act
of expansion of access to AT
1994.     through coordination of Head Start services with
activities for children with disabilities.

     Action: School-to-Work Contribution: Aid to
     Opportunities Act.  states to establish state
     Established national     and local partnerships
     network of transition    between school and the
     systems from school-to- workplace; presumes
work.     systems of support for students with disabilities, such
as AT.

Chart courtesy of Michael W. Morris, Deputy Executive Director
and Christopher Button, Director of Governmental Activities,
United Cerebral Palsy Association, Washington, DC.
Table 2.  Disability Paradigms Compared

     Issues    Individual Defect   Technology/Ecology
     Paradigm  Paradigm

Focus of The patient, the     The system of resources
     the client, the student, for AT: information, Paradigm the
individual with a financing, availability
     disability     and development of AT

     Nature Failure of individuals Lack of access to
     of the to perform major life appropriate resources:
Problem   activities such as  tools, information and
     walking, seeing,    training
     working, learning, self-
     care

Source A physical, mental or Lack of fit between a of the
emotional malfunction person's goals,
Problem   of an individual    capabilities and environmental
resources, the "medicalization" of resource problems

Evidence The indisputable     Consistent, widespread
     That a    observation of reports of failure to
Problem   impairments in acquire appropriate AT
     Exists    individuals and the from people with
confirmation by medical disabilities; extensive diagnosis;
dependency levels of poverty,
     on welfare, medical unemployment and
     assistance, support or segregation among
other services people with disabilities; meager gains in
ameliorating the problem even after enormous expenditures of
resources

Conseque Internalization of a Internalization of
nces of   deviance role and   "consumer/customer"
     the acceptance of a lesser role status and
Problem   status    externalization of
for the   action to acquire
Individu  resources
     al

Solution Restoration of  Access to AT that
s Sought function, if possible, supports achievement of
     or adaptation to    economic, social,
     defects, e.g., using educational and
     crutches or an community goals
     artificial limb

Strategi Medical evaluation and Development of
     es   treatment,     technology and
Employed rehabilitation, special integrated service
     education,     delivery systems that
     rehabilitation are responsive to
technology; services consumer expectations designed for and used
and need; a market exclusively by people driven system with
disabilities

Conseque Individual gains in  The removal of systemic
nces of functional abilities and structural
     the (e.g., ability to walk, barriers; regarding Strategi
acquired trade skill), oneself and being
     es   acceptance of and   regarded as an equally
     reliance on service capable person; greater
     systems,  reliance on the
     internalization of the economic,
     role behaviors environmental, legal
associated with being a and social tools used "patient" or
"client" and valued by
     mainstream America

Desired   Improved functional Equal opportunity,
Outcomes capacity, return to  freedom of choice,
work, improved personal achievement of personal adjustment, less
use of goals
     support services
Daniels, 1990.

----------
Disability Demographics


I.   Introduction

One current estimate suggests there are upwards of 49 million
individuals with disabilities in the U.S.  As such, they comprise
the single largest minority group ever defined, eclipsing the
elderly (about 26 million) and African American population (about
28 million). Furthermore, the population is extremely
heterogeneous. The definition and estimation
of its size has been based on demographics research by census and
survey that shows variation both in severity of disability and in
identification of persons as having a disability, whether by
self-assessment or assessment by others (LaPlante, 1991).

     Definitions

Definitional issues are one of the major concerns in the field of
disability demographics.  There is not one widely accepted
conceptual foundation for the measurement of disability and there
are a variety of operational definitions employed in data
collection efforts.  As a result, estimates of disability
prevalence vary.

There are two major conceptual models of disability - the
International Classification of Impairments, Disabilities and
Handicaps (ICIDH) (WHO, 1980), and the functional limitation
framework developed by Saad Nagi (Nagi, 1991).  The basic
disability-related concepts coming out of these models are:

� abnormal changes in structure and functioning of the individual

� anatomical, physiological, mental or emotional abnormalities or
loss

     � limitation in performance of basic activities without
     regard to situational and contextual
     factors

� limitation or disadvantage in social role performance.

Little disagreement exists over the concept of limitation in the
performance of actions and/or activities resulting from some
physical and/or mental difference, in part, because the
assessment usually takes place at the clinical level. This is not
the case for the concept of limitation or disadvantage in social
role performance, as persons who consider themselves to have a
disability, professionals who study disability, and the general
public disagree about the meaning and interpretation (LaPlante,
1991).

The interrelationship of social role limitation and functional
limitations makes it difficult to measure either one.  An
individual with a functional limitation may not experience a
social role limitation.  For example, a person with paraplegia
may hold a job and maintain a household with minimal
accommodations.  A person who does not have a limitation, but is
perceived to have one, may actually experience a social role
limitation.  For example, an individual who is HIV positive but
experiencing no symptoms may be prevented from working because an
employer thinks the individual cannot perform the job ( Ing &
Tewey, 1994).

The Americans with Disabilities Act (ADA) of 1990 provides
another definition of disability:

     a.   A physical or mental impairment that substantially
limits one or  more of the major life activities of
such individual
     b.   A record of such an impairment
     c.   Being regarded as having such an impairment

The ADA definition restricts disability to impairments that
substantially limit one or more of the major life activities. The
Senate and House reports accompanying the Act provide guidance as
to what constitutes major life activities and substantial
limitations:

A physical or mental impairment does not constitute a disability
under the first prong (part (a)) of the definition for purposes
of the ADA unless its severity is such that it results in a
"substantial limitation in one or more major life activities." A
"major life activity" means functions such as caring for one's
self, performing manual tasks, walking, seeing, hearing,
speaking, breathing, learning, working, and participating in
community activities (U.S. House of Representatives 1990, 51).

Because the concept of major life activity is defined by
examples, the precise range of activities covered by the
definition is not clearly circumscribed. A further clarification
relating to "substantial limitation" is given:

A person is considered an individual with a disability for
purposes of the first prong (part (a)) of the definition when the
individual's important life activities are restricted as to the
condition, manner, or duration under which they can be performed
in comparison to most people (U.S. House of Representatives 1990,
52).

In addition, the operational definitions used in the major
national surveys that collect data on the disability community
and in the major federal programs serving individuals with
disabilities all vary.  It is clear that the field of disability
research has not reached a consensus on the definition of
disability. Therefore, it is important to use care in
interpreting and comparing disability data from different sources
and making appropriate applications to policy issues.

II.  Disability Statistics

The field of disability statistics lags well behind many areas of
health and social statistics. Data collection is often episodic
and incomplete. Different agencies collect information for
different purposes with little integration.  (Levine, Zitter &
Ingram 1990). Therefore, there is no straightforward answer to
the question -- How many people with disability are there in the
United States? The major national surveys that collect data on
disability are summarized below.  The differences in definitions,
purposes, and resultant data are highlighted.

     Major National Surveys

Several national surveys, conducted by federal agencies, provide
most of what we know about disability demographics.  There are
many other specialized studies that can offer additional detail
on program use or on special aspects of services. The three major
national sources of data are the National Health Interview
Survey, the Survey of Income and Program Participation, and the
Current Population Survey.

     National Health Interview Survey

The National Health Interview Survey (NHIS) is a nationwide
sample of households conducted by the National Center for Health
Statistics (NCHS). It surveys the civilian, noninstitutionalized
population of the United States on its health. For disability
purposes, it is concerned with activity limitations and chronic
conditions. In the NHIS, disability refers to any long-or
short-term reduction of a person's activity as a result of an
acute or chronic condition. Chronic condition is a condition
noticed for three months or more or a condition on the NCHS list
of chronic conditions. Limitation of activity is a long-term
reduction in a person's capacity to perform the average kind or
amount of activities associated with his or her age group. This
survey includes a limitation in any activity including community,
recreational, and other nonmajor activity. Restriction of
activity is described as behavior usually associated with a
reduction in activity due to either short-term or long-term
conditions. In general, the major activities people are expected
to be able to perform depend on age, for example, play for
children under age 5, school attendance for older children,
working at a job or business or keeping house for working-age
adults, and caring for oneself and managing one's home without
assistance from other persons for elderly adults.

Of the total noninstitutionalized population in the United
States, 34.2 million (14.1%) were limited in activity due to a
chronic health condition in 1989. Of people limited in activity
due to a chronic health condition, 10.1 million were unable to
perform their major activity, 13.2 million were limited in amount
or kind of the major activity they could perform, and 10.9
million were limited in nonmajor activity. Limitation in activity
increases with age. Of the population aged 70 and over, 7.5
million (39%) were limited in activity. Of children under 18
years of age, 3.4 million (5.3%) were limited in activity.

Survey Of Income And Program Participation

The Survey of Income and Program Participation (SIPP) is a
longitudinal survey conducted by the Bureau of the Census.  Core
areas are covered at every survey period, while specific areas of
interest are done in one period. The SIPP covers the
noninstitutionalized population of residents living in the United
States. The SIPP collects information based on need for personal
assistance as well as functional limitation.

According to 1984 results, 37.3 million (20.6%) of all
noninstitutionalized people aged 15 and over in the United States
had a physical functional limitation. Of those people, 13.4
million (36.29%) had a severe functional limitation.

     Current Population Survey

The Current Population Survey (CPS) is a monthly survey,
conducted by the Bureau of Labor Statistics, which deals mainly
with labor force data for the civilian noninstitutionalized
population. Questions relating to labor force participation are
asked of all members in a household who are 14 years or older. In
March, supplementary questions are asked about income
and work disability. People are classified as having a work
disability if they

(1)  have a health problem or disability that prevents them from
working or limits the kind or amount of work they can do,

(2)  have a service-connected disability or ever retired or left
a job for health reasons,

(3)  did not work in the survey week because of long- term
physical or mental illness or disability that prevents the
performance of any kind of work,

(4)  did not work at all in the previous year because of illness
or disability,

     (5)  are under 65 years of age and are covered by Medicare,
or

     (6)  are under 65 years of age and a recipient of SSI (Rehab
Brief, 1993).


     Types Of Disabling Impairments

Different impairments have varying effects on functioning.  With
the demographic transition from acute to chronic diseases and
increasing life expectancy and aging of the population that has
occurred during this century, impairments due to chronic disease
have become increasingly significant as causes of disability (see
Table 1). The emergence of chronic diseases as causes of
disability has broadened the conceptualization of disability and
how society responds to disability.

[Insert Table 1 about here]

About 29 percent of these persons limited in activity owe their
limitations to physical and sensory impairments. The majority of
persons with activity limitations have chronic diseases. People
with activity limitations have an average 1.6 conditions that
cause them to be limited.  Arthritis is now the leading disease
that causes activity limitation in the United States and is
second in prevalence to orthopedic impairments (LaPlante, 1992).
Health conditions and impairments vary in the likelihood of
causing activity limitation. Many of the most disabling
conditions are childhood diseases, such as mental retardation and
cerebral palsy. In general, highly disabling conditions tend to
be low in prevalence, whereas those that occur frequently tend
not to be highly disabling.

Persons with Disabilities Living in Institutions

Most of the national surveys focus on noninstitutionalized
populations. However, it is important to include individuals
living in institutions to determine the size of the disability
community in the U.S. Data from the 1990 Census indicate that 2.3
million residents of institutions have disabilities. The majority
of these individuals reside in nursing homes. Others reside in
mental hospitals, correctional institutions and mental
retardation facilities.  Mental impairment is the most frequent
cause of disability among the institutional population (LaPlante,
1992).

     Work Disability

People with disabilities may not have jobs because the severity
of their impairments precludes them from working at all, because
their level of human capital (skills, education, and experience)
renders them less competitive, or because physical and social
barriers in the environment prevent their obtaining employment.

Work disability is highly prevalent in the working age
population. An
estimated 9.6% of the population aged 16-64, or approximately
15.6 million persons, have a work disability.  Over half of these
- 9.1 million people - have a severe work limitation. People with
disabilities are twice as likely to be unemployed as people
without disabilities. The 1993 Current Population Survey shows
that as many as 10 million Americans with physical, mental, or
emotional impairments are not participating in the labor force,
with a cost to society estimated at roughly $150 billion.

Just two percent of working aged people need help in activities
of daily living (ADL) such as bathing, eating, etc. or need help
in instrumental activities of daily living (IADL), such as
managing money, shopping, etc., yet they comprise over 3 million
people. The execution of ADL activities are necessary, if not to
fulfill the requirements of working at a job, at least to enable
people to get to the worksite. The majority of people who need
such help are unable to work: about 82% of people who need help
in ADLs are unable to work (729,000) and 66% of those who need
help in IADLs (1,440,000) are unable to work. Only 12.9 percent
of people needing assistance in ADL are working, and 24 percent
of those with assistance needs in IADL are working.

People with work disabilities are poorer than those without
disabilities. An
estimated 28.9% of people with work disabilities have incomes
below the poverty level, compared to 10.1% of the working-age
population without work disabilities. Among persons with a severe
work limitation, 35.8% have incomes below the poverty level.

Work disability increases with age. Only 4.5% of persons aged
16-24 report
a work disability, compared to 21.8% of persons aged 55-64. 
African Americans have a higher rate of work disability than
whites or Hispanics, and are more likely to have severe work
limitation. About 14.2% of blacks ages 16-64 have work
disabilities, and 73.9% of these are considered severe. The
comparable rate for whites is 9.0% (with 55% having severe work
disabilities) and for Hispanics is 9.4% (with 69.7% having severe
work disabilities). People with work disabilities have less
schooling. Almost 36% of people with work disabilities have not
graduated from high school, compared to 17.7% of those without
work disabilities (LaPlante, 1994).

The 1994 National Organization on Disability/Harris Organization
Survey Of Americans with Disabilities indicates that 60% of
people who rate their impairments as "slight" are working,
compared to 45% of those with "moderate" impairments, 25% of
those with "somewhat severe" impairments, and 8% of those with
"very severe" impairments.  This survey provides results similar
to the Current Population Survey: an overall employment rate for
people with disabilities of 31%, with 44% of the sample either
"unable to work" or retired and not working (Louis Harris &
Associates, 1994).

Most people with disabilities who are not working are favorably
disposed
towards work. The National Organization on Disability/Harris
Survey (1994)
indicates that 79% of non-working people with disabilities aged
16-64 would like to have a job, up from 66% in an earlier 1986
poll.

But many people with disabilities who are not working also state
that they
are unable to work. Despite their desire to work, only 42% feel
they would be able to work if a suitable job were available to
them. This percentage varies by severity - from 64% for those
with "slight" or "moderate" impairments (who make up 27% of the
total in this group), to 47% with "moderately severe" impairments
(39% of the total), and finally only 18% of those with "very
severe" impairments (32.5% of the total).

Millions of working-age people with disabilities depend on Social
Security, and the numbers are increasing rapidly. As of 1993, 6.5
million people with disabilities aged 16-64 were on the Social
Security rolls, with an average monthly payment of $626 on SSDI
or $409 on SSI. The number of beneficiaries has increased 50%
since 1982 (SSA, 1993).

Millions of people may be eligible for vocational rehabilitation
(VR)
services who are not currently receiving them. VR serves about a
million people and rehabilitates about a quarter of a million
people a year. In 1991, 945,000 people were served. However, the
GAO estimates that in any one year, only 5 to 7% of those
potentially eligible receive VR services (U.S. GAO, 1993).

III. Assistive Technology Device Use

Recent developments in public policy have emphasized the
significant contribution of assistive technology for individuals
with disabilities.  However, there is virtually no national level
statistical data on the use of assistive technology. In response,
the National Institute on Disability and Rehabilitation Research
(NIDRR) and the National Center for Health Statistics (NCHS)
co-sponsored a survey on assistive technology devices and homes
with accessible features as part of the National Health Interview
Survey of 1990 (LaPlante, Hendershot & Moss, 1992). Selected
findings from the study are presented below.

     Prevalence

The survey shows that in 1990 more than 13.1 million Americans,
about 5.3 percent of the population, were using assistive
technology devices (see Table 2). More people use assistive
technology devices to compensate for mobility impairments than
any other general type of impairment -- 6.4 million use some kind
of mobility technology, and 4.4 million use a cane or walking
stick. Other prevalent assistive technologies are hearing aids
(3.8 million), walkers (1.7 million), wheelchairs (1.4 million),
and back braces (1.2 million).

Of the 7.1 million people living in homes that have special
equipment, the most common adaptations are hand rails (3.4
million), ramps (2.1 million), extra wide doors (1.7 million),
and raised toilets (1.3 million).

[Insert Table 2 about here]

     Age Patterns

Among persons who use any assistive devices, the majority are
over 65, reflecting the higher prevalence of impairments in that
population (Table 3). However, for some specific assistive
technologies, a significant proportion of users are under age 25
-- foot braces (38%), artificial arms or hands (35%), adapted
typewriters or computers (25%), and leg braces (24%).

[Insert Table 3 about here]

     Payment Source

The source of payment for assistive technology was also assessed
(Table 4). Nearly half (48%) of individuals surveyed said they or
their families paid for the devices with no assistance form
third-parties. Third-party sources made complete or partial
payment for more than half of the users' assistive technology
devices (52%), and for about one- fourth of users' home
adaptations. The percent of assistive technology devices paid
solely out-of-pocket increased with age, but the percent of home
accessibility features paid solely out-of-pocket did not change
with age.

[Insert Table 4 about here]

     Perceived Need for Assistive Technology

Survey respondents were asked about their unmet needs for
assistive technology (Table 5). According to the responses, more
than 2.5 million persons have an unmet need for assistive
technology. Of these, 1.2 million persons were of working age
(25-64). Overall and in every age group, the reason most often
given for not having an assistive device is financial.
Three-fifths said they could not afford the assistive technology
they needed with the figure being the highest (70%) in the 25-44
age range.

[Insert Table 5 about here]

     Discussion

The total population of the U.S. increased by about 13% between
1980 and 1990, but the use of assistive technology increased more
rapidly. Use of braces more than doubled, and use of canes and
artificial limbs also increased more rapidly than the general
population. Because the population aged between 1980 and 1990,
and because older people are more likely than younger people to
use assistive technology devices, some increase in prevalence of
devices can be attributed to the aging of the population.

Despite financial problems in acquiring assistive technology
devices, use of devices has increased dramatically over the past
decade. The number of wheelchairs and walkers almost doubled from
1980 to 1990, and the number of leg, foot, and other braces has
more than doubled. These increases may be due to improved
coverage by public programs, reduced costs of technology, and
improved design which has made devices lighter, stronger, safer,
easier to use and more attractive.  The aging of the population
has contributed to the increased number of mobility devices but
orthoses tend to be more used by the younger generation.

Nevertheless, considerable unmet demand for assistive technology
remains. Of the 2.5 million persons in 1990 who stated they
needed technology they did not have, some need an enhanced
version of a device they already have and others need a device
they do not have at all. The main reason for this unmet need is
inability to pay for it out-of-pocket and lack of coverage by the
health insurance or programs in which they are enrolled.


References

Ing, C.D. & Tewey, B.P., Summary of Data on Children and Youth
with Disabilities (Washington, DC: NIDRR, June 1994).

LaPlante, M.P., "The Demographics of Disability," The Milbank
Quarterly 69 Supplements 1/2: 55-77, 1991.

LaPlante, M.P., How Many Americans Have a Disability?  Disability
Statistics Abstract (Washington, DC: NIDRR, December 1992).

LaPlante, M.L., "Employment, Disability, and Social Security:
National Statistics on Prevalence and Benefits Recipiency,"
National Academy of Social Insurance Workshop, (Santa Monica, CA:
1994).

LaPlante, M. P., Hendershot, G. E., and Moss A.J., "Assistive
Technology Devices and Home Accessibility Features: Prevalence,
Payment, Need and Trends," Advance Data , No. 217, (PHS)
9212501992 (Hyattsville, MD: U.S.  Department of Health and Human
Services, September 1992).

Levine, D.B., Zitter, M., Ingram, L. (eds.), Disability
Statistics: An Assessment (Washington, DC: National Academy
Press, 1990).

Louis Harris & Associates, National Organization on
Disability/Harris Survey of Americans with Disabilities (New
York: 1994).

Nagi, S.Z., "Disability Concepts Revisited: Implications for
Prevention," Disability in America: Toward a National Agenda for
Prevention, A.M. Pope and A. Tarlov (eds.) (Washington, DC:
National Academy Press, 1991).

Rehab Brief, Disability Statistics 14(8):1-4, 1993.

Social Security Administration, "Annual Statistical
Supplement-1992," Social Security Bulletin 55 (Supp), 1993.

U.S. Congress, General Accounting Office, Vocational
Rehabilitation: Evidence for Federal Program's Effectiveness is
Mixed, GAO/PEMD-93-19 (Washington, DC: 1993).

U.S. Congress, House of Representatives, Americans with
Disabilities Act of 1990, Report Together with Minority Views,
Report No. 101-485, Part 2 (Washington, DC: U.S.  Government
Printing Office, 1990).

World Health Organization, International Classification of
Impairments, Disabilities and Handicaps (Geneva: 1980).

----------
Table 1.  Prevalence of Impairments Causing Activity
Limitation
in the U.S., 1990

     Main Cause     Number of Percentage of
     People    people
     in 1000's limited in
     activity
Orthopedic impairments   5,873     17.4
Arthritis 4,010     11.9
Heart disease  3,430     10.2
Intervertabral disk 1,762     5.2
disorders
Asthma    1,710     5.1
Nervous disorders   1,560     4.6
Mental disorders    1,525     4.5
Visual impairments  1,347     4.0
Mental retardation  1,069     3.2
Diabetes  1,032     3.1
Hypertension   837  2.5
Cerebrovascular disease  679  2.0
Hearing impairments 649  1.9
Emphysema 560  1.7
Osteoporosis/bone   322  1.0
disorders
All impairments     33,753    100.0

Source: National Health Interview Survey, 1990.

----------
Assistive Technology: Public Policy and Financing

Steven Mendelsohn


I.   Introduction

While considerable debate surrounds the wisdom of our nation's
historical approach to persons with disabilities (tenBroek,
1966), the content and sources of our policies have not been
difficult to find or to describe. For the most part, our policies
have focused on providing specialized services, compensating for
economic loss or need, and otherwise "taking care" of individuals
who had some claim on our charity and protection. Often the
protection carried with it a significant measure of restriction,
and the variety of specialized educational, medical and social
services that society provided were usually administered through
specialized institutions, including medical facilities and
schools (Scotch, 1984).

The landmark legislative enactments embodying our policies over
the past two generations can largely be organized and understood
in light of these objectives and in the service of long-standing
and prevailing attitudes regarding those we now characterize as
"persons with disabilities." During the period from the Great
Depression through World War II, such national programs as the
library system for the blind (the Pratt-Smoot Act of 1931),
Federal procurement for sheltered workshops (Smith, 1987), the
vocational rehabilitation system (the Barden-La Follette Act of
1943), and the various legislative enactments establishing the
post-war system of veterans rehabilitation and benefits were
established.  All of these programs continue in operation today,
though in greatly modified forms. In the period of economic
expansion and national optimism following the war, these programs
continued to expand, and were joined by such measures as the
inclusion of "aid to the permanently and totally disabled" in the
Social Security Act in 1956 (70 Stat. 815), the funding of a
variety of programs for the training of teachers and other
specialized personnel to work in various service capacities, and
a variety of other measures, culminating with the adoption of the
Supplementary Security Income (SSI) program in 1972 (P.L.
92-603).

All these programs have three major elements in common that
afford them a measure of consistency not readily attainable amid
the complex choices and competing priorities of the present day. 
These elements are:

� Identification of specific needs � No demand on society
     � Separate operations

First, all of these programs identify specific, categorical needs
-- reading materials for the blind, income support, therapeutic
employment, rehabilitative services, restorative services for
veterans -- that the government could and should provide. With a
few minor exceptions, little dispute, ideological or partisan,
attached to these programs.

The second feature shared by these programs is that although they
commit the government to the provision of specified services, the
conduct of programmatic activities and the expenditure of
designated funds, they do not generally impinge upon the
business, nonprofit or mainstream educational institutions of
society. Services are provided by agencies set up and funded
expressly for this purpose; little or nothing, beyond
countenancing the use of its tax money for these programs, is
demanded of society as a whole.  As such, there is in these
traditional program models no notion of civil rights, beyond the
right of those who meet program eligibility requirements to
receive services.

This leads to the third feature that traditional program
approaches have in common. In return for the willingness of those
they serve to comply with their rules, they generally offer a
range of services, facilities and supports entirely separate and
distinct from the parallel institutions and opportunities of
mainstream society.  Neither law nor custom imposed any
obligations regarding the treatment of people with disabilities.
Most could rest content in the comforting belief that appropriate
institutions and programs existed, with the support of their tax
funds and charitable impulses, to "take care" of "the
handicapped." To be sure, the notion that an employer could be
subjected to any external constraints or legal mandates in
deciding who to hire or what criteria should be used would have
been greeted with widespread incredulity as recently as a
generation ago. Not until enactment of the Civil Rights Act of
1964 (42 USC Sec.  6000e-1) was this unfettered discretion
seriously challenged. Yet it would take nearly thirty more years
for disability to join race, gender and ethnicity among criteria
that could not freely be used in making employment decisions
(ADA, Title I; USC Secs. 12111 et seq.), and many remain
uncertain, frightened and angry about the requirements and
limitations that inclusion of disability imposes (Dart, 1995).

Commensurate with other dramatic social changes in our society,
attitudes toward disability began changing in the late 1960's
(Shapiro, 1993). These changes had their first legal flowering at
the end of the 1960's, with the passage of the Architectural
Barriers Act of 1969 (P.L. 90-480) (which imposed accessibility
and design requirements upon buildings and facilities constructed
with Federal funds) and in Sections 503 and 504 of the
Rehabilitation Act of 1973 (P.L. 93-112) (which imposed
nondiscrimination and related requirements upon federal
contractors and recipients of "Federal financial assistance").

This early movement toward "mainstreaming" reached its zenith
with enactment of the Education of the Handicapped Act of 1975
(the famous Public Law 94-142), now the Individuals with
Disabilities Education Act (IDEA) which mandated a "free and
appropriate public education" in the "least restrictive
environment" possible for elementary and secondary school
students with disabilities.

For the past quarter century then, the legislation embodying our
public policy on disability has proceeded along two, often
intersecting, sometimes contradictory tracks. Efforts to improve
the service system for people with disabilities have continued on
many fronts, some reflecting visions of that system as a
self-contained and autonomous entity, the increasing majority
attempting to bring it into partnership with parallel
institutions and services in the wider society. Numerous laws
that address disability as a civil rights issue and that
implicate the interests of persons with disabilities in the
deliberations of a wide variety of economic and social settings
have also come into existence.  In the wake of statues ranging
from the widely-known ADA to the fairly obscure Air Carrier
Access Act (DOT, 1992), or the Fair Housing Amendments of 1988
(Freer, 1994), few institutions or individuals that play an
active role in contemporary society can long develop their plans
or conduct their activities without some attention to the
concerns and the existence of America's estimated 49 million
citizens with disabilities.

While attitudinal change may be the driving force behind the
emergence of these new and integrated models, neither attitudes
nor the laws they shape exist or evolve in a vacuum. Many factors
contributed to the views of disability that are gaining
increasing prominence today, but no meaningful account of this
history is possible without an understanding of the key role that
technology has played in the process.

II.  The Advent of Assistive Technology

Technology has had a dramatic impact on the lives of Americans,
those with and without disabilities alike. As such, technology
has come to represent one of the key areas in which the interests
of people with disabilities and the interests of all Americans
intersect, creating opportunities and challenges for public
policy that have no precedents in our experience. How we define
and choose among the policy options for technology's use will
determine, as much or more than any other set of decisions we
make, the future prospects, economic status, educational
attainments, quality of life and levels of contribution for
Americans with disabilities. And the role we assign to these
citizens in the life of our nation will in turn influence our
collective future, economically and socially, to a degree perhaps
unequaled by any other demographic group.

Transcending all other traditional demographic classifications,
such as those of age, race, gender, lifestyle or socioeconomic
class; steadily growing in number, people with disabilities are
in the end all of us, in every size, faith and walk of life. As
an American Medical Association publication recently pointed out,
the average American will live for 13 years with "some sort of
activity limitation" (AMA, 1994).

In order to understand our nation's policies and funding
arrangements for assistive technology (AT), it is necessary to
consider the evolution of this technology.  Conceptually, the
development of AT can be divided into three major sequences,
which are best described as the specialized device, the
interactive device, and the integrated device phases.

     Specialized Device Era

People with disabilities have long been integral to the
development of technology. History records how their interests
and concerns helped motivate the development of many of our
familiar technologies. We need only remember that the concerns
for enhancing the communication of people with hearing
impairments contributed to the invention of the telephone, or
that the desire to enable people with visual impairments to write
print informed the development of the typewriter. Not
surprisingly then, equipment and devices have been a component of
our provision of goods and services for people with disabilities
for sometime. As early as the 1930's, the Library of Congress was
sponsoring the development and distribution of record-players
(called "talking books") for people who were blind. Beginning at
the end of World War II, the Veterans Administration supported
numerous research projects on equipment and devices in the
prosthetic, orthotic, and sensory communication areas.

Technology has entered the lives of people with disabilities from
many sources. Much of this technological input has derived from
our conception of health care, including devices such as
wheelchairs, braces, canes, artificial eyes or limbs, hearing
aids and eye glasses, and many others.  Since no branch of
technology exists in a vacuum, the rapid and numerous
developments in technology for "the handicapped" were informed by
advances in the broader technological environment. Absent major
developments in the synthesis of new, lightweight materials, the
major advances in wheelchair design we have witnessed could not
have taken place. Without major developments in electronics, new
generations of braille typewriters and embossers would not have
made their appearance.

Such then was the nature of our technology and our attitudes
during the 25 year post-World War II period that what we now call
assistive technology could be addressed as a largely
self-contained subject by public policymakers. Research could be
funded, ideally building upon the advances of the broader
research community; product development could be stimulated and
distribution could be subsidized, but all of these activities
could be conducted without the direct involvement of mainstream
industry and without reference to devices other than those which
were the object of our efforts. A device such as the Perkins
Brailler (the modern braille equivalent of a manual typewriter)
which revolutionized the teaching and use of braille following
its introduction in the early 1950's, epitomizes this era of
technology. Save for the availability of paper the brailler's
utility did not depend on the existence of, or on interface with,
any other devices. The Perkins was the classic "stand-alone"
device.

     Interactive Device Era

The introduction of mainframe computers into the university
sector and the work place has been properly heralded as a
watershed in the dawning of the information age, not only for
technology in general, but for AT as well. The industrial age had
long been marked by a high degree of interaction between
"regular" and "specialized" technology so far as materials and
design capabilities were concerned, but the computer age signaled
their convergence in the applications realm as well. This
convergence was accelerated by the development of home computing,
dating roughly from the mid-1970's.

Before the computer, assistive technology could be analyzed and
categorized without much reference to the general technological
environment or to other devices in the environment where it would
be used. Suddenly, the context of much discussion and development
in the area of AT shifted from stand-alone, self-contained
devices to peripherals, add- ons and other equipment that would
facilitate access to the mainstream computing, telecommunications
and transportation environments.

Apropos the intricate connection between technology and
attitudes, it should be noted that these developments also
occurred in tandem with the growth of a new awareness of the
interplay between assistive technology and the physical or
"built" environment. New wheelchairs, van lifts and adaptive
driving controls (the first a stand-alone device, the latter two
interactive, since they could not be used without reference to
the host vehicle) were extremely important, but if the buildings
and facilities to which they transported people were
inaccessible, their ultimate value was severely compromised.

Once the interactivity between technology and the physical
environment became clear; once the nature and utility of
assistive technology came to depend, at least in part, upon the
infrastructure into which it was to be put, the complexity of
policy decisions and implementation practices was materially
increased. No longer was it necessarily sufficient for job
developers to persuade employers to adhere to the spirit of "hire
the handicapped month." No longer was the mere welcome of the new
employee or the gracious admittance of the new graduate student
enough.  Without some attention to task analysis and to the
interface between mainstream technology and specialized
peripherals, not to mention the accessibility of the physical
environment, good intentions and stand-alone technology did not
suffice to resolve the key issues or to assure success.

For the emerging possibilities that technology offered to be
realized, new kinds of knowledge, unprecedented levels of
technical cooperation, and new categories of funding were
increasingly required. Even if the superiority for a given
individual of one or another assistive device could be determined
in principle by appropriate evaluation, the device's ultimate
utility could not be known until the context of its use and the
needed interfaces had been fully taken into account (Mueller,
1990).

     Integrated Device Era

In recent years it has become apparent that we have progressed to
yet a third generation of AT. This may be called the era of
"universal design." Universal design means design that permits
full use of the technology or system by all people, irrespective
of disability, through the use of redundant input and output
methodologies, so that the absence of any one of the modalities
of hearing, vision, speech or motor coordination will not
preclude use.  Changes in the mainstream technological
environment have brought us to this point.

What we increasingly confront today is an environment in which
the accessibility and usability of mainstream technology hinges
on initial design decisions made by its designers and
manufacturers. Whether a telephone will work effectively for an
individual who needs amplification depends as much or more on its
design components as on the ingenuity of hearing aid
manufacturers (FCC, 1993). Whether a computer system will be
usable by persons who use braille or synthetic speech-output is
as much or more a function of the features designed into its
operating system as the resourcefulness of those who design such
peripherals or who write screen-access software. And whether
mobility access technology can be used to full effect depends,
given the expense of retrofitting existing structures
(Barrier-free Environments, 1993), on the planning that goes into
the design of our public and private buildings and facilities.

Thus, even as the concept of "assistive technology" is reaching
new levels of visibility and familiarity, its very definition and
distinctness are becoming progressively more blurred. The
convergence between assistive and mainstream technology, with all
that entails for the interconnectedness of people and
institutions, and as reflected in laws such as the ADA of 1990
(P.L. 101-336) that make people with disabilities a necessary
consideration in the deliberations of all institutions of
society, is now more compelling and indisputable than it has ever
been before.

In our world, technology reflecting each of these three eras
exists side by side, the lines between them often far from
distinct. Yet, the policy issues raised by each type can be quite
different. A service system's approach to providing assistive
technology might have to be different depending on the type of
technology in question. Providing specialized devices would be
relatively straightforward. Additional skills and resources would
be required for interactive devices.  And when it comes to the
issues posed by integrated devices, what is to be done then? If
there is no means of separating the assistive from the mainstream
component, does the service system have to provide a mainstream
device, indistinguishable from the one that a person without a
disability would use, in order to meet its AT commitment? Against
this backdrop, what is our public policy toward assistive
technology today.

III. The Public Policy Response

Faced with these changes, and with the immeasurable consequences
of technology for our society as a whole, it is well to ask what
the response of our public policy has been.  This question itself
is not an easy one to operationalize.  It is best addressed by
being broken down into three subsidiary inquiries: What is our
definition of the technology that people with disabilities need?
Who should receive such technology? How should the costs of such
technology be allocated?  The first two issues are covered in
this section.  The third is dealt with in Section IV.

     The Evolving Definition

Throughout the 1970's and 80's, various attempts were made by
Congress to enhance the availability of technology to persons
with disabilities and to create a more accessible physical and
communications environment. These efforts significantly broadened
the scope of AT in law, but reflected no consistent philosophy or
clearly articulated set of goals. Measures adopted or retained to
promote these goals included: enactment in 1976 as Section 190 of
the Internal Revenue Code of the architectural and transportation
barriers removal tax deduction for businesses; imposition of
design requirements for telephone equipment through the Hearing
Aid Compatibility Act of 1988; establishment of a "relay service"
to be used by the Federal government in the Telecommunications
Accessibility Enhancement Act of 1988; adoption in the
Rehabilitation Act reauthorization of 1986 of Section 508,
directing Federal agencies to adhere to accessibility guidelines
in their purchase of electronic office equipment for their own
use; and addition, through the same reauthorization, of new
service categories such as "rehabilitation engineering services"
to the vocational rehabilitation system. Notably, such efforts
also included publication of the OTA's first report on this
subject, "Technology and Handicapped People," in 1982.

Not until 1988 were the concept or the importance of AT
sufficiently crystallized to allow for the promulgation of a
broad definition of the term. In that year Congress passed the
Technology-Related Assistance for Individuals with Disabilities
Act (the Tech Act, P.L. 100-407). As set forth in Section 3 (2)
of the Act (and codified at 29 USC Sec.  2202 (2)), assistive
technology is defined as "any item, piece of equipment, or
product system, whether acquired commercially off the shelf,
modified, or customized, that is used to increase, maintain, or
improve functional capabilities of individuals with
disabilities."

Also introducing the term "assistive technology services" into
the law, the Tech Act goes on to define them as "any service that
directly assists an individual with a disability in the
selection, acquisition, or use of an assistive technology
device..." (29 USC Sec. 2202 (3)).

These definitions, which were retained in the Tech Act Amendments
of 1994 (P.L. 103-218), are important for a number of reasons.
Armed with a broadly applicable definition, it has proved
possible to incorporate a more uniform nomenclature into a
succession of programs, including the special education (20 USC
Sec. 1401 (a 25)), the developmental disabilities (42 USC Sec.
6001 (2)), and the vocational rehabilitation (29 USC Sec. 706
(23)) programs. Existence of a definition of assistive technology
has proved helpful in defining the range of "reasonable
accommodations" that a variety of other programs must or may
adopt to ensure access for and to avoid discrimination against
people with disabilities. In a number of programs not designed to
meet the needs of citizens with disabilities, the availability of
this clear definition has helped to clarify the nondiscrimination
and reasonable accommodation obligations and opportunities.
Typical of these are the Head Start Amendments of 1992 (P.L.
102-401) and the AmeriCorps program as established under the
National Community Service Trust Act of 1993 (P.L. 103-82)
(codified at 42 USC Secs. 9835 and 12635).

The Tech Act definition of assistive technology is a functional
one, in that it applies to any device, equipment or product
system that contributes to the "functional capabilities" of
individuals with disabilities. The Tech Act represents a crucial
evolution of public policy on AT. Not only does it offer a
workable definition of AT, but it elevates the subject for the
first time to a position of national legislative concern in its
own right, and it authorizes the appropriation of funds to states
to conduct "consumer responsive, statewide programs of technology
assistance" (29 USC Sec. 2202 (5)).

     Yet, as historic a breakthrough as the Tech Act undoubtedly
represents in the development of public policy, the measures that
Congress omitted from the legislation may be as revealing as
those it adopted. The Tech Act did not mandate the distribution
of a single item of AT to any end- user.  Nor did it require that
any existing service system dramatically upgrade the priority
accorded to AT among the goods and services it was authorized to
provide. Given the broad discretion it vested in states to choose
among various program options, a number of states did in fact
allocate a portion of their funds, through grants or loans, for
the provision of AT to individuals and families. Nevertheless, in
light of the relatively small sums appropriated to implement the
Act (about $500,000 to each qualifying state at the beginning),
resources would quickly have been dissipated by a predominantly
direct- service focus.

Faced with a need that was certain to outstrip the capabilities
of any direct- service or end-user-funding model, the Act
employed a number of strategies to maximize the creativity of
state projects and the degree of grass- roots and community
involvement. Through information and referral (I & R) programs,
the conduct of technology demonstrations and conferences, and
other forms of outreach, the Act encouraged the dissemination of
information about technology and the stimulation of awareness of
AT and its potential among the public, business and
service-provider communities. This emphasis was clearly intended
to increase demand for greater support of AT from all levels of
government and from all sectors of the community.  Nevertheless,
though the 1994 Amendments are regarded by some as having taken a
decidedly confrontational turn (Trachtman, 1994), even this
heightened emphasis on systems- change advocacy (29 USC Sec. 2202
(12)) falls far short of, and is more indirect than, a number of
steps Congress could have taken.

Congress could, for example, have mandated, in the Tech Act or in
each major service program as it came up for reauthorization and
review, have mandated, not merely the obligation to consider AT
for all service-recipients and to use it where appropriate, but
also that AT, where potentially useful, should be the strategy of
choice and always the first option considered.  That congress did
not take so bold a step is entirely understandable, however.  In
light of our limited knowledge and experience with AT as a public
policy tool and the absence of hard data on its efficacy relative
to other expenditures, such a commitment would surely have been
premature.  Instead of creating new policy on a grand scale, the
approach adopted represented an attempt to promote the
development of new public policy priorities over the long-term. 
Ideally, if AT was as instrumental and beneficial as its
proponents claimed, the public awareness, educational and other
outreach efforts of consumer-responsive State programs would
yield a steady growth in grass-roots demand that would inevitably
lead to systems change through the reprioritization of technology
in a broad range of program settings.

If the Tech Act has fallen short of the expectations of many of
its supporters, another lesser-known statute, embodying a wholly
different approach to the formulation of technology policy, bids
for ranking among our greatest successes to date. The Television
Decoder Circuitry Act of 1990 (P.L. 101- 431) represented the
embrace in law of the concept of universal design. This statute
mandated the inclusion of closed-captioning decoder chips in all
televisions with 13- inch or larger screens manufactured or sold
in the United States after mid-1993. The logic of this law is
simple.  Rather than requiring individuals who use captioning to
bear the costs or find the extra funds needed for the acquisition
of add-on decoders, the statute ensures that as our stock of old
televisions turns over and is replaced, every person who wants or
needs this technology will have access to it at virtually no
add-on cost.

By taking this approach, the legislation makes all TV's into
assistive devices, since they will contain the decoder chip. 
Looked at from the standpoint of eligibility to receive AT, the
Decoder Act effectively defines all persons who are deaf or who
have hearing disabilities as appropriate recipients of AT,
irrespective of any individualized assessment of means or need.

Clearly, the Decoder Act could not have been enacted if any of a
number of powerful industry sectors had been determined to defeat
it. And clearly too, not every technology or communications
system lends itself to mandated universal design as readily as
television captioning does. Indeed, for many rapidly emerging
technologies, including interactive, multimedia systems that
utilize sound, text and images, major design issues remain to be
overcome before a viable design strategy can be postulated or
implemented.  Nevertheless, the universal design approach
constitutes a dramatic policy departure from the paradigms
evident in traditional services programs.

     Who is Eligible for AT Services

The federal government supports access to assistive technology
devices and services through a variety of policy approaches. 
Four models are discussed below:  direct service, facilitation,
leverage and universal design. Each has very different
implications for who will benefit from and be eligible to receive
AT.

     Direct Service Model

Utilizing the same definitions of AT devices and services that
the Tech Act uses, a number of categorical aid programs, most
prominently vocational rehabilitation (VR) and special education,
include AT among the goods and services that eligible individuals
can receive. But to say that AT is available is not to say when
or to whom it will be provided. Just as eligibility for any
services hinges upon an individualized assessment of need, so too
does the content of services offered to any individual depend
upon the perceived exigencies of each case, the service options
available, the interactions between and negotiating strategies of
the parties, often the advocacy skills of service recipients and
families, and a significant element of discretion vested by law
in rehabilitation and educational personnel to evaluate each
case. While the governing Federal statutes place no limits on the
kinds of AT devices or the levels of AT services that can be
provided, it is equally true that no individual has an absolute
right to AT under either of these programs and that the
determination of eligibility for services carries with it no
guarantee that technology will be forthcoming or used.

Various efforts have been made to raise the profile and increase
the availability of AT under these programs. For example, the
Rehabilitation Act Amendments of 1992 (P.L. 102- 569) contain a
clear and expansive definition of "rehabilitation technology" (29
USC Sec. 706(13)), mandate that State Plans describe "how a broad
range" of rehabilitation technology services will be provided at
each stage of the VR process (29 USC Sec. 721(a 5 C)), and
requires such State plans to describe the manner in which AT
devices and services will be provided (29 USC Sec. 721 (a 31)). 
Similarly, in the delineation of the scope of services available
under the program, rehabilitation technology (which includes AT
devices and services) is listed (29 USC Sec. 723 (a 12)).

Leaving aside the broader questions of how well a system like VR
is doing in meeting the needs of its service- recipients and in
fulfilling its responsibilities (GAO, 1993), one might also ask
how well it is doing in fulfilling its mandate and meeting the
promise of technology.  Notwithstanding the efforts that have
been made, serious barriers to the provision and utilization of
AT remain operative in VR, special education and other programs.
These will be discussed in detail in section V below, but from
the standpoint of understanding the policy assumptions that
underscore our approach to eligibility for AT across the spectrum
of service programs, one recurrent feature should be addressed
here.  All of the traditional, direct-service systems operate
under a "deficit model."

Disability alone will not confer eligibility for services to an
adult or to special education services for a child.  One must
have identifiable service needs, resulting from the disability
but still separable from it, to which the services and objectives
of the particular program can be responsive. Once eligibility is
established in principle, the scope of services to be provided
remains to be determined.  AT is not necessarily the routine
response of these systems.  In VR, the provision of technology
(as distinguished from its use in the evaluation or vocational
training processes) would hinge upon the existence of a
vocational goal to which it is germane, and upon some assessment
that the individuals is capable of using it. In special
education, where AT comes within the ambit of "related services"
(20 USC Sec. 1401 (a 17)), its availability would depend upon the
identification of some barrier to educational achievement or
participation, to which again technology would be an appropriate
response.  In essence, before being eligible to receive AT, you
must face obstacles to education which technology would help to
overcome.

Compare this to our policy toward educational technology in
general. When a school district purchases computers or audio-
visual equipment for the use of the student body, no one suggests
that its decision to do so is based on some limitation or need on
the students' part. No one conditions the access of students to
this equipment on a finding of individualized needs that
distinguishes them from their classmates. So too in mainstream
vocational training, and certainly in employment, technology is
not taught and used because of some deficiency for which it will
compensate. No, in all of these settings, technology is used
because its role as a tool in contributing to productivity and to
the performance of a range of necessary functions is axiomatic.

Here then is the dichotomy in our public policy. We regard
technology in society as a tool of broad general usefulness but
treat AT as a form of therapy or as a discretionary benefit that
must be justified. Of course, the circumstance that government is
providing the AT in the direct-service context partly accounts
for this disparity, necessitating as it does some rationale
beyond general usefulness. The need for individualization or
customization in the selection of AT devices partly accounts for
this difference too, given that mainstream technology for a
school system can usually be purchased in bulk, without much
consideration of the qualities and capabilities of each
individual student. Yet the fact remains that public funds go
into the equipping of schools with technology all over this
country, their investment proceeding from the all but universally
held assumption that technology and technology education are an
empowering and unmitigated good. Now that technology is so widely
valued as a teaching modality and educational tool in America's
schools, what values inform a public policy that requires the
student with a disability to prove some specific, individualized
need, and that further conditions technology access upon a
demonstration, with the help of a quasi-medical evaluation, of
some likelihood of ameliorating that need if technology is
provided?

To put this question another way, what is the policy goal that
underlies the requirement that a student who cannot speak must
prove her individualized educational need for an augmentative
communications device in a school environment where classroom
participation and discussion are uniformly encouraged and
regarded as the norm? Perhaps she will be successful more often
than not in demonstrating that obvious need. Perhaps the obstacle
posed by the need to offer a justification derives only from
budgetary concerns. Perhaps the notion of equality is not yet so
firmly rooted as our commitment to mainstreaming would lead many
to hope.  Whatever the answer, so long as we utilize program
models that predicate access to AT on the deficits arising from
disability rather than on the values of technological literacy
and use, this disparity will not be altered. If we mean to
approach technology policy in this bifurcated way, supporting its
unquestioned use in mainstream education and other settings
subject only to financial resources, and supporting its
availability through a complex network of strategies and
incentives, while rationing its role in the lives of people with
disabilities according to some notion of need, it is at least
incumbent upon us to candidly acknowledge our dualistic approach
and to attempt to explain the values giving rise to these
distinctions in policy.

From the standpoint of what goods and services people receive,
direct-service programs, even when they offer AT, do not
highlight this component of their work. As noted earlier, in both
VR and special education, AT is subsumed under another service
category, rehabilitation technology and related services,
respectively. Under the Medicaid program, which also represents
an important source of technology today, the term "assistive
technology" appears nowhere in the statue, and AT must be reached
via "durable medical equipment" (42 USC Sec. 1395x (n)) or as a
treatment modality that can meet the program's strict medical
necessity test.

In all these direct-service systems then, penetration to the
availability and content of an agency's AT jurisdiction may
therefore prove difficult for service recipients and providers
alike. A corollary feature is that even when legally available
and when determined appropriate in the particular case, AT is
rarely provided as an isolated service. This again underscores
the therapeutic model that governs its provision under such
programs.

One direct-service system in which AT services are provided
relatively independent of other service inputs (typically in the
form of hands-on exposure, training or advocacy assistance in
seeking funding, or evaluation and assessment on behalf of a
third-party funder) is the independent living services program,
funded under Title VII of the Rehabilitation Act (42 USC Sec. 796
et seq.). But even here, it is primarily AT services, and not
support for end-user device acquisition, that Federal independent
living funds are designed to support.  And even then, AT is not
denominated as a "core service" of independent living (29 USC
Sec. 06 (29)).  For this reason, independent living may better be
regarded as falling under what we call the facilitation model
than the direct services model.

Adherence to the policy of individualized needs-based eligibility
to AT has several serious consequences in the direct-service
systems.  While society may feel that these costs are worth
enduring, the questions of their utility must at least be used. 
First, to the degree that the content of services in each case is
specified in a form of contract between the service system and
the recipient (the individualized written rehabilitation plan
(IWRP) in VR, the individualized education plan (IEP) in special
education), success in obtaining technology often depends on the
knowledge-base, the inclinations and the negotiating skills of
the VR counselor and the service-recipient, rather than upon an
objective assessment of the need.  Too often the relationship
becomes adversarial.

The second major policy implication of reliance on the
individualized-need approach is that it tends to promote
confusion between budgetary and programmatic, between needs and
costs issues.  Where all decisions need to be formally based on
individual need, it is frequently simpler to deny that need than
to refuse to expend the necessary funds. In the cases of all the
direct- services programs, their funding and administrative
structures put AT into competition with a variety of other
compelling service objectives and needs for finite resources.  In
a broad sense, every public policy initiative is always in
competition with every other for attention and resources, so the
point here is not to suggest that additional funding resources
are either available or that if available, would service to
resolve the problem.  Rather, the point is that AT requirements
were engrafted on these established programs without 1) provision
of infrastructural resources and technical assistance needed to
ensure full appreciation and effective implementation; 2)
structural changes in program governance that would reward
effective AT utilization; and
3)   any dispensations in other programmatic demands that would
allow AT to become a welcome adjunct to existing services.

In the VR system, Congress has attempted to deal with possible
resource short-falls by requiring those states that may lack
adequate resources to develop "order of selection" plans (29 USC
Sec. 705).  These are designed to create clear priorities that
will ensure that those with the most severe disabilities and with
the greatest service needs will be given priority.  From the
policy standpoint, this solves one problem, but it does little to
clarify the relative priority of AT vis-a-vis other services,
since it does not involve distinctions among services, only among
people based on the number of service needs they may have.

In special education, which unlike VR is an entitlement program
(meaning that unavailability of funds can never be legally used
to justify the denial of services), even the order of selection
approach is foreclosed.  It seems highly likely therefore, that
school personnel purport to deny need when cost is really their
major concern.  Presumably, much confusion and much needless
litigation have resulted, circumstances that could have been
avoided were school officials able to be more candid.

One additional element of our policy on eligibility for AT
remains to be noted.  Virtually every statue mentioned so far
contains language designed to foster interagency cooperation and
coordination among programs in the delivery of services (e.g., 29
USC Sec. 721 (a 11 and 33)).  Most widely known in this
connection are the efforts to develop "transitional services"
programs (Clark, 1990) that jointly involve the educational and
rehabilitation systems in planning for persons who are about to
leave school.  However it may be that the chronic lack of
coordination between systems and among programs represents a
barrier to effective AT initiatives, the more fundamental issue
is that of identifying the policy measures that arguably ensure
its persistence.

The parceling out of responsibility for people's needs to a
variety of service systems is a hallmark of all categorical
services programs.  Such programs are created and funded because
of the perception of specific, unmet needs among identifiable
members of the population.  Vesting one agency or service system
with the responsibility for meeting educational needs, another
with authority in the case of vocational needs, and still a third
with jurisdiction where the needs are medical, is a reasonable
approach, except in those cases where the needs transcend the
conceptual boundaries between systems, or where they fall between
the cracks.  Perhaps nowhere are the inherent limitations imposed
by current policy more dramatically illustrated than in the area
of AT, where devices provided by one system may need to be
forfeited when someone comes under the jurisdiction of another,
or where the availability of some needed technology from one may
preclude the provision of other needed devices by another.  In
sum, the following factors related to the policies underlying our
current direct-service model of AT delivery render the creation
of a seamless system that is responsive to technology needs
throughout the lifespan highly unlikely:

� the criteria for assessing individualized needs for technology
necessarily vary from service system to service system

� our fundamental traditions of federalism and of local control
of education operate to perpetuate a fragmentation in
decision-making

� methods of governmental accounting do not readily lend
themselves to overall assessments of the costs and benefits of
particular grants or denials of service

� no general authority exists under current law to compel the
various systems to share jurisdiction and financial
responsibility on a widespread basis.

For these reasons, other AT program models beyond direct
provision of devices to consumers need to be examined and
evaluated as well.  In current policy, the primary alternative to
the direct-service model is one we may call the facilitation
model.  The Tech Act and the independent living services programs
both represent this model.  Instead of expending their resources
on the direct provision of AT devices, they engage in a variety
of activities, on the individual and institutional level,
designed to increase access to and availability of technology.

     Facilitation Model

By the facilitation model we refer to that range of programs and
services that offer advocacy, training, technical assistance,
product development and basic research support, even indirect
consumer funding (such as loan funds or tax advantages), in
connection with AT.  Examples in current law and policy include I
& R services, advocacy skills training and "systems change"
advocacy, technology transfer, rehabilitation engineering, or
other services that, while including no direct role in funding
equipment, have the capacity and the intent to heighten its role,
efficacy or availability.

Of course, the complexity of AT policy does not lend itself to
the easy division of programs according to these categories.  In
practice the lines will be blurred. Are state equipment loan
programs, Social Security work incentives, or tax credits for ADA
compliance expenses examples of the direct-service or the
facilitation model?  After all, they all leave consumers and
families to pay for their technology themselves, but they make
resources available for this purpose that would otherwise have
reverted to the government.  As such, they contain features of
both the third-party and self-financing approaches. In either
case, their effective utilization requires considerable
knowledge, and their availability seems far less-known than their
potential warrants.

To the question what AT devices and services can people expect to
receive under the facilitation model, the only answer that can be
proffered is the provocative but frustrating one: everything and
nothing. Each of the approaches included under this model has the
potential to increase the availability and potentially to lower
the cost of AT for all prospective users or for some subgroup of
people with disabilities, but none guarantees that the needed
resources or the desired results will be forthcoming.  Examples
of the facilitation model will be explored in greater detail in
section IV.

     The Leverage and Universal Design Models

Two other important models of AT programming are discernible in
public policy.  These are what we may call the "leverage" and the
"universal design" models.

Under the leverage model, nongovernmental entities are made
responsible for paying the costs of AT under certain
circumstances.  This model is best exemplified by the "reasonable
accommodations" and "auxiliary aids and services" requirements of
the Americans with Disabilities Act.  These too will be discussed
in detail below.  For the moment, two points should be noted. 
First, with the ADA, as with the programs mentioned in
connections with the facilitation model, the line between
leverage and facilitation is far from clear.  After all, to the
extent that virtually all ADA compliance expenses incurred by
private-sector entities are eligible for some sort of favorable
tax treatment (Mendelsohn, 1993), the real cost is being shared
between the entity and all taxpayers.

The second point to bear in mind is that although civil rights
statutes including the ADA have been exempted from the coverage
of the Unfunded Mandates Reform Act of 1995 (P.L. 104-4) (see,
Cong. Rec., 1995), the frequency of allegations that it
nevertheless constitutes just such a mandate reflect widespread
misunderstanding of the protections it affords against "undue"
expense (42 USC Sec.  12111 (10 and 13)).

The universal design model has already been introduced in our
discussion of the Decoder Circuitry Act.  This model also
overlaps the leverage model, insofar as the private sector is
being asked to bear the costs of accessibility.  But the model
has the virtue of distributing these costs over the broadest
possible payer base, meaning that they tend to be negligible for
any one individual or entity (OTA, 1993).

IV.  Financing of Assistive Technology

Although it is possible to describe all of our major AT funding
strategies, the key questions of how much we spend and what we
obtain for it remain elusive. While each of the delivery system
models discussed above -- the direct service, the facilitation,
the leverage and the universal design models -- differ in their
characteristic results for would-be technology users and in the
practical demands they make on various sectors and institutions
of society, by far the greatest distinction among them relates to
how they define and allocate the costs of AT. This contributes to
the difficulty surrounding any comprehensive assessment of the
level of resources going into AT, let alone the benefits derived
from such expenditures. This imprecision arises from three
principle causes:

     � No systematic reporting requirements for AT
services among direct-service programs

     � Nonuniformity in the characterization of AT expenditures

     � Lack of clarity between assistive and mainstream
technology

First, although a number of direct service programs are
authorized to provide AT devices and services, no systematic
provisions exist for reporting expenditure or outcome data in
relation to this component. Second, even where program
expenditures for AT can be tracked, as a number of states are
beginning to do (RESNA, 1995), there is no guarantee that all
expenses which meet the definition of AT will necessarily be
recorded as such. Overlapping definitions such as "rehabilitation
technology" or "telecommunications and sensory access" equipment
or "durable medical equipment," not to mention "other goods and
services," introduce an inevitable element of discretion and
nonuniformity into the characterization of expenditures for AT.
Different accounting protocols used for allocating overhead costs
also contribute to this nonuniformity.  Moreover, such systems
expend a portion of their resources on efforts to minimize costs
-- designating various programs as "payers of last resort" and
requiring or permitting the search for "comparable services and
benefits -- that further complicate the handling and outcome of
many cases.

The third reason for the lack of definitive expenditure
information returns us squarely to the question of how assistive
technology is to be defined. If there is presupposed a fairly
clear juxtaposition between mainstream and assistive devices,
then the task is relatively straightforward.  The automobile is
the mainstream technology, the add-on adaptive driving controls
the assistive; the set-top box that controls the combination
television/telephone/computer is the mainstream technology, the
remote control device that both voices and prints out all
commands and feedback and that allows for alternative input
methods to the pressing of keys is the interactive, assistive
part. But what happens when, because of their increased reliance
on electronics, automobiles are no longer capable of having hand
controls "wired-on" to them but must incorporate such controls
into their basic design?  Or what happens when the set-top box,
as a proprietary closed system, cannot be interfaced with a
remote control device of the kind needed, meaning that it must be
created with the alternative input and output capabilities
already on-board?  What if any portion of total device cost is
allocable to assistive technology? And as important, if buying
the car becomes the most viable strategy for getting features
needed to drive it, what changes will the service systems need to
make to accommodate these new realities?

Because the accessibility and usability of a growing array of
electronic devices will be determined by whether they were
designed according to principles of inclusiveness and universal
access, the concept of "assistive technology" has little meaning
in relation to them. Would we call an automated teller machine an
assistive device because, in the absence of any add-on or
substitute capability that could facilitate its access and use,
it had built-in speech output to facilitate its use by blind
persons? Would we describe a new TV set as assistive technology
because it has a built-in decoder chip to facilitate access to
the audio by persons who are deaf, and if not, will we do so when
add-on decoders disappear from the marketplace for lack of
demand? On one hand, the answer might logically be yes, but
unless our paradigm for defining and funding AT is broad enough
to include accessible technology, funding streams that uphold a
narrow definition of what technology is "assistive" may prove
decreasingly relevant to the day-to-day issues and compelling
access needs in the lives of those they aspire to serve.

As discussed in Section I, bifurcation of funding streams and the
creation of separate and specialized funding resources and
priorities for assistive technology have remained a hallmark of
our policy at every stage of the process, from research and
design to marketing and distribution to the consumer. The forces
and assumptions that have created and maintained this duality,
along with the potential for integrating assistive technology
more fully into the economic and social mainstream, are as
central to the analysis of AT financing as any dollar figures or
outcome statistics could be.

     Major Categories of Federal AT Funding

     Direct Consumer Acquisition Support

Vocational Rehabilitation:  Among Federal-State categorical grant
programs, perhaps none has touched the lives of more persons with
disabilities than the VR system. VR is not an entitlement
program. That is, the right to and level of services which
eligible individuals will receive depend among other things on
the availability of adequate, appropriated funds. VR provides its
services, including AT, to individuals pursuant to individualized
plans of service, IWRPs. To qualify for AT support, an individual
must first be found eligible for VR services and must then have
an IWRP in place that provides for the provision of AT devices in
the context of the individual's goals, needs and capacities. 
When provided, AT may be forthcoming under its own name, under
the broader service rubric "rehabilitation technology" or under
alternative service categories such as "sensory aids," "tools and
equipment" or the residual "other goods and services." In
addition, in evaluating applicants' eligibility for VR services,
the law requires that technology be taken into account in
assessing vocational potential and in determining the viability
of vocational goals.

Nothing in the governing federal law makes the "designated state
agencies" administering the VR program responsible or accountable
for unrelated provisions of state law that interfere with the
fulfillment of agency obligations with respect to AT.  If state
procurement regulations impose lengthy delays on technology
acquisition, or if state law competitive bidding requirements
prevent the item of choice from being selected, no remedy appears
to exist in federal law.

Special Education:  Pursuant to the Individuals with Disabilities
Education Act (IDEA), states are required to provide "special
education services" to students who face barriers to educational
performance by reason of disability.  States and local school
districts are required to provide these services, aimed at
insuring a "free and appropriate public education" in the "least
restrictive environment" possible.

As with VR, determination that a child is eligible for special
education services represents only the beginning of the process.
The vehicle for identifying and specifying what particular
services the child needs is the IEP. Assistive technology devices
and services are among the modalities that the federal law
specifies should be provided in appropriate cases. They fall
under the category of "related services" which are distinguished
from "special education services" largely by their role in
facilitating the educational process and removing barriers to the
attainment of agreed upon educational activities and goals. 
Related services are noninstructional.  Transportation, speech
pathology and audiological services are among the best-known
examples of related services.  Each of these facilitates
participation in the educational process, and creates the
underlying conditions allowing the student to benefit from any
educational program.

Medicaid:  Medicaid is the program of medical assistance for
individuals whose incomes fall below specified levels (Social
Security Act, Title 19, 42 USC Sec. 1396 et seq.).  Recipients of
Supplementary Security Income (SSI) qualify for Medicaid in most
states.  Like VR and Special Education, Medicaid operates through
state agencies with a combination of federal and matching state
funds.

Because it is a medical assistance program, not one concerned
with rehabilitation or community integration, Medicaid does not
purport to provide AT devices or services, and the governing
statute makes no reference to these terms.  Nevertheless, the
program has paid for AT in a limited but growing number of
instances (Myers, 1995). So far as explicit recognition of
technology is concerned, states that participate in the program
are required to make available in appropriate cases only "durable
medical equipment" (DME).  DME has a well-established definition,
encompassing hospital beds, oxygen tents, iron lungs and
wheelchairs (42 USC Sec.  1395x (n)). Of these, only wheelchairs
would typically be thought of as AT.

The Medicaid definition of DME offers a striking glimpse into the
impact of the deficit model discussed in Section
III. Recently the definition was amended to include power, as
well as manual, wheelchairs, "but only where the use of such a
vehicle is determined to be necessary on the basis of the
individual's medical and physical condition..." With respect to a
seat-lift chair, "such term includes only the seat-lift mechanism
and does not include the chair.

For roughly the same reason that most people would prefer their
cars with rather than without motors, many people would find a
power chair more convenient and less demanding than a manual one. 
But as the statutory definition makes clear, some identifiable
medical necessity, serving to prove that the manual chair cannot
suffice, will be required to justify the motorized chair.  To
obtain any equipment through Medicaid, it is necessary to
demonstrate medical necessity, whether the technology is
requested under the DME category, as prosthetics (42 USC Sec.
1396d (a 12)), under the early periodic screening, diagnosis and
treatment (EPSDT) service for children (42 USC Sec. 1396d (r)0 or
under other potential service categories.

Although Medicaid is replete with many procedural pitfalls that
can themselves represent obstacles, the main conceptual problem
in obtaining AT through it derives from the fact that the goals
of AT and the criteria used by Medicaid are not consistent.  Only
by broadening Medicaid's definition of medical necessity can a
better fit be achieved. Given the inelasticity of the DME concept
over the years since Medicaid's enactment, it is unlikely that
the scope of DME will expand to include a broader range of
devices. Rather, the impetus for broader provision of AT under
Medicaid must come primarily from situations where devices
characterizable as AT are found to be "medically necessary" in
light of the diagnosis and of the prevailing medical opinion
regarding treatment and therapeutic modalities (e.g., Detsel,
1990).

Independent Living Services:  Since publication of the original
OTA report, one of the major developments in the disability
rights and services field has been the growth of the independent
living movement. Independent living centers (numbering about 400
around the country) vary a great deal, but they have in common a
reliance on peer support and a philosophy aimed at promoting
advocacy skills and autonomy for those participating in their
programs.

Although AT is not a "core" independent living service under the
Rehabilitation Act, it does qualify as a non-core service (29 USC
Sec. 706 (30)0, meaning that centers can provide these services
with Federal funds passed-through statewide independent living
councils.  Many centers offer assistive technology services,
typically in the form of demonstration cites, hands-on exposure,
funding advocacy assistance or training. Such centers can play an
especially valuable role by providing advocacy assistance to
people involved in efforts to obtain technology through the
direct- service systems, as well as by helping to identify
experts who can give the technical justifications and
documentation that these systems demand.

Veterans' Rehabilitation:  Dating back to the World War II Era,
the Veterans Administration (now the Department of Veterans
Affairs) has operated rehabilitation programs and sponsored
research into prosthetics, sensory aids and related devices.
These programs have varied over time but essentially have been
aimed at facilitating the rehabilitation of Veterans with
disabilities.

     Indirect Consumer Acquisition Support

There are a number of ways in which the federal government
provides support to consumers for the acquisition of assistive
technology, but where instead of providing devices or dispersing
funds directly, it does so indirectly by allowing individuals,
families and even businesses to retain funds that would otherwise
have been retained by or returned to the federal government.

Internal Revenue Code:  Our federal income tax law contains many
provisions that confer favorable tax treatment upon expenditures
for AT. Although the term "assistive technology" appears neither
in the Internal Revenue Code nor in the voluminous regulations
interpreting it, numerous rulings have repeatedly conferred tax
deductibility or other preferential status to a broad range of
devices and services that fall within the scope of AT.  The
medical expense deduction (26 USC Sec. 213) has been applied to
devices purchased to overcome the functional limitations
associated with a disability such as telecommunications devices
for the deaf (TDDs) and closed-caption TV decoders (e.g., IRS,
1980), as well as a long list of items used to overcome
functional limitations associated with visual, motor,
communicative and developmental disabilities (Mendelsohn, 1993).
Similarly, the itemized deduction for impairment- related work
expenses (26 USC Sec. 67 (d)) has enabled many people with
disabilities to deduct the costs of a wide variety of goods and
services needed by them in the pursuit of gainful employment.

The disabled access credit (or small business accommodations
credit, as it is sometimes called), was added to the law in 1990.
It allows small businesses to claim a tax credit for 50% of up to
$10,000 of ADA compliance expenses each year including expenses
for the "acquisition or modification of equipment" (26 USC Sec.
44 (c)).

For anyone who pays taxes, these tax advantages have the same
value as a direct cash subsidy. For an individual or family in
the 28% tax bracket, a deduction for AT devices is worth the
equivalent of a $28 subsidy on each $100 spent.

Social Security Work Incentives:  Under both the Social Security
Disability Insurance (SSDI) and the Supplementary Security Income
(SSI) programs (Social Security Act, Titles 2 and 16),
beneficiaries or recipients risk reduction or termination of
benefits under various circumstances. While the SSI and SSDI
programs differ in their eligibility conditions (SSI principally
depending on income and resources remaining below prescribed
levels; SSDI hinging primarily upon inability to work due to a
disability), both programs contain major provisions allowing the
retention of funds for various work-related and income-producing
purposes (SSA).  Terms such as the trial work period, impairment-
related work expenses, blind work expenses and the plan for
achieving self-support may strike a responsive chord with some.
These and other provisions are explicitly applicable to equipment
and therefore, when effectively understood and implemented, serve
to make federal funds available for the purchase of AT devices
and services in the employment or employment training context.

Other Federal Support For Assistive Technology

Beyond its direct and indirect roles in financing acquisition of
AT by consumers, federal support plays a central part in the
development and dissemination of assistive technology.

     Technical Assistance

The Tech Act:  Federal funds support the development of greater
public awareness and information dissemination about assistive
technology in a number of ways. In addition to the activities
carried out under the Tech Act's program of grants to states,
that statute has supported a number of "programs of national
significance" that have yielded valuable information and
contributed to its dissemination.  Perhaps most notable among
these is the major study, "Study on the Financing of Assistive
Technology Devices and Services for Persons with Disabilities,"
published by the National Council on Disability (NCD) in 1993. 
Coupled with state program activities such as public service
announcements in the media, assistive technology demonstration
centers, conferences aimed at familiarizing consumers with the
existence and potential of AT, and efforts aimed at promoting
advocacy skills among technology consumers, these activities have
contributed significantly to raising the collective consciousness
around AT.

Another important component of the Tech Act is the two technical
assistance programs that operate under its auspices.  The RESNA
Technical Assistance Project is aimed at providing technical
assistance to the state Tech Act programs. The Assistive
Technology Funding and Systems Change Project, operated by a
consortium of organizations spearheaded by United Cerebral Palsy
Associations Inc., is designed to bring a broad range of AT
funding resources and information to as large a segment as
possible of the disability community. Both programs operate under
competitively bid contracts with the National Institute on
Disability and Rehabilitation Research (NIDRR).

ADA Awareness:  Through several mechanisms including a network of
ten regional Disability and Business Technical Assistance Centers
(DBTAC), public funds administered principally through NIDRR and
The Department of Justice provide technical assistance to
individuals and businesses in connection with their efforts to
understand and comply with the requirements of the ADA. To the
degree that the ADA includes "reasonable accommodation" and other
comparable requirements, assistive technology represents an
important tool for the achievement of ADA compliance, as well as
a vital component of any informational or technical assistance
strategy to support the Act.

     Research and Development

However negligible in relation to the overall federal investment
in technology, federal R & D support does play a significant role
in the development of AT. Several programs currently exist that
play a part in fulfilling this role.

Rehabilitation Engineering:  Through a network of competitively
funded Rehabilitation Engineering Research Centers (RERC) around
the country, NIDRR supports a variety of specialized and targeted
projects addressing basic and applied research, technology
transfer, technology needs of specific age groups, and other
matters (Hammer, 1993). Taken together, the RERC's have produced
a large and impressive body of data.

Architectural and Transportation Barriers Compliance Board:  The
Access Board, as it is called, is primarily known for its work in
the establishment and implementation of accessibility standards
for the "built environment" under the Architectural Barriers Act,
Section 504 of the Rehabilitation Act, and most recently, in the
development of the Americans With Disabilities Act Accessibility
Guidelines (ADAAG). Less well known is the research sponsored and
conducted by the Board in developing these standards. 
Telecommunications legislation currently pending before Congress
would expand the role of the Access Board by making it
responsible for the development of guidelines for implementing
the telecommunications devices accessibility requirements of the
proposed new law (104th Cong., H.R.  1555).

     Leveraged Funding Sources

The federal role in AT funding goes far beyond the direct
appropriation of public funds. This is so because a large number
of federal programs such as the federal-state efforts noted above
involve the combined use of federal and state matching funds. It
also occurs in the context of a number of partnership
relationships between governmental and private or nonprofit
sector entities.  All of these represent forms and sources of
leverage, but federal law leverages expenditure of non-federal
funds by obliging states, localities, nonprofit organizations,
and businesses to follow specific practices and to conduct
themselves in prescribed ways that can involve the expenditure of
their funds, including expenditures for AT, in order to avoid
violation of nondiscrimination and reasonable accommodation
requirements.

While no federal civil rights law specifically requires any
non-federal entity to spend money on AT, a variety of anti-
discrimination, equal access, and reasonable accommodation
requirements may have this effect as a practical matter. To the
extent that technology frequently represents the most cost
effective and feasible approach to meeting a law's requirements,
it is essential that the leverage value of these requirements as
a source of AT funding be both candidly acknowledged and fully
understood.

     The ADA

The ADA requires employers or prospective employers to provide
"reasonable accommodations" to qualifying individuals with
disabilities, and mandates the furnishing of "auxiliary aids and
services" by public accommodations and commercial entities in
cases where barrier removal, or modification of practices or
procedures are insufficient to meet the needs of the situation. 
Assistive technology becomes a factor because the definitions of
both reasonable accommodations and auxiliary aids and services
include, among numerous options, the "acquisition or modification
of equipment" (42 USC Secs. 12102 (1 C) and 12111 (9 B)).

The impact of ADA as an AT funding lever remains to be
determined. Only as workers, employers and public accommodations
become aware of the potential of technology as a solution of
choice will the law's potential in this regard be ripe for
assessment.  To the degree that technology is likely to prove an
increasingly prominent strategy for the resolution of reasonable
accommodation requests, its standing in the hierarchy of
solutions and its frequency of use are likely to rise.

     Funding of Universal Design

The most creative approach for lowering the cost of AT is by
designing accessibility into our mainstream technology. Put
another way, the best way to pay for AT is to eliminate the need
for it in as many products and systems as possible. We call this
concept universal access or universal or accessible design. It is
a concept which, however grudgingly, has gained fairly widespread
understanding in relation to the physical or "built" environment,
but one which has thus far played a far lesser role in the design
and implementation of our information and other technological
infrastructures (GSA, 1994).

Against this background, the role of federal statutes in
coordinating or establishing the use of accessible design
standards is extremely important. In contrast to other funding
strategies, this federal role does not relate primarily to the
allocation of funds, for in many instances little or no outlay
will be required. On the statutory level, two prototype examples
of this approach to AT funding can be cited. The first is the
Television Decoder Circuitry Act of 1990 discussed earlier. The
feasibility of universal design principles naturally varies with
the technology and the issues involved, but where such design
enhancements are possible at little or no cost, approaches such
as that embodied in the Decoder Act represent an effective means
for both minimizing and allocating the costs of AT.

The second example of this approach is Section 508 of the
Rehabilitation Act, Electronic and Information Technology
Accessibility Guidelines (29 USC Sec. 794d), which requires that
in its purchase of information technology, the Federal government
purchase equipment and software that are accessible. The
underlying logic of the provision is that by requiring bidders on
Federal procurement contracts to offer accessible products, the
massive buying power of the Federal government could be brought
to bear as an instrument for bringing about positive design
changes in all sectors of the computer and related electronics
and information technology industries. After all, if bidders on
federal contracts had to make their products and systems
accessible, there would hardly be economic justification for
continuing to design and produce duplicate lines of inaccessible
products for other customers. Moreover, if all bidders and all
products are required to comply with accessibility guidelines,
interference with the competitive balance among bidders and
distortion of the market are likely to be almost wholly
avoidable.  Of course, accessibility is easier to define and to
achieve with some products than with others.  To require it in
situations where its achievement is infeasible would make little
sense, but guidelines that are promulgated pursuant to
consultation with industry and in light of existing technological
capabilities and design concepts, pose little risk of stifling
the ability of the government to meet its procurement needs at
costs and within timeframes comparable to those that currently
exist.

Without mechanisms for enforcing accessibility guidelines, and
given our limited experience with evaluating contractor
performance in this area, much work remains to be done before
accessibility can become a real priority in public sector
procurement.  The General Services Administration's Office of
Emerging Technology is working on these problems, and offers
technical assistance on identifying accessibility issues and
implementing workable and cost effective solutions.  Pending
further development of these strategies, it should be noted that
broad-based adoption of an accessible design standard by
governmental or other large- scale information technology
purchasers should dramatically reduce and help to finance the
cost of AT be redefining the universe of potential users whose
needs must be taken into account in product manufacture and
design.

V.   Conclusions and Policy Options

Looked at from the standpoint of a self-contained system, the
principle barriers to AT funding under our current arrangements
are fairly well known. Evaluations of the efficacy of
governmental expenditure on AT have typically focused on such
issues as level of public awareness, training of service-system
personnel, coordination among agencies and programs, availability
of expertise in needs assessment and device selection, lack of
product comparison data or opportunity for hands-on assessment
and experimental use prior to acquisition, adequacy of monitoring
and tracking data, means of collecting outcome data, and methods
for assuring quality control in the development and selection of
AT devices and in the delivery of AT services.

In an era of increasing cost consciousness, these questions are
altogether appropriate. Yet, even if means could be found for
remedying the internal problems plaguing our AT delivery system,
we would still face two fundamental barriers to the financing of
AT in our society.

In this country we neither have nor are likely to have any
provisions for systematically meeting the technology needs of
people with disabilities. Indeed, it is far from clear how or
against what standard such needs could even be measured. For the
majority of Americans, this is not an issue. The government plays
no particular role in defining or meeting their technology needs,
and the matter is left largely to private decisionmaking.
However, in the case of Americans with disabilities, we have
undertaken to provide certain technologies, but we have done so
on the basis of a "deficit model." With the exception of a few
sources, eligibility for services under the programs that provide
device acquisition assistance to consumers is predicated on the
existence, not of a potential benefit, but rather of an
identifiable deficit or need for which technology, usually in
context with other services, represents an appropriate treatment
or remedy.

Even under the most optimistic scenarios for funding,
coordination and administrative reform, it is inconceivable that
currently available or foreseeable public sector resources could
meet the existing need, let alone satisfy the demand from those
who wish to enhance or maintain their functional capabilities in
response to rapid technological change. Nor do we have material
evidence to date that our current strategies for leveraging
private sector resources or for broadening the payment base have
resulted in significant decreases in the cost differentials
between assistive and mainstream technology on a function-for-
function or activity-for-activity basis.

One way of quantifying the barriers may be to postulate a goal
against which our success to date can be measured.  Stated
simply, our goal must be to ensure that the invaluable tool of
technology is made available to the largest possible number of
persons with disabilities who can benefit from it in the
economic, educational, family and community spheres. This goal
must be accomplished in a manner that minimizes required outlays
of public funds while maximizing the involvement of all sectors
of society. Such broad-based participation must be stimulated in
a fashion that is noncoercive and that encourages, demonstrates
and rewards the value of all relevant efforts. Lest this goal be
questioned, one need only mention the profound commitment of our
society and government to technology at every level and in every
domain of life, and the dense web of legal, budgetary and other
decisions made and sustained by government in keeping faith with
these commitments. In such an environment, the only possible
question today is not whether people with disabilities should be
allowed to fully participate, but rather what possible argument
exists for their exclusion.

With the aging of our population, the incidence of functional
disabilities will rise steadily, as the concerns of disability
and longevity intersect. In light of this demographic trend, of
our increasing awareness of disability as a public policy issue,
of our profound belief in technology and support for its
application and development in all possible settings, the major
barrier can now be easily stated. We have not devised a means for
leveling the playing field such that disability ceases to be an
obstacle to the use of all technology and such that the costs of
accessing technology need not be materially higher for people
with disabilities than for people without them.

Surely few people would argue that assistive technology should
not be widely available, or even that mainstream technology
should not be generally accessible. Disputes have arisen over
what approaches should be taken: i.e., is it ultimately more
efficient to provide assistive technology to those supposed few
who need it or to make the investment in designing more
accessibility into all devices? Such disputes are ultimately not
so much about the amounts of money that should be spent on AT as
they are about the allocation of costs. Even if reprioritization
in the use of current public funds were to result in a shift of
disability-related resources from traditional services to AT,
foreseeable levels of government investment could neither
generate the R&D capital necessary for AT to keep pace with rapid
changes in mainstream technology nor the consumer demand
sufficient to provoke significant increases in the level of
private sector investment.

Policy Options for Emerging Funding Strategies

As a starting point for evaluating how available government funds
could best be used to stimulate technology for people with
disabilities, we should ask the baseline question what does the
government do to encourage the development and deployment of
mainstream technology? Of course, many of the support systems it
offers are already available to the developers and vendors of
assistive and mainstream technology alike. Patent and copyright
protection, technology transfer programs (such as those operating
under P.L. 89-502), the numerous tax law provisions aimed at
stimulating business and product development, are available for
all technologies. But many other public policies designed to
enhance the development and use of technology in our society are
not so readily available for assistive technology.

Accordingly, a major review of all federally-funded or
legally-protected technology initiatives should be undertaken
with a view to ensuring that their potential in the AT area is
fully utilized. For example, through a number of legal
provisions, the government has promoted the creation of consortia
among otherwise competitive companies for research and
development in various high technology areas including advanced
microchips. Could the government similarly encourage the creation
of consortia among AT developers, or between large mainstream
companies and smaller AT partners, to achieve similar goals or to
facilitate broader application of existing AT solutions?

Application of the tax law to encourage utilization of AT in the
private sector is illustrated by the disabled access credit. If
the tax law can be used to enhance the availability of AT for
small businesses, it can also be used to stimulate the
development and marketing of AT devices or, as important, to
reward capital investment in products and technologies that,
without regard to denomination as "assistive" or "mainstream,"
meet established standards for accessibility and usability.

Many examples could be cited of how the law could be used to
encourage specialized AT product development, to stimulate
inclusive design practices among mainstream developers and
manufacturers and to reward the deployment of accessible
technology. Apart from the tax law, the following examples, each
designed to attract private capital to the development and
marketing of accessible technology, and each involving little or
no cost to the Treasury, should suffice to give a sense of these
opportunities.

First, technology currently exists by which published materials
could be made accessible to readers with visual or other reading
disabilities, in electronic formats such as on disk, CD-ROM or
through other emerging modalities. Given the imminent necessity
of revising our copyright laws to take account of the myriad
issues posed by electronic publishing, opportunities certainly
exist for designing experiments or incorporating provisions
designed to encourage commercial publication of
electronically-accessible versions of many books and periodicals.
Incentives could be provided such as lengthening the duration of
copyright protection, and enhanced protections against
infringement could also be offered. If successful, such an
experiment could dramatically reduce the need for expensive
scanning technology or human readers while simultaneously serving
to allay publishers' fears while giving them important economic
incentives at no cost to the taxpayer.

A second area where the goals of AT could be facilitated by legal
change is in providing incentives for the production and sale of
accessible household appliances and consumer electronics. Such
incentives as lengthened patent protection over the current 17
years, addition of accessibility to UL and FCC certification
where applicable, or exemption from state sales taxes for that
component of product cost attributable to accessible design could
all serve to make an inclusive design strategy more attractive.

Our third example deals with motor vehicles. What if automobile
manufacturers were encouraged to offer hand controls, lifts, and
other accessibility features, and what if these were offered as
no-cost options to anyone requesting them? While the design of
fully-accessible models of most or all of their vehicle lines
would arguably involve real cost to manufacturers, methods exist
for defraying such costs so they need not be passed on in the
form of price increases to all buyers. What if the cost of
providing these features were essentially paid by offering
participating manufacturers extra credit toward meeting fuel
economy requirements applicable to their fleets? To the degree
that addition of accessibility features to a certain number of
vehicles might increase vehicle weights and therefore decrease
average gas mileage, such an adjustment in fuel economy
expectations would be justifiable.

While many technologies lend themselves to universal design,
others do not. Even for those that do, it may not be feasible or
desirable to make each unit fully accessible.  The automobile is
a good example of this distinction in that while we would like to
have appropriate assistive devices ready for addition to the
basic vehicle when required, no one would suggest that every
vehicle marketed in the U.S.  should be equipped with hand
controls as standard factory equipment. Accordingly, there will
be many contexts in which the government's most effective role in
promoting AT financing will be to encourage the use of design
standards that readily allow for the addition of AT peripherals
or software when requested.  The automobile lends itself to such
an approach, because selection among various options is
commonplace in the buying experience.  So long as these factory
options were available at no add-on cost, such a solution would
represent a sensitive and effective balancing of interests.

With some technologies, incorporation of full access is likely to
remain costly or problematic.  In such instances, the government
should seek to encourage specialized, typically small producers,
to provide appropriate interactive assistive devices.  For this
to be possible, inducements for cooperation between mainstream
and AT developers will need to be strengthened.  What the
government could do in this regard is encourage "open design."
For open design to work, designers and vendors need to know that
their proprietary systems in areas ranging from "set-top boxes"
to switching systems will not be jeopardized by this approach.
Analysis of the several forms of such jeopardy that are feared
lies beyond the scope of this report. Suffice it to say, in all
the areas where government promotes or sponsors the development
of standards for device design or interface, and in all the
contexts in which government encourages and rewards the
development of proprietary technology, measures can be taken to
foster the use of standards and approaches that either include
access from the beginning or that leave the possibility open for
its incorporation later on.

The foregoing illustrations are meant to suggest the
impossibility of separating assistive technology from technology
as a whole or of attempting to deal with AT in its own narrow
programmatic framework. Nonetheless, opportunities for the
funding of AT within the framework of programs traditionally
associated with disability and health should not be overlooked.
Prospective block grant programs in the area of job training and
placement should be designed with funding formulae that create
incentives for the achievement of successful outcomes with
hard-to-place populations, and that put a premium on the
identification and utilization of appropriate technology to
facilitate placement of individuals with disabilities.

Likewise, contemplated medical insurance reform should be
undertaken with a view to encouraging incorporation of
rehabilitation and restoration of functional capacity into the
definition of covered services.

Among the variety of loan guarantee programs in which the federal
government is involved, consideration should be given to the ways
that assistive technology and accessibility could be promoted,
including recognition of AT as a discreet cost category in higher
education and including possible waiver of otherwise applicable
borrowing limits under federal home mortgage loan guarantee
programs in order to help defray the costs of making residential
premises fully accessible.

Consideration should also be given to the establishment of a
national assistive technology loan program which, if modeled on
successful state-based efforts such as Maine's, would bear a high
likelihood of returning a profit to the Treasury within five
years, and to the further encouragement of interstate compacts
designed to make scarce but critical AT services and support
resources available to larger numbers of people than can
currently benefit from or afford such assistance.

Finally, whether one's goal is the re-invention or the downsizing
of government, existing laws, such as Section 508 of the
Rehabilitation Act, should be energetically enforced.  Although
unique individual needs will always arise, and although the means
for making certain kinds of equipment fully accessible are not
yet in place, it is nevertheless fair to say that the goals and
methods of accessibility for much of our technology involve no
great mysteries. Subject therefore to the flexibility and common
sense with which we should approach any public policy commitment,
Section 508 has the potential to bring about rapid and
significant changes in design practices within a wide spectrum of
information-oriented industries if it is vigorously and
systematically applied.

In a number of basic technological fields, we are currently
making decisions that will determine the course of events and the
pattern of our lives for many years to come. For example,
legislation currently making its way through Congress (S.
652/H.R. 1555), revising the Federal Communications Act, will
heavily influence the character of our "national information
infrastructure" (the information superhighway) long into the next
century. If only because the costs of "retrofitting" will be too
great and the constituency for doing so too small, the decisions
made now regarding accessibility will surely prove irreversible.

Efforts to promote universal design need not be undertaken in a
vacuum.  Our experience offers several techniques of demonstrated
value, some drawn from the physical and some for the
communications environments.  These noncoercive measures,
designed not to punish inaccessible design so much as to create
incentives for designing the built and communications environment
with all people in mind, must be urgently identified and
marshaled, for use on behalf of the information superhighway and
in the context of other major technological changes that are
imminent.

By way of illustration, such measures include: tax credits such
as the ADA compliance credit to help meet the add-on costs of
accessible design research; enhanced copyright and patent
protection for devices determined to be accessible and for
documents produced in accessible, alternative formats; waiver of
antitrust restrictions on the pooling of research and resources
concerning accessibility; provision of assistance comparable to
that forthcoming under the Trade Adjustment Act of 1974 for
specialized AT-oriented firms harmed by competition from easily
designed products emanating from larger, mainstream companies;
establishment of high profile awards similar to the Malcolm
Baldridge Prize to acknowledge and reward firms that successfully
invest in the accessibility of mainstream products; creation of
technical assistance capabilities to assist business, industry
and government in designing programs, facilities and equipment in
an optimally accessible and usable fashion; creation of
appropriate registries of persons with disabilities or with
relevant expertise who can consult with various sectors of
industry in connection with the design parameters to be used;
provision of accelerated depreciation to product lines that meet
standards of accessibility; promulgation of workable definitions
of accessible design to guide developers and manufacturers; and
many, many more.

The role of technology in our lives is ever increasing and
rapidly changing. The question for society is not whether all
Americans should participate, since no one can be excluded or
exempt; the question is can we develop mechanisms to ensure that
the technological revolution benefits and empowers everyone. Many
great issues surround the implementation of new technology, and
many fear that technology itself is becoming a new source of
stratification and separation in our society. Whatever one's
views regarding these dangers, it is abundantly clear that at
relatively small cost in relation to total technology
expenditures, with little risk of unintended consequences and
with minimal intrusion into the processes of the marketplace,
participation of America's already 49 million and growing
citizens with disabilities, together with all the tangible and
intangible benefits such participation portends, can confidently
be expected and sought.

References

American Medical Association, Guidelines for the Use of Assistive
Technology:  Evaluation, Referral, Prescription (Chicago: 1994).
Barrier-free Environments Inc., The UFAS Retrofit Guide: 
Accessibility Modifications for Existing Buildings (Florence, KY:
Van Nostrand Reinhold, 1993).

Clark, G., and Kolstoe. Career Development and Transition
Education for Adolescents with Disabilities (Allyn and Bacon,
1990).

Dart, J., "Fallacy and Truth about the ADA," Washington Post ,
July 18, 1995.

Detsel v. Sullivan, 859 F.2d 59 (2d Cr. 1990) (U.S. Court of
Appeals ruled state must
change its Medicaid definition of a nursing service where that
definition inconsistent with contemporary medical thinking).


Federal Communications Commission, Emergency Request to Reinstate
Enforcement of the Hearing Aid Compatibility Rules, (Washington,
DC: CC Docket No. 87-124, May 25, 1993).

Freer v. U, f. Supp. - (WDNY 1994) (U.S. District court held that
landlord must allow tenant's installation of a ramp under the
Fair Housing Act Amendments of 1988).

Hammer, G., "Guide to the new Wave of Rehabilitation Technology."
Team Rehab Report. Sept. 1992.

Internal Revenue Service: Revenue Ruling 80-340

Mendelsohn, S., Tax Options and Strategies for People with
Disabilities (New York: Demos Publications, 1993).

Mueller, J., The Work Place Work Book: An Illustrated Guide to
Job Accommodation and Assistive Technology (Washington, DC:  Dole
Foundation, 1990)

Myers v. Miss., Supp. - (.D. Miss 1995); accord., Matter of Olson
v.  Minnesota, (Minn. Department of Human Services, March, 1994).

National Council on Disability, Study of the Financing of
Assistive Technology Devices and Services for Persons with
Disabilities (Washington, DC: 1994).


RESNA, Compendium of Tech Act Grantee Programs and Practices
(Arlington, VA: February, 1995).


Scotch, R., From Goodwill to Civil Rights: Transforming Federal
Disability Policy (Philadelphia: Temple U. Press, 1984).

Shapiro, J., No Pity: People with Disabilities Forging a New
Civil Rights Movement (Times Books, 1993).

Smith, M., Sheltered Workshops for Persons with Handicaps: 
Background Information and Recent Legislative Changes
(Washington, DC: Congressional Research Service, 1987).


tenBroek, J., and Matson,"The Disabled and the Law of Welfare" 54
Cal. L. Rev. 809 (1966).

Trachtman, L., 'Tech Act Reauthorization: Who Wins, Who
Loses?''(editorial), Assistive Technology J 6(1):1-2, 1994).

U.S. Congress, Office of Technology Assessment, Access to
Over-the-Road Buses for Persons with Disabilities (Washington,
DC:  U.S. Government Printing Office, 1993).

U.S. Department of Transportation, New Horizons for the Air
Traveler with a Disability (Washington, DC: USDOT, 1992).

U.S. General Accounting Office, Vocational Rehabilitation: 
Evidence for Federal Program's Effectiveness is Mixed
(GAO/PEMD-93-19, August, 1993).

U.S. General Services Administration, People with Disabilities
and NII: Breaking Down Barriers, Building Choice (Washington: GSA
Center on Information Technology Accommodation, discussion paper,
September, 1994).

U.S. Social Security Administration, The Red Book on Work
Incentives (Baltimore: SSA Pub. No. 64-030).

Unfunded Mandates Act. S3888: Congressional Record, March 14,
1995

Williams, T., Biographical Directory of Scientists (editor)
London, A @ C Black, 1982.

----------
Consumer-Responsiveness in
Assistive Technology Service Delivery

Jan C. Galvin


I.   Introduction

The importance of the participation of individuals with
disabilities or their representatives in the service delivery
process has been acknowledged for some time.  In fact, such
participation has been mandated by Congress in several
state-federal programs. The Rehabilitation, Comprehensive
Services and Developmental Disabilities Amendments of 1978 (P.L.
95-602) required the joint development of the IWRP by the staff
member and the individual client or representative in VR.  Under
this same law, in the case of developmental disabilities, the
habilitation plan is also required to be jointly developed.  The
Education of the Handicapped Act (P.L. 94-142) and its
implementing regulations provides for the disabled child's or
parent's participation in the entire assessment and planning
process, including IEP development.  While these policies
represented a major shift in philosophy, implementation was
elusive. The 1982 OTA report, Technology and Handicapped People,
concluded that techniques to design and implement participation
are not well developed nor has much effective effort been
directed to making them work.  In terms of technology, decisions
seem to be based on the needs of disabled clients as perceived by
professionals rather than a joint decision with the full
participation of the individual with a disability.

More recently, the issue has been taken up under new terminology
such as consumer involvement and consumer- responsiveness.  Yet,
the problem remains the same.  There is a lack of effective
involvement by individuals with disabilities or their
representatives in the provision of assistive technology devices
and services.  Several studies of AT users indicate such lack of
involvement often results in inappropriate technology being
received ( Corthell, 1986; Gitlin & Levine, 1992; Grady, Kovach,
Lange, & Shannon, 1991; Phillips & Zhao, 1993; Rogers & Holm,
1992).  Effective collaboration among professional service
providers and consumers continues to be a shortcoming of AT
service delivery in most settings (Scherer & Galvin, 1994).

     Direct Service Delivery Settings

Assistive technology services are delivered in a variety of
settings today from medical rehabilitation to university- based,
to state agency to private programs. The major types of settings
and their characteristics are summarized briefly below.  Against
this backdrop, general problems and concerns related to
consumer-responsiveness will be discussed.

Rehabilitation Programs:  Assistive technology services are part
of a comprehensive medical rehabilitation program.  Since the
primary purpose of AT services is to support other services,
there is usually multidisciplinary team involvement.  Typically,
these programs serve individuals with spinal cord injuries, head
injuries, cerebral vascular accidents, and amputations.  Services
are usually billed to third-party health insurance payers.

University-Based Programs:  Direct assistive technology services
in this setting have largely evolved from a research component
and may include education and training.  Staff usually consists
of personnel capable of performing clinical, research and
educational duties.  The professionals involved in the team will
depend on the functional areas addressed by the program. The
research components provide a national service and the consumer
service components are usually regionally oriented. Funding is
largely through grants and contracts, although portions of the
direct consumer services may be billed to third-party payers.

State Agency Programs:  State agency-based programs are usually
part of vocational rehabilitation departments or special
education departments.  Assistive technology services are
provided to further the main mission of these departments -
attaining and sustaining employment in vocational rehabilitation
and facilitating education in special education.  Administration
of these programs varies and may be on a statewide or local
level. Designated funding is usually mandated at a state or
federal level for these programs.

Private Practice:  A small number of assistive technology
providers have gone into private practice. They may provide
consultation to state agencies or rehabilitation centers.  The
population served and functional area addressed varies depending
upon the professional background of those involved in the
business.  These providers usually operate as small for-profit
businesses, based in one local area, and charge on a fee for
service basis.

Durable Medical Equipment (DME) Suppliers:  DME suppliers
typically provide a range of devices.  Walking aids, bathing and
toileting aids, wheelchairs and seating systems are standard
fare.  Some suppliers provide communication and environmental
control equipment.  Suppliers usually operate as a for-profit
agency and are reimbursed by third party payers. They are known
for their technical resources and ability to provide repair and
maintenance services. Some DME suppliers operate on a nation-wide
basis while others are primarily local.

Veterans Affairs (VA):  Assistive technology services are
provided at many VA hospitals to veterans with service- related
disabilities.  Veterans with spinal cord injury have been a major
group served by the VA.  The clinical services are largely
multidisciplinary.  The VA has also made significant
contributions in assistive technology research.

Local Affiliates of National Nonprofit Disability Organizations: 
National organizations such as United Cerebral Palsy Association
(UCPA), National Easter Seal Society (NESS), Muscular Dystrophy
Association (MDA), The Arc, and the American Foundation for the
Blind (AFB) provide assistive technology services through their
local affiliates.  They provide services geared toward the
disability group they serve.  The extent of services varies with
the local program from complete AT team services to an equipment
loan program.  Funding for the agencies is through grants,
contracts, donations, and fundraising events.

Volunteer Programs:  Volunteer organizations in the United States
that provide assistive technology services include such groups as
the Telephone Pioneers of America, the Volunteers for Medical
Engineering, and the Rehabilitation Volunteer Network.  Most of
these groups have developed out of private industry with the
purpose of providing philanthropic services. The services are
usually local or regional and the functional areas addressed
depend on the expertise of the volunteers involved ( Cook &
Hussey, 1994; Hobson & Shaw, 1987; Smith, 1987).

II.  Consumer-Responsiveness Concepts

Traditionally, "access" to services has been interpreted to mean
simply "getting served" in the human service arena, implying
little or no choice by the consumer. If there are multiple
programs or services available in the community they are
generally earmarked for certain people -- people who have a
certain label, certain functional needs, of certain ages or with
certain prior service histories (Gradel, 1990).  Unfortunately,
the human service world has typically not had to think about its
customers in much more than a paternalistic way (McKnight, 1988).

However, the Independent Living (IL) Movement has begun to effect
change in policy and practice.  The IL philosophy espouses
consumer control and self-determination, environmental
adaptation, community integration, access to ongoing support
mechanisms, and freedom of choice for individuals with
disabilities (Enders, 1991; Rubin & Roessler, 1987).  While the
concept of consumer- responsiveness applies to all types of
services for individuals with disabilities, the field of
assistive technology has made a concerted effort to improve in
this area.

     Definitions

The Technology-Related Assistance for Individuals with
Disabilities Act of 1988 (PL. 100-407) highlighted the importance
of "consumer-responsiveness." Never before had this term been
included in federal legislation.  In the original law, Congress
did not define the term but left it up to individual states to
re-think and re-engineer their traditional services.  However, in
the amendments of 1994, the following features of
consumer-responsive programs were put forth:

� Easily accessible to, and usable by, individuals with
disabilities and when appropriate, their family members,
guardians, advocates or authorized representatives

� Responds to the needs of individuals with disabilities in a
timely and appropriate manner

� Facilitates the full and meaningful participation of
individuals with disabilities and their family members,
guardians, advocates or authorized representatives in:

-    decisions relating to the provision of devices and services

-    the planning, development, implementation, and evaluation of
the comprehensive statewide programs of technology-related
services.

Each state Tech Act program is working with the myriad agencies
and organizations that serve individuals with disabilities to
encourage the development of a consumer- responsive approach to
assistive technology services.  This is largely a systems change
effort as the state Tech Act programs are limited to ten years. 
They hope to leave an existing system in place that is founded on
principles of consumer-responsiveness.

Principles of Consumer-Responsive Services

Two basic beliefs about the rights of individuals with
disabilities with regard to assistive technology underlie a
commitment to consumer-responsive services:

� People with disabilities have a right to live in an accessible
society and to have access to adapted materials and technology
that enables them to lead productive and satisfying lives.

� Assistive technology must be used to enhance the independence,
integration, and productivity of people with disabilities in
school, at work, and in the community.

To achieve the goals inherent in these beliefs, consumer-
responsive systems are most effective.  Consumer-responsive
programs must adhere to the following principles:

� People with disabilities will benefit most from AT services
that they, their families, or advocates have played an informal
and vital role in assessing and selecting.

� Individuals with disabilities, their families and advocates
must have the greatest involvement in and ultimate control over
the design, delivery, and evaluation of assistive technology
services.

� Assistive technology services, policies and practices must be
flexible and foster organizational change in order to best
respond to the needs of people of all ages with disabilities and
their families.

� The continued satisfaction of the individual using AT, his or
her family or advocate, is of primary importance in achieving
success
     (SMART Exchange, 1989).

Implementing Consumer-Responsive Services

Actually implementing consumer-responsive services is complex. 
There are a number of barriers that must be overcome to make the
change to a consumer-oriented approach:  formal organizational
structures, "turf" issues, adherence to old ways of looking at
work, system inertia and lack of resources (Luthans, Hodgetts &
Lee, 1994). To combat these obstacles, a strong commitment to
consumer-responsiveness is required.

First, to implement such services you must first know your
customer. That is, you must know what they value - what is
important to them, what they want or need, and what they think
about the services. The focus is on the customer or customers.
This needs assessment process must be open to all issues and
consumers must be asked directly for their input.  Second, you
must identify key practices that 1) ensure consumer-friendly
access to services and an equalitarian climate, 2) match consumer
expectations, and 3) result in the delivery of outcome valued by
consumers. Third, you must make the choices, prepare staff, try
out the approaches and measure the success. This last process is
ongoing to promote continuous improvement (Gradel, 1990; Luthans,
Hodgetts & Lee, 1994).

Specific steps that can be taken to ensure AT services are truly
responsive to the needs and preferences of individuals with
disabilities and their families have been identified.  These
steps include:

� Involving people with disabilities, their families and
advocates in all phases of the planning and development of
assistive technology services.

� Appointing such individuals, their families and advocates to
governing and policy making boards and committees.

� Valuing and soliciting the active participation of persons with
disabilities, their family members and advocates in all stages of
the AT service delivery process.

� Employing qualified individuals with disabilities in staff,
consultant, and volunteer positions.

� Providing training to individuals, their families and advocates
to enable them to develop knowledge and skills in key areas such
as
how to identify personal technology needs; how to review existing
equipment; when to use AT devices and services; and how to obtain
payment for appropriate AT devices and services.

� Informing people with disabilities, their families and
advocates that
appropriate AT services and devices are available; suitable
solutions to their needs can be found; and they have a right to
assistive technology (SMART Exchange, 1989).

There is no single way to go about designing a reliable,
responsible and responsive assistive technology service delivery
system to benefit people of all ages with disabilities and their
families. However, a consumer- responsive model has as its goal
consumer satisfaction.

The benefits of a consumer-responsive approach are many. By
including individuals with disabilities at an organizational
level, in the development of policies and procedures, programs
will more likely meet their real needs and wants.  By including
individuals with disabilities in the direct service situation,
real needs are identified and choices are offered.  Usually there
is greater cooperation and commitment to making the solution work
because all parties agree it will work.  Greater satisfaction
with outcomes results because consumers have more information and
participation (Phillips, Bennett & Galvin, 1993).

III. Access to Assistive Technology Information

Consumer access to assistive technology information has been a
problematic issue for over 20 years.  The problems occur on
several levels, from making consumers aware of the existence of
assistive technology services, to informing them about the
availability of devices, to teaching them how to select assistive
technology. In the 1994 Amendments to the Tech Act, Congress
found that there was still a lack of information among
individuals with disabilities and other related persons about the
availability and potential of assistive technology.

     Information and Referral Programs

For individuals with disabilities to effectively participate in
the AT service delivery process, they need understandable
information.  Providing access to such information is a key
feature of consumer-responsive systems.  A variety of information
and referral programs are a major source of AT information.  As
information technology continues to evolve to offer a variety of
choices, and is designed to empower people with increasing
amounts of access to information, it is also a source of numerous
problems.  These problems vary from physical access to making
meaningful use of the information received. A disproportionate
amount of resources are commissioned to address the physical
access to data, largely due to Section 508 of the Rehabilitation
Act coupled with the ADA.  While this is commendable, there is no
clear policy regarding the need for continued funding to ensure
that timely access to updated, quality information is available.

The challenge of providing accurate, timely and quality assistive
technology I & R is still ahead of us as a society.  Advances in
information technology such as worldwide networks,
teleconferencing, use of multimedia and computers will make
managing complex information increasingly easier. This is the
time to apply innovative technologies to merge the needs of
service delivery systems and information requirements of people
with disabilities.

While services do exist, there are many difficulties in operating
assistive technology I & R programs.  First, I & R programs are
labor intensive, requiring significant staff resources to
compile, catalogue, and maintain information; ensure the
integrity of the database; and provide the personal attention
necessary to meet the needs of requesters.

Second, no consistent funding mechanisms exist to support these
activities.  While providing accurate information is a critical
component in the process of acquiring AT, it is not so highly
valued because it is difficult to determine the impact of I & R
on outcomes.  Therefore, entities providing I & R services often
must absorb the cost of the service themselves.

Third, the demand for information is so great that individuals
providing I & R services are often overwhelmed by the volume or
complexities of the requests. This makes it difficult to document
the true cost of providing the service, the value of the service,
and the consistency of the service.

The Center for Developmental Disabilities at the University of
South Carolina recently completed a study entitled The
Feasibility and Desirability of Establishing a National
Information and Program Referral Network for Assistive Technology
(19??).  The study documented technical factors in five key areas
affecting the AT information and program referral process.

Lack of Uniform Services Definition:  The study found that
services offered, population served and geographic area served
differed from program to program.  In addition, access to the
services differed and were not necessarily reflective of the
accessibility needs of the target population.  Overall, there was
a lack of coordination of services across community, state,
regional, and national levels.

Varying Organizational Structures:  The study showed that the
responsibilities of I & R staff varied from program to program
and that there were no guidelines for staff patterns and
requirements.  In addition, it was determined that there were no
standards regarding the confidentiality of consumer information
obtained during the provision of information services.  The study
also concluded there was no correlation between budget allocation
and services or quality of services.

Lack of Standards for Staff:  The study reported that training
for I & R staff is flawed by a lack of standards.  Staff are not
trained to deliver assistive technology I & R services, but to
respond to the limited information requests of a particular
database or written publication.  The whole- person concept is
often not employed, with emphasis placed on responding only to a
specific request for a device.  There is a heavy reliance on
written materials and time- dated databases where the information
may or may not be accurate.

Inconsistent Information Management Methods:  A lack of
consistent information management methods to maintain, verify and
update information is identified in the study.  Some of the
impediments to the quality of information include lack of funding
and training on evaluation methodology, lack of training to guide
information management, lack of a standard taxonomy and
definition of terms, and lack of standards for data collection,
verification, and updating. The lack of formal evaluation of
services can result in the continuation of services that do not
meet the needs of the target audience. The study also noted that
lack of compatible hardware and software can impede the ability
to transfer and share data from program to program.

Ineffective Outreach:  The study reported that outreach efforts
tend to rely on traditional publicity methods, thus limiting the
target population reached.  The study also noted there is a lack
of information on problem-solving strategies that allow consumers
to maneuver through a complex system of care and on quality
indicator measures for assistive devices that allow consumers to
judge a device.

     AT Training for Consumers

For consumers to effectively participate in the service delivery
process, they may frequently need training.  The content of
technology-related training aimed at consumers is frequently
designed to increase their awareness of the availability and
effectiveness of assistive technology (Alexander, 1993).  Other
more sophisticated training efforts help consumers develop skills
to access assistive technology information systems themselves
(RESNA, 1993).

Beyond awareness, consumer training to utilize and maintain
technology has not been systematically considered.  Whereas, some
technology requires little training for its use, computer
technology and augmentative communication devices often take a
significant amount of both motor and cognitive training.

Consumer training needs to start prior to selection with hands-on
experience with technology before it is purchased.  A consumer
selection checklist needs to be developed to help them through
the various decisions that need to be made (Galvin, 1994).  If
possible, consumers need the opportunity to check out assistive
technology devices and use them for a period of time to determine
how they fit within the environment and if they accomplish the
objective they wish to achieve.  A proper tryout period would
improve assessment and reduce the amount of technology
abandonment significantly.

IV.  Unserved and Underserved Populations

A system that does not serve, or serve well, certain groups of
people may not be considered consumer-responsive.  In the 1990's,
there has been an emphasis on outreach to unserved and
underserved populations for rehabilitation services generally and
assistive technology services specifically.

The need for such outreach has become readily apparent.  Research
has shown that ethnic and cultural minority groups in the U.S.
are disproportionately affected by disabilities.  Poverty, lack
of adequate prenatal and health care, manual labor employment and
high neighborhood crime rates all contribute to disability among
these groups (McCrimon, 1994). Minority individuals with
disabilities earn less and are more likely to be unemployed and
undereducated than their majority counterparts (NCD, 1993).

In addition, there is growing concern over the increase in
disability related to social factors.  The rise in domestic and
gang violence, drug use and addiction, the increasing numbers of
adolescents who are becoming infected with HIV, and the increase
in numbers of young people who are homeless contribute to this
increase.  The increased survival, due to technology, of babies
born to mothers with AIDS or drug addictions and adults with AIDS
has generated new disability- related issues. The incidence of
AIDS cases in poor urban areas, particularly among women and
minorities, is rising (Conwal, 1994).

The needs are great among these various minority groups, but they
have traditionally not had the same level of access to services. 
While there is little hard data available to document needs offer
policy guidance, the problem is well- recognized. Recently,
policies and procedures have been developed to improve outreach
and thus consumer- responsiveness.  Both the Rehabilitation Act
of 1973 as amended (1992) and the Technology-Related Assistance
for Individuals with Disabilities Act of 1988, as amended (1994)
have prioritized the development of appropriate outreach to
identify and serve traditionally unserved and underserved
populations.

Several definitions and criteria for identification of these
populations have been put forth. The Tech Act Amendments of 1994
(PL. 103-218) defines an Underrepresented Population as "a
population such as minorities, the poor, and persons with limited
English proficiency." The Rehabilitation Services Administration
(RSA), which administers the State-Federal vocational
rehabilitation program, defines "unserved and underserved"
populations as groups of individuals who are not served or are
inadequately served as the result of a variety of policy,
practice, and environmental barriers.  These barriers include:

� Lack of referral to or identification by the VR system
� Lack of resources to address needs of particular populations
     � Lack of transportation
     � Waiting lists for services
     � Implementation of an order of selection
     � Racial/ethnic issues
     � Communication barriers
     � Attitudes of service delivery personnel and the
     general public
     � Geographic dispersement, i.e., in rural/urban
     poverty areas
     � A depressed economy/job market

In October of 1992, the Nineteenth Institute on Rehabilitation
Issues at Stout Vocational Rehabilitation Institute met to
formulate a model which could be applied to any
unserved/underserved group of individuals with disabilities.
Institute members believed that additional criteria of inclusion
are relevant in making the case that a certain group is
unserved/underserved. In addition to the factors identified
above, other conditions germane to the task of identifying
unserved and underserved groups were described.

First, individuals may be unserved or underserved by virtue of
the type of disability they have.  For example, people with
hidden disabilities (e.g., hard of hearing) are often viewed as
less severely disabled than people with visible disabilities
(e.g. amputation) because they appear to have no significant
functional limitations.  Some conditions are secondary to another
serious disability leaving the individual with twice the
disability-related problems to overcome (e.g., diabetic
retinopathy or substance abuse leading to traumatic brain injury
or epilepsy). However, if a condition is identified as a
"secondary disability," it suggests to some service providers
that the condition does not merit their full attention.  All
individuals with disabilities face stigma, but some conditions
evoke even stronger stereotypes, which often limits access to
services further.  Conditions such as AIDS, epilepsy and mental
disabilities are among these.

Second, other reasons for underservedness emanate from the
individuals with disabilities themselves. Some individuals with a
particular type of disability may hold the same misconceptions
and prejudices that are held by the general public and thus will
not seek assistance. To avoid negative social feedback, members
of some disability groups are unwilling to self-identify. Thus,
incidence and prevalence figures are artificially low, and a
collective group identity for advocacy purposes fails to develop.
Others may adopt self-limiting attitudes and not seek services
because of negative developmental experiences and lack of a
feeling of personal empowerment.

Lastly, other contributing factors to underservedness grow out of
gaps in disability and rehabilitation research.  For some
disabilities, epidemiological research is insufficient to provide
an accurate estimation of the prevalence and incidence of the
condition.  Therefore, it is impossible to estimate the extent of
the group and the extent of its being unserved or underserved. 
Without data to support claims of underservedness, it is
difficult to advocate for new policies and practices to meet the
perceived needs of these groups.  Lack of research on "best
practices" demonstration projects that experiment with innovative
service techniques is another research gap.  Without shared
knowledge about effective services to different disability
groups, some groups will continue to be unserved and/or
underserved by the current service delivery system.

V.   Conclusions and Policy Options

The policy is in place to support the development of
consumer-responsive assistive technology service delivery
systems.  However, in practice, there are many shortcomings in
the day-to-day operations of current service delivery.  Major
efforts to further the development of consumer- responsive
systems are needed to make real improvements in the effectiveness
of AT service delivery with particular emphasis on the
implementation of consumer-responsiveness concepts; access to
information about assistive technology through I & R programs and
training; and outreach to unserved and underserved populations. 
Specific recommendations are outlined for each area below.

     Policy Options

Implementation of Consumer-Responsiveness Concepts

Mandate the Interagency Committee on Disability Research (ICDR)
to develop and coordinate a program of research to develop
strategies effective collaboration between AT service providers
and individuals with disabilities in the gamut of service
delivery settings such as medical rehabilitation, vocational
rehabilitation and education.  The development of a comprehensive
program evaluation approach to help programs assess themselves in
this area should be part of the research program.  The
identification and dissemination of best-practices in
consumer-responsive AT services should also be included.

Establish a national training initiative for service providers on
consumer-responsive service provision.  This initiative should
feature interagency coordination and collaboration with private
sector providers.

     Access to Information

Conduct a national awareness campaign on assistive technology
with parallel emphasis on I & R activities at the regional, state
and local levels.  The target population of this campaign will be
consumers of technology-related services, with emphasis on
reaching both formal and informal resources utilized by persons
with disabilities.

Under NIDRR and the Interagency Coordinating Council, develop a
National Assistive Technology Information and Program Referral
Coordinating Bureau that would:

     � facilitate an orchestrated approach for the
delivery of AT I & R     services
     � provide technical support to AT I & R services
     � develop guidelines for the coordination of AT I & R
services
� develop generic training and support materials � initiate a
process to address I & R quality
standards
     � provide training to enhance the capacity of I & R staff

Establish a National Assistive Technology Information and Program
Referral Task Force to develop strategies for improved
interagency coordination of technology-related services. This
Task Force should include representatives from consumer groups,
professional association, public sector agencies, private
non-profit agencies, private for- profit companies, and I & R
practitioners.  This initiative should examine ways to capitalize
on the use of computers and other similar technologies in other
disciplines and agencies such as NASA, OTA, GSA, NSA Center for
Computer Assistive Technology, related NIDRR projects, etc.

Direct NIDRR to establish annual priorities for field initiated
research on "best practices" in the delivery of AT I & R services
including innovative outreach approaches.

Mandate support for research to develop, demonstrate and validate
successful strategies, models and programs for training consumers
how to use and maintain assistive technology. The emphasis should
be on more complex technology requiring complicated motor skills
and cognitive memory.  Training modalities such as
self-instructional programs, instructional manuals, and video
manuals should be included.

Require vendors and manufacturers to provide consumer support
services.

Outreach to Unserved and Underserved Populations

Ensure that all funded disability research conducted is
culturally sensitive, inclusive of all types and severity levels
of disability, and involves people with disabilities who live in
the community.

Mandate the development of research priorities to:

     � build a knowledge base on the relationship of
various   socioeconomic risk factors and
disability

     � develop strategies to improve service delivery
systems to     address the needs of ethnic/cultural
minority groups

     � devise strategies to improve data sources related
to diversity and    emerging disability issues.

Coordinate federal, state and local agency policy and programs to
meet the needs of minority persons with disabilities.

Support the development of training programs for AT service
providers in all service delivery settings to work with
multicultural populations.


References

Alexander, G.B., "The Development and Implementation of a
Training Module to Increase the Awareness of Assistive
Technology," unpublished Master's thesis, Nova University,
Florida, 1993.

Center for Developmental Disabilities, The Feasibility and
Desirability of Establishing a National Information and Program
Referral Network for Assistive Technology (University of South
Carolina, 1993).

Conwal Incorporated, McLean, VA, "The New Universe of Disability:
Report of Focus Group Proceedings," unpublished contractor report
prepared forthe National Institute on Disability and
Rehabilitation Research, U.S. Department of Education, July 1994.

Cook, A.M., and Hussey, S.M., Assistive Technologies:  Principles
and Practices (St. Louis: Mosby, 1995).

Corthell, D.W., Thirteenth Institute on Rehabilitation Issues:
Rehabilitation Technologies (Menomonie, Wisconsin:  University of
Wisconsin-Stout, Research and Training Center, 1986).

Enders, A., "Rehabilitation and Technology: Self-Help Approaches
to Technology: An Independent Living (IL) Model for
Rehabilitation," International Journal on Technology and Aging
4:141-152, 1991.

Galvin, J.C., "To Evaluate and Select Appropriate Assistive
Technology Devices," unpublished paper presented at the
Technology and Persons with Disabilities Conference, conference
sponsored by California State University, Northridge, Los
Angeles, CA, March 17, 1994.

Gitlin, L., and Levine, R., "Prescribing Adaptive Devices to the
Elderly: Principles for Treatment in the Home," International
Journal on Technology and Aging, 5:107-120, 1992.

Gradel, K., "Open the Customer Service Window NOW!," Smart
Exchanges (S.M.A.R.T. Exchange, newsletter), 3(1), 1991.

Grady, A., Kovach, T., Lange, M., and Shannon, L., "Promoting
Choice in Selection of Assistive Technology Devices," Proceedings
of the Sixth Annual Conference on Technology and Persons with
Disabilities (Los Angeles:  California State University,
Northridge, 1991).

Hobson, D.A. and Shaw, C.G., "Program Development and
Implementation," Rehabilitation Technology Service Delivery:  A
Practical Guide (Washington, DC: RESNA Press, 1987).

Luthans, F., Hodgetts, R. and Lee, S., "New Paradigm
Organizations: From Total Quality to Learning to World- Class,"
Organizational Dynamics Winter 1994.

McCrimon, A., "Rehabilitation Services and Employment Outcomes
for Culturally Diverse Consumers," Disability, Diversity and
Change in Rehabilitation Proceedings of the 1994 National
Symposium (Washington, DC: Rehabilitation Cultural Diversity
Initiative, 1994).

McKnight, J.L., "Do No Harm: A Policymakers Guide to Evaluating
Human Services and Their Alternatives," unpublished manuscript,
Northwestern University, Evanstan, IL, 1988.

National Council on Disability, Meeting the Unique Needs of
Minorities with Disabilities: A Report to the President and
Congress (Washington, DC, April 1993).

Nineteenth Institute on Rehabilitation Issues, Serving the
Underserved: Principles, Practices and Techniques (Menominie, WI:
Research and Training Center, University of Wisconsin-Stout,
October 1992).

Phillips, B., Bennett, J. and Galvin, J., Assistive Technology:
Practical Intervention Strategies (Washington, DC: Consumer
Satisfaction with Assistive Technology Project, Assistive
Technology/Rehabilitation Engineering Program, National
Rehabilitation Hospital, 1993).

Phillips, B. and Zhao, H., "Predictors of Assistive Technology
Abandonment," Assistive Technology 5:36-45, 1993.

RESNA, Project Reaching Out: Technology Training for Minorities
with Low Incidence Disabilities (Washington, DC:  1993).

Rogers, J., and Holm, M., "Assistive Technology Device Use in
Patients with Rheumatic Disease: A Literature Review,"American
Journal of Occupational Therapy 46:120- 127, 1992.

Rubin, S.E. and Roessler, R.T., Foundations of the Vocational
Rehabilitation Process (Austin, TX: Pro-Ed, Inc., 1987).

Scherer M.J. and Galvin, J.C., "Matching People with Technology,"
Rehab Management Feb/Mar, 128-130, 1994.

The SMART Exchange, Quality Indicators Applicable to Assistive
Technology Service Delivery Programs (P.O. Box 724704, Atlanta,
GA, 30339, 1989).

Smith, R.O., Models of Service Delivery in Rehabilitation
Technology in Rehabilitation Technology Service Delivery: A
Practical Guide (Washington, DC: RESNA, 1987).

U.S. Congress, Office of Technology Assessment, Technology and
Handicapped People (Washington, DC: U.S. Government Printing
Office, May 1982).

----------
Assistive Technology Service Delivery


In the 1982 OTA report a number of issues were identified in
relation to direct service delivery of assistive technology.  A
structural framework for the selection and application of
assistive devices was outlined.  The variety of public and
nonpublic programs that serve people with disabilities and
provide some access to assistive technology devices and services
were described.  Five general issues affecting the use of
assistive technology were presented:

     1.   The lack of coordination and consistency of services
and funding

     2.   The gaps in enrollment for programs due to lack of
public awareness

     3.   The difficulty in maintaining devices

     4.   Consumer involvement in service delivery

     5.   The shortage of rehabilitation providers

Effective implementation of new policies, such as the Tech Act,
designed to address such concerns has been slow in coming about. 
While progress has been made since 1982, all of these issues are
still identified as problems today. The next four chapters focus
on the following cross-cutting critical issues in the assistive
technology service delivery arena today:

     1.   Consumer Responsiveness

     2.   Training for Service Providers

     3.   Outcomes Measurement

     4.   Aging and Assistive Technology Use

----------
Education and Training of Individuals Involved in
Delivery of Assistive Technology Devices

Marvin G. Fifield, Ed.D.
Bryce Fifield, Ph.D


I.   Introduction

The growth in the assistive technology (AT) field during the past
decade has been spectacular.  Stimulated by the
Technology-Related Assistance for Individuals with Disabilities
Act (Tech Act), information about the benefits and availability
of technology has expanded significantly each year. However,
awareness of sophisticated devices, even additional sources of
funding, does not create true access to assistive technology. 
Rather, it has increased the demand for greater professional
expertise in assistive technology evaluation, selection, and
ongoing training support.  "Creating true access...means building
in training, building in ongoing support, and building in
opportunities for self instruction and troubleshooting, both for
the individual relying on the device and his/her partners or
assistants" (Williams, 1995).

No service or support can be better than the skills and
preparation of those trained to provide such services and support
(Fifield, 1988).  Thus, it is necessary that competent
professionals be involved in the delivery of AT devices and
services and that such professionals come from a variety of
clinical and technology disciplines.

Training for awareness is quite different than training to teach
competencies and skills to facilitate the evaluation and
selection of technology and to provide ongoing support. 
Awareness is the process by which information is provided.  Skill
training takes awareness beyond information and familiarity
toward the acquisition of skills and competence necessary to
achieve desired outcomes.

Although Title II of the Tech Act authorized training, a very
small amount of funding was allocated for skills training
projects.  In 1988, the Tech Act focused on information,
dissemination, awareness, and consumer participation.  The 1994
Amendments focused on advocacy (particularly legal advocacy) and
systems-change as priorities.  These activities have expanded the
need for professionals with skills and competencies to evaluate,
select, deliver, and provide ongoing support for assistive
technology.


     Assistive Technology Literature

The topic of training as applied to assistive technology only
appears in the professional literature on a sporadic basis over
most of the past decade.  Even though three specific
recommendations on the need to expand AT training were presented
in the book, Technology and Handicapped People (OTA, 1982), very
few of the early publications dealt with training issues.  More
recently, the professional literature that describes the role
training plays in the evaluation, selection and delivery of
assistive technology to people who have disabilities is growing. 
For example, a review of the articles and publications cited in
the ERIC database (which includes citations listed in Resources
in Education and the Current Journals in Education) shows that in
1993, articles that addressed training issues accounted for over
one third of the publications on assistive technology (see Figure
1).

[ Insert Figure 1 about here]

By far the most frequently addressed topic in the professional
literature on training and assistive technology is that of
training service providers.  Some authors have discussed the need
for preservice AT training in specific disciplines such as
occupational therapy (Anson & Kanny, 1989; Somerville, Wilson &
Shanfield, 1989; Somerville, Wilson, Shanfield & Mack, 1990),
rehabilitation counseling (Smith, Christiansen & Vanderheiden,
1989), special education (Wirth, Stile, & Cole, 1983; Reeb &
Scadden, 1989; Cramer, 1992), and health care (Blackman, 1985). 
Training programs are described that address preservice training
of professionals (RehabTech Associates, 1992; Noll, 1991;
Parette, 1991) as well as inservice or continuing education
programs of professionals already in the workforce (Hartmann &
Navickis, 1992; Phillips, Bennett & Galvin, 1993).  Programs have
also been developed to provide training to secondary consumers of
assistive technology such as parents (Frank & Thuma-Rew, 1984).

Although many of the existing training programs have been
designed to meet the needs of specific disciplines, some authors
have proposed assistive technology content that should be
addressed in all curricula.  Some of these suggestions are in
direct response to consumer-specified needs and desires rather
than the needs as specified by accrediting systems (Hammel &
Smith, 1993).  Of particular note are those suggested by members
of the American Association of University Affiliated programs ad
hoc Task Force on Assistive Technology Training (Bergman, Hardy,
Calkins, Offner, Myers, Newman & Fifield, 1991).  Their
recommendations were not only based on a consumer-responsive
model, but were designed to address cross-discipline issues
(Moore, Fifield, Spira & Scarlato, 1989).  The
institutionalization of formal procedures for incorporating
consumer input into assessing needs and selecting assistive
technologies is also being incorporated into some training
efforts (Hotchkiss, Pfaelzer & Nemon, 1989; Frank & Thuma- Rew,
1984).

The most common training that occurs at the preservice level is
an assistive technology unit that provides information and
materials.  Such units are generally taught as components of
other courses.  The least common are those that focus on
assistive technology as a practice or specialization.  Recently,
some professional journals have advertised assistantships in
rehabilitation engineering and in clinical AT practices.  These
assistantships are usually in rehabilitation engineering and
research centers or in an assistive technology service center
connected with a university.  However, the number of people such
programs can train is limited.  Few universities offer degrees in
rehabilitation engineering, and most often, these are
subspecialties of other programs in the engineering or
rehabilitation disciplines and, at best, offer certificates of
accomplishment (Cook & Hussey, 1995).

Most inservice training, likewise, focuses on awareness and
familiarity.  It is generally provided in short workshops or
units of instruction inserted into other inservice programs. 
There are limited opportunities in which clinical professionals
have a training experience at a service center where hands-on
opportunities to work with consumers and other disciplines under
supervision is provided (Perlman & Hansen, 1989).

Expanding training activities was identified as a critical need
by the Coalition on Technology and Disabilities:  "The most
critical need at this time is for inservice training of consumers
and of individuals who are already in the field providing
services to people with disabilities.  The shortage of trained
personnel was identified as a key problem..." (Beattie, 1990).

II.  Essential Characteristics of AT Training

There are a number of factors that are important in considering
the structure of assistive technology training.  Although some of
these overlap with other training content areas, others are
unique to the field of assistive technology.

1.   The application of assistive technology crosses many
disciplines in the human service field (e.g., occupational
therapy, physical therapy, speech and language pathology, special
education, audiology, recreation, and rehabilitation).  By its
very nature, AT training must be interdisciplinary (Wright,
1989).

2.   Assistive technology requires bridging the clinical and
human service disciplines with the technology disciplines (e.g.,
engineering, computer science, industrial science and medical
specialties).  Bridging social sciences and hard sciences is not
only essential, but it presents some unique challenges.  The
difference in language and terminology between these fields must
be overcome (Behrmann, 1989).

3.   Technology has not been included in traditional training. 
Most discipline training curriculums were established decades
ago.  Breaking into established and approved curriculum sequences
and replacing topics traditionally felt important presents
problems.

4.   Assistive technology services, for the most part, are
components of other human service delivery systems such as
education, rehabilitation, health and social services.  These
systems are each organized and administered differently.  They
determine eligibility consistent with their mission, and they
focus around predominant disciplines (Mueller, 1989; Mendelsohn,
1989).

5.   The interest and acceptance of a technology solution is not
always consistent or predictable.  Technology affects people in
different ways.  To some, technology is fascinating; it is
attractive and heady stuff.  To others, it generates fear,
avoidance, and resistance.  These reactions are influenced by
age, training, experience and other factors.  Such reactions are
as common among professionals as consumers.  Fear and avoidance
of technology increases when training moves from information and
awareness to skills and competence.  Most people are fascinated
by the future, particularly gadgets and technology and how it
affects their lives.  However, when required to go beyond glib
awareness and demonstrate competence and skills, limitations and
lack of basic understanding are exposed and resistance increases
(Thorkildsen, 1993).

6.   The role of the consumer, the family, and environment are
major issues in delivering assistive technology.  Technology
requires an investment in time and energy on the part of the
consumer and a fit within the environment that is quite different
than most other services (Mueller, 1989).

7.   Technology is changing very rapidly.  Seldom does an
assistive device become available before a newer model is
developed.  The temporal nature of technology is sometimes used
as an excuse for not investing the time to understand and use it. 
The belief that at some time the ultimate device will be
developed and one can avoid wasting time learning to use what may
be obsolete is not realistic.  Most of what is learned, even
using obsolete technology, is readily transferred to new devices
and systems.  Furthermore, technology competencies are
accumulative with skills and knowledge building upon each other. 
The real concern should be for outdated skills and information
rather than outdated technology.

To teach skills and competencies to professionals requires
attention to the above-listed factors.  Many of the skill
training models that are very effective in teaching human service
skills (i.e., counseling, resource management, or rights) fall
short in teaching skills concerning assistive technology. 
Assistive technology competence clearly requires a hands-on,
problem-solution, and trial-and- evaluation approach.

Conceptual Design of Assistive Technology Training

Figure 2 presents a conceptual design of the relationship between
training at the information and awareness level and training at
the knowledge, skills, and competency levels.  The pyramid
structure reflects the decreasing number of people needing
training at each level, and the boxes identify the disciplines
needing training and the content of such training.  This
schematic presents a broad look at training issues and their
relationship.  It also helps to identify the role of the federal
government, state service agencies, higher education, and
professional organizations that have responsibilities and issues
concerning standards.

     Level 1 - Technology Awareness

Level 1 includes the general public, family members, business
people, legislators, and people from all walks of life. 
Information at this level includes what technology is available,
how it benefits people with disabilities, and how technology can
facilitate inclusion of people with disabilities in employment,
school, recreation and all dimensions in society.

     Level 2 - Technology Familiarity

Level 2 focuses on the professionals who work in the generic
service systems such as education, health, human services,
recreation, transportation, and communication.  The professionals
in Level 2 need more than technology awareness.  They need
familiarity with assistive technology to the point that they can
recognize what technology should be considered and what is
available.  The generic service professionals are often the
primary referral source and act as the gatekeepers to either
encourage or discourage consumers from seeking more technical
information.

     Level 3 - Technology Literacy

Level 3 addresses the AT training needed by the professionals in
disciplines that provide specialized services to persons with
disabilities (e.g., special education teachers, rehabilitation
personnel, occupational therapists, speech and language
therapists, physical therapists, recreation therapists, music
therapists, and medical specialists).  The assistive technology
training needed by these professionals includes the skill and
competency to use and apply the technology of their disciplines
to the needs of people with disabilities.  They need to know
about the strengths and weaknesses of various technology devices
used in their disciplines.  They need the skills to demonstrate
the technology, to program it, and to teach consumers to use it
(Behrmann, 1989).  The disability professionals must also be
familiar with the broad range of assistive technologies and
understand the relationships of technology to human factors such
as seating, posture, communication, and hygiene.

     Level 4 - Technical Specialization

Level 4 training focuses on assistive technology practitioners. 
These are the professionals that select assistive technology as
an emphasis or sub-specialty.  Such training and experience
generally comes after the completion of professional training in
a disability discipline with a certificate or a license. 
Assistive technology practitioners' training must include
extensive periods of time working in an AT service setting with
other disciplines.  This experience should include selecting,
evaluating, modifying, prescribing, teaching, and maintaining
technology (Mueller, 1989; Cook & Hussey, 1995).

The AT practitioner needs interdisciplinary and trans-
disciplinary training, for they need to cross the professional
boundaries and share roles and functions (Pronsanti, 1991).  For
example, speech and language pathologists need good understanding
of seating and posture variables.  Occupational therapists and
physical therapists need understanding of computer applications,
language, and sensory enhancement technologies.  The assistive
technology practitioner needs extensive experience in assessing
consumer needs; evaluating the fit between technology, the
environment, and the consumer; training consumers in the use of
technology; and troubleshooting.  They need to be able to
consider ethical and efficacy factors including safety and
liability.

     Level 5 - AT Practitioners

Level 5 describes the role of the advanced assistive technology
specialist and the type of training needed.  The professionals at
this level specialize in assistive technology research and
training other AT practitioners.  Level 5 also includes the
specialists in industry who design, develop, test, and repair
technology such as rehabilitation and bio-engineers, computer
specialists, industrial technologists and assistive technology
technicians.  One of the major shortages of personnel at Level 5
is at universities.  Most departments of special education,
communication disorders, occupational therapy and physical
therapy do not have faculty members prepared to teach assistive
technology to students.  Likewise, qualified people to teach
inservice training to professionals already in the discipline are
extremely hard to find.  It is for this reason that so much of
the current training, both preservice and inservice, focuses on
an overview or survey of the field at an awareness level.

[Insert Figure 2 about here]

III. Current Training Activities for Providers

Consumers report that professionals frequently do not know what
technology is available or where to find up-to-date information
on devices and services.  Often consumers feel they are better
informed about technology than providers (Edelman et al., 1991;
Juhn, 1991; Fifield & Seiler, 1991; Todis & Walker, 1993). 
Finding competent AT professionals is frequently identified as a
major barrier to services (Lawler, 1995).  Providers report they
have received little training in assistive technology.  What they
have learned has been on the job or through short workshops
(Center for Rehabilitation Technology Study, ??).

Faculty members in university training programs recognize the
need for their students to be better informed and skilled in AT
services.  However, they point out that other topics also need to
be added, and no one is willing to give up course work already in
their curriculum.  The democratic governance structure of
universities makes it particularly difficult to establish
training priorities and separate skill from theory.  The lack of
resources and faculty members who are skilled in assistive
technology are also reported as reasons that preservice AT
training is either not offered or presented as a brief component
of another class.

     Professional Associations

The professional associations of the disability disciplines
(i.e., rehabilitation, occupational therapy, physical therapy,
special education, speech and hearing, and rehabilitation
engineering) are considering a variety of activities to increase
the awareness and skills of their membership in assistive
technology services.

The American Occupational Therapy Association (AOTA) has had a
major commitment to adaptive technology since it became a
discipline.  The term adaptive equipment is being broadened to
address a wide application of assistive technology.  AOTA
published one of the first formal position papers on assistive
technology and established an assistive technology special
interest section.  For the last five years, the assistive
technology section has provided an assistive technology
laboratory at each of their annual conventions and scheduled
presentations, papers, demonstrations, panels, etc.  At the
preservice level, many occupational therapy training programs
cover assistive technology in course work and require expanded
clinical experience in the assessment and selection of assistive
technology.

Together with RESNA, an interdisciplinary association for the
advancement of rehabilitation and assistive technologies, AOTA is
preparing a technical competency paper identifying the entry,
intermediate, and advanced level skills occupational therapists
should have in assistive technology.  Also under development is a
12-lesson, self- study program in assistive technology to be used
for continuing education.  Planning is underway for a special
training institute for occupational therapy faculty members.  The
institute is designed to update their skills, so they can
appropriately teach and supervise students at the preservice
level.

The American Speech and Hearing Association (ASHA) has had,
likewise, a traditional interest in augmentative communication
technology.  This interest has expanded to other related
assistive technology systems.  In 1989 ASHA published one of the
first descriptions of competencies in augmentative communications
for speech/language pathologists (ASHA, 1989).  In 1995, the ASHA
legislative council published guidelines for the structure and
function of an interdisciplinary team for persons with brain
injury (ASHA, 1995).  This publication contains many implications
for interdisciplinary services in assistive technology.

Clearly, the most significant professional organization effort in
promoting assistive technology training has been RESNA.  As an
interdisciplinary association, members from disability
disciplines make up the professional specialty groups of RESNA. 
The special interest, professional status, and major interest
groups address various AT systems, services, and issues, each
including a mix of interested disciplines.

     Federally Supported Activities

With federal support from the National Institute on Disability
and Rehabilitation Research (NIDRR), national guidelines for
education of AT providers are being developed.  This project
includes curriculum development, credentialing, and training and
will define outcome measures and criteria for services. 
Credentialing standards are being prepared for rehabilitation
engineers, assistive technology practitioners, and rehabilitation
technology suppliers.  Drafts of curriculums and credentialing
are currently being finalized.  They will then be forwarded to
appropriate RESNA members to validate the roles, tasks, skills,
and knowledge from the field of practice.  From this information,
competency measures will be identified and standards for training
and credentialing developed.  RESNA, working with AOTA and ASHA,
is also developing standards for specialty areas in augmentative
communications, mobility, seating and transportation.

Recently, the Center for Persons with Disabilities at Utah State
University has developed eight assistive technology instructional
modules comprised of a set of video and print materials
(available in alternate formats), along with review and text
exercises.  This material was developed to be used as inservice
training for practicing professionals and for university
students.  The modules are designed to provide basic knowledge in
skills related to selection of appropriate assistive technology. 
They can be used for either independent study or group
instruction (Lowry, 1994; Justesen & Menlove, 1993).

The U.S. Office of Special Education Programs (OSEP), NIDRR, and
the Rehabilitation Services Administration (RSA) have funded
several technology training programs.  Usually these are focused
on specific disciplines, such as speech/language pathology,
special education, or audiology.  Several leadership training
grants have also been funded.  The RSA provides funding for both
short-term and long-term technology training programs. Virtually
all clinical rehabilitation programs funded in the disciplines of
occupational therapy, physical therapy and rehabilitation
medicine have increased their emphasis on the application of
technology and expanded opportunities for clinical experience. 
The RSA has also funded several projects in rehabilitation
technology and one project in rehabilitation technician training
which emphasizes assistive technology.

The above efforts are significant, but they do little to reach
the thousands of students in special education, communicative
disorders, rehabilitation, and physical therapy who finish
undergraduate and graduate work and enter their profession with
little more than awareness of available technology.  A greater
effort is needed from all interested parties.  The essential
characteristics of assistive technology training, particularly
its interdisciplinary nature, are seldom addressed.  Very limited
opportunities are provided for hands-on, clinical experience in
an assistive technology service setting.

The National Science Foundation (NSF) recently expanded its
program for Projects to Aid the Disabled.  This program,
administered by Bioengineering and Research to Aid the Disabled
(BRAD) Programs in the Division of Biological and Critical
Systems, provides funding to undergraduate engineering students
who select assistive devices as their senior design project
(Bioengineering and Environmental Systems Section, Announcement
of Programs, NSF, 90-130, Washington DC).  In 1991, this program
supported construction of 110 designed devices and software for
individuals with disabilities at 16 universities (Enderle, 1991). 
NSF has expanded this program by making it available to more
universities, supporting more engineering students, and providing
additional funding for supplies and materials.  In addition, NSF
has provided support for undergraduate engineering cooperative
experiences in assistive technology design, fabrication and
manufacturing (Enderle, 1994).  Participating universities and
students in the program sometimes lack an ongoing relationship
with a disability service program.  As a result, engineering
students may have limited opportunities to work with other
disciplines or to work with consumers with a variety of
disabilities.

The Interdisciplinary Training Program in Assistive Technology at
Utah State University combines support from NSF, RSA, and the
Administration on Developmental Disabilities (ADD) to conduct a
program that focuses on undergraduate training, bringing together
seniors from the engineering and computer sciences with speech
and language, special education, social work, and rehabilitation
counseling students.  Working together in an assistive technology
laboratory, they form interdisciplinary teams that work directly
with consumers under the guidance of faculty members.  The teams
conduct consumer and environmental assessments, select devices,
fabricate and customize devices, and make them available to
consumers.  One of the most exciting outcomes of this project is
the enthusiasm it has generated among the engineering and
computer science students.  It has opened them up to alternate
career opportunities, increased their awareness of the value of
universal design, provided opportunities for them to use their
technical skills to improve someone else's life, and to
experience real examples of technology transfer.

In addition to the above activities, many universities are
conducting intensive short courses, usually in the summer or as
pre-session workshops accompanying national conventions like
RESNA, ASHA and AOTA.  Many people rely on these one- or two-day
workshops for information on new technology.  A special assistive
technology laboratory has become a regular part of the AOTA
national convention.  Workshops and labs of this nature provide
an excellent format for sharing ideas, but there is little
hands-on experience.  They primarily provide state-of-the-art
information on assistive technology devices.

IV.  Conclusion and Policy Options

Training beyond awareness and familiarity has been a neglected
issue in the assistive technology field.  Information available
in the professional literature focuses on specific disciplines
with less attention to the interdisciplinary nature of assistive
technology; the need for clinical, hands-on experience; and
familiarity beyond the technology related to one's clinical
discipline.  Most professional organizations for disciplines
concerned with assistive technology have initiated activities to
expand the skills and knowledge of assistive technology service
providers.  Much of the effort at the present time has been
focused on competencies leading towards special certifications or
credentialing.  As this effort continues, care must be taken to
ensure that the net effect of standards is not job security or
increased income for a select group.  Real quality assurance will
expand the number of experts in the field, not merely keep the
charlatan out.

Many of the technology advances during the past decade have come
from outside the rehabilitation engineering field, often from the
space or defense industries.  Other breakthroughs were the result
of a need to address a practical problem by a family member or
someone close to an individual with a disability.  In considering
future AT training needs, particular attention must be given to
ensure that a variety of technical disciplines (engineering,
computer science, communications technology, industrial
technology, etc.) are provided opportunities to work with people
with disabilities and apply their technical skills to address
environmental and societal barriers to independence.  Such
experience will ingrain the values of universal design and,
perhaps, prevent built-in access barriers in the technology of
the future.

As we further formalize AT training, standardize the experiences,
curriculum and skills, we must recruit and encourage "AT hackers"
who may not be associated with any discipline but have
outstanding technical skills as tinkerers, fix-it specialists,
craftsmen, and problem solvers.  Ways must be found to attract
and accommodate as large a talent pool as possible if quality and
comprehensive assistive technology services are to become a
reality.

     Policy Options

The federal government plays an important role in stimulating
programs to train the professionals to provide needed services
(Rehabilitation Act Amendments of 1992, Title III, P.L. 102-569;
and The Individuals with Disabilities Education Act of 1990, Part
D, P.L., 101-476).  The disciplines serving the needs of people
with disabilities have benefited a great deal from such
legislation, although there are still critical shortages.

Traditionally, Congress appropriates funding for which university
training departments apply for student and/or faculty support. 
The content of the training is generally determined by members of
the discipline at the university or in the professional
organizations that influence licensing and credentialing. 
Although federal legislation has stimulated much more training in
the interest of quality and high standards, professional
organizations have increased the training requirements and
pressed for higher degrees before professional credentialing. 
Licensing and certification requirements for professional
practice currently focus primarily at the master's level, and
there is increased interest in specialization.  Requiring longer
training periods and higher degrees is costly in terms of time
commitments of students, costs of universities to maintain
training programs, and the increased costs to service agencies
that employ people with higher degrees.  The empirical evidence
that advanced degrees result in greater service quality is rather
thin.

At times Congress has inserted language specifying that training
be competency-based, represent state-of-the-art practices, and/or
take place in appropriate settings (i.e., the Developmental
Disabilities Act of 1994).  Traditionally, Congress has left
professional standards, credentials and content of training up to
the professional organizations.

Considering the extent and nature of Congressional training
support, the following policy options are identified for
consideration:

Insert language in personnel training or authorization of
appropriations legislation addressing needed training in AT
service competencies to:

1)   ensure that applicants for training support include
appropriate skills training to facilitate evaluation, selection
and delivery of assistive technology

2)   allocate a percentage of funding appropriated for AT
practitioner training and specify that such training be
interdisciplinary with direct clinical, hands-on experience in
assessing, selecting and delivering assistive technology

3)   prepare policies and regulations that would ensure current
training funds address the needs for skills and competencies in
assistive technology services.

Fund a stated number of short-term training programs (e.g.,
summer workshops) to upgrade the skills of university faculty
members so they could appropriately teach selection, evaluation,
and delivery skills in their academic departments.

Provide support for diffusion and replication of model assistive
technology training projects that have been validated and
appropriately field tested.  Several such projects have been
funded.  However, techniques to get them disseminated,
replicated, and utilized have been less effective than desirable
(Foulds, 1995).

Expand the number of projects under the National Science
Foundation providing support for senior design projects to aid
the disabled by providing funding under NSF to support
engineering and computer science students as members of
interdisciplinary teams to work with students from the disability
fields in clinical and laboratory assistive technology service
settings.

Add language to technology research appropriations legislation to
encourage greater attention to training.  This language should
require applicants to discuss how results of their project would
benefit people with disabilities through technology transfer and
require reviewers to give additional points in rating a proposal
that demonstrated appropriate assistive technology training.

Direct NIDRR to make grants to universities and professional
organizations to develop and field test assistive technology
service competencies for appropriate curriculums and disciplines.

Either through appropriation of funding or reauthorization,
direct funding to Title II of the Technology-Related Assistance
for Individuals with Disabilities Act for training purposes.

Supplement the funding provided to NIDRR Rehabilitation Research
Engineering Centers to expand the training activities.

Provide directive language requiring states to describe how they
are addressing assistive technology training needs in IDEA
through their Comprehensive Personnel Development Plans and in
the Rehabilitation Act through their vocational state plan.

Mandate a cost-benefit study to compare the cost- benefit ratios
of services provided by bachelor's level and master's level
providers.

Require applicants for funding of special disability health
centers (e.g., head injury, spinal cord injury, deaf/blind) to
address not only rehabilitation and medical technology, but
assistive technology needs, and provide special funding for
interdisciplinary assistantships.

Provide special programs to focus on interdisciplinary training
activities in assistive technology at the undergraduate level.

Provide funding to accreditation agencies to support the
development and field testing of standards and accreditation
criteria in their disciplines for assistive technology.

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Speech-Language Pathologists Providing Services in Augmentative
Communications (Rockville, MD: March 1989).

American Speech/Language/Hearing Association 1995 Legislative
Council, Guidelines for the Structure and Function of an
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MD: ASHA, 37:3, Supplement 14, 1995).

Anson, D., and Kanny, E., "Training Occupational Therapists in
Rehabilitation Technology," Proceedings of the 12th Annual RESNA
Conference (Washington, DC: RESNA, 1989).

Beattie, T., Statement prepared for a Public Forum of Part C of
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National Institute on Disability and Rehabilitation Research,
1990.

Behrmann, M.M., "Technology and Employment: The Need for Trained
Professional Personnel," Technology and Employment of Persons
with Disabilities , L.G. Perlman and C.E. Hansen (eds.)
(Alexandria, VA: National Rehabilitation Association, 1989).

Bergman, J., Hardy, J., Calkins, C. Offner, R., Myers, B.,
Newman, E., and Fifield, M., Recommendations for Training
Personnel for Assistive Technology Programs ( Silver Spring, MD:
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Blackman, J.A., "Application of Videodisc Technology to Training
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(Menominie, WI: Stout Vocational Rehabilitation Institute,
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Edelman, S., Kloniger, C., Dennis, R., Downey, K., and Barnard,
P., Training Needs Assessment: Final Report. ( Burlington, VT:
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Disabilities, University of Vermont, October 1991).

Enderle, J.D., letter of instructions for faculty summer support
graduate assistance and increased project support for research
experience for undergraduates, National Science Foundation,
Division of Bioengineering and Environmental Systems, Biomedical
Engineering and Research Aiding Persons with Disabilities
Program, Washington, DC, October 18, 1994.

Enderle, J.D., Engineering Senior Design Project to Aid the
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19, 1988 (Washington, DC: U.S. Government Printing Office, 1988).

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Individuals with Disabilities," speech to the NIDRR Project
Directors Meeting, Crystal City, VA February 2, 1995.

Frank, B., and Thuma-Rew, S., "Training Teachers and Caregivers
in Rural Areas on the Use of Low Technology Switching Devices,"
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Competencies and Training Guidelines for Occupational
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47(11):970-979, 1993.

Hartmann, K.D., and Navickis, R.M., Technology Teams in a School
Setting: A Training Guide (Quinnipiac College, CT:  Connecticut
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Engineering Technology Training: A Consumer Driven,
Interdisciplinary Approach," Proceedings of the 12th Annual RESNA
Conference (Washington, DC: RESNA, 1989).

Juhn, C., Utah Consumers Assistive Technology Evaluation Survey:
Report of Frequencies, Qualitative Data and Quantitative
Responses (Logan, UT: Center for Persons with Disabilities, Utah
State University, 1991).

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(Center for Rehabilitation Technology, newsletter), Winter 1995.

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Power of Independence (Logan, UT: Utah Assistive Technology
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Employment of Persons with Disabilities , L.G. Perlman and C.E.
Hansen (eds.) (Alexandria, VA: National Rehabilitation
Association, 1989).

Moore, K.J., Fifield, M., Spira, D., and Scarlato, M., "Child
Study Team Decision-making in Special Education:  Improving the
Process," Remedial and Special Education 10(4):50-58, 1989.

Mueller, J.L., "Technology: Training and Awareness Needs,"
Technology and Employment of Persons with Disabilities , L.G.
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Rehabilitation Association, 1989).

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Science and Engineering:  An Application Guide , NSF 92-89,
(Washington, DC: October 1992).

Noll, A.J., "Training Models for the Utilization of Assistive
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Training of Persons with Mental Retardation," Education and
Training in Mental Retardation 26(2):165-178, 1991.

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of Persons with Disabilities: A Report on the 13th Mary E.
Switzer Memorial Seminar (Alexandria, VA:  National
Rehabilitation Association, 1989).

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Practical Intervention Strategies (Washington, DC: Consumer
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Pronsanti, 1991 (incomplete)

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"TECHSPEC: A Technology Training Model," Proceedings of the 12th
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----------
The Importance of Outcome Measures for
Assistive Technology Service Delivery Systems

Frank DeRuyter, Ph.D.


I.   Introduction

The relationship between the delivery of goods or services and
the resultant outcomes has been long recognized.  Tom Peters
commented that "each day, each product or service is getting
relatively better or relatively worse, but it never stands
still".  Over the past century, there have been many examples in
which the manufacturing and service delivery sectors have
advocated employing various objective measurements to improve
upon goods
and services.  In recent years, the monitoring of service
delivery practices and the evaluation of outcomes has taken on a
renewed emphasis due to the escalating societal importance being
placed on accountability, performance monitoring and
responsibility.

As a result of the rush to develop and implement systems of
accountability and performance monitoring, providers in the
clinical service delivery sector have witnessed an evolutionary
change in the efforts to improve upon quality.  Over a relatively
short period of time, providers have shifted from retrospective
record reviews to concurrent statistical analyses and are rapidly
moving toward prospective neural network estimations of outcomes
of care.  Along with this major shift, much debate has surfaced
regarding distinctions made relative to the terminology used to
describe the evaluation of the various parameters and systems
being held accountable.  While it is not the intent of this
article to resolve the terminology debate, it is important to
define the context in which the various nomenclature may be used
within the assistive technology community.

     Definitions

An activity refers to some specified endeavor, effort or field of
action.  The purpose toward which such an effort is directed,
worked toward or aspired to is referred to as the goal or
objective.  The final consequence or end result of that effort is
the outcome.  Goals, objectives and outcomes are all measurable
and change oriented, however, they are not activities.  For
example, the creation of a program evaluation system in assistive
technology is an activity designed to accomplish the
goal/objective of obtaining increased information regarding
assistive technology services that are delivered in order to
improve the ultimate outcome of providing the most effective and
efficient service or the greatest value at the best cost.

The evaluation process in the service delivery system that is
designed to measure and establish a baseline of what works; how
well something works; for which clients it works; and, at what
level of economic efficiency it works is known as outcomes
research.  Taking that baseline information to evaluate specific
providers to determine how well they perform, either against past
performance or amongst one another is referred to as outcomes
measurement.  Outcomes measurement in the clinical service
delivery system has proven to be an effective tool that enables
identification of the most effective and efficient providers for
purposes of provider selection, contracting, reimbursement,
education, and quality improvement.  The process whereby data are
managed in an ongoing and systematic manner
to improve care is termed outcomes management.  By analyzing and
evaluating the data as well as disseminating the results it
becomes possible to improve the outcomes.  Outcomes management
research encompasses information along several important
dimensions which, when taken together, embody numerous components
and parameters of service delivery important to various assistive
technology stakeholders.  Five dimensions are most typically
characterized in the evaluation of clinical service delivery
systems.  These are:

     � clinical status/results
     � functional status
     � quality of life
     � satisfaction
     � cost.

Outcomes management, therefore, plays a pivotal role in judging
the merits and best practices of assistive technology services,
products, programs and practitioners by providing qualitative and
quantitative data on the comprehensiveness, effectiveness and the
efficacy of service provision.  While it is reasonable to assume
that each stakeholder desires a successful outcome, it is
unreasonable to assume that each stakeholder desires the same
outcome.

Outcomes management is often conducted within the framework of
continuous quality improvement (CQI).  Outcomes data can be
correlated with specific processes or systems which may be
modified, thereby enhancing the effectiveness and efficiency of
service delivery, ultimately improving the outcome.  Some also
refer to this process as total quality management, or TQM. 
Measuring outcomes provides the best evidence that process or
system changes are actually increasing quality levels.  Outcomes
management initiatives in measuring clinical service delivery
environments have improved client outcomes and have decreased
variations in clinical practice.  Despite the conventional wisdom
that better quality costs more, most outcomes projects have found
that in the long run, good care usually costs less than poor
care.  In fact, leading practitioners claim that the best way to
reduce costs is to improve quality.

Grounded within the CQI philosophy and methodology is a clinical
management tool, known as critical pathways.  These were designed
to improve quality by reducing variance.  Originally developed as
a project planning tool in industrial engineering and managerial
sciences, critical pathways organize, sequence and time the major
interventions delivered by practitioners for particular case
types or conditions.  More specifically, critical pathways are
charts or "road maps" which show the key events that typically
lead to the successful treatment of individuals within a
homogeneous population.  Critical pathways have also been
referred to as critical paths, clinical pathways, and care maps
although there are subtle differences to distinguish amongst
these various terms.

Albeit not intended to be rigid programs of care or cookbooks,
critical pathways do begin to stipulate a preferred pattern of
service delivery as they reflect the practice patterns of the
clinicians who develop them.  Preferred practice patterns are the
statements that are supposed to represent a high degree of
consensus in a particular discipline or field by defining
universally applicable characteristics of activities directed
toward individual clients.  These statements typically address
the structural requisites of practice, the processes to be
carried out, and the expected outcomes.  They may also be
referred to as standards of practice or practice parameters. 
Statements that offer even more detailed measures of a clinical
process are referred to as practice guidelines.  These are a
recommended set of procedures for a specific area of practice,
based on research findings and current practice, that details the
knowledge and skills needed to perform the procedures
competently.  They are developed to assist in making appropriate
decisions for specific clinical circumstances and offer more
detailed measures of the clinical process.

Finally, the organized method for monitoring all of the above
parameters and the effectiveness and efficiency by which the
results are achieved is known as program evaluation. Program
evaluation enables the various stakeholders to systematically
evaluate their activities, goals/objectives and outcomes in terms
of the overall operation, provision of services, efficiency of
the delivery system, and adequacy of serving client needs.  The
provision of this information allows continuous improvement upon
the results.  Integration
of program evaluation with other management information systems
provides the detail and accountability to effectively monitor and
manage clinical service delivery systems.

II.  Measuring Outcomes In Acute Care/Rehabilitation Settings

Over the past century, numerous individuals and organizations
have advocated utilizing different objective measurements to
improve the delivery of various related products and services for
the ailing and disabled.  Specific to evaluating the quality of
clinical service delivery, Florence Nightingale is probably most
widely credited with the first scientific approach dating back to
the Crimean War in the 1850's.  However, it has only
been over the past three decades that an increased emphasis and
importance has been placed on the accountability and performance
monitoring of activities.  Much of this monitoring has focused on
measuring and assessing varying aspects of the quality of care
provided with the most recent emphasis placed on the measurement
of both clinical and cost outcomes.

Thirty years ago, the monitoring of clinical service delivery
system activities focused primarily on evaluating the allocation
of resources against such parameters as treatment necessity,
length of stay, level of care, and use of tests/services.  This
was referred to as utilization review.  Utilization review plans
were eventually mandated in 1966 with the inception of Medicare
and Medicaid.  Gradually, utilization review evolved into a more
comprehensive system for controlling how human and material
resources were allocated in
the provision of clinical services.  This comprehensive system
was subsequently termed utilization management.  An outgrowth of
utilization review and utilization management is what has
recently been called resources management.  The essence of
resources management is to actively manage the delivery of goods
and services in order to achieve maximum efficiency and
effectiveness through the coordination of clinical care, discrete
allocation of resources, and the integration of information.  The
specific components include admission planning, resource
allocation, productivity appraisal, cost-benefit analysis,
discharge planning, quality assessment and improvement
activities, implementation of practice guidelines, and
risk management (Malkmus & Johnson, 1992).  Resources management
is what has become known today as managed care.  Theoretically,
the careful monitoring and control over the goods and services to
be rendered enables the focus to be more directed at quality.

The focus on quality is not a recent phenomenon.  The mandated
utilization review plans of the late 1960's were a form of
quality assessment although they were carried out
retrospectively. In 1972, professional standards review
organizations (PSROs) were established to evaluate the quality of
services provided to participants in government health programs. 
These were replaced in the early 1980's by peer review
organizations (PROs) which were designed to monitor the quality
of services provided under a prospective payment system.  Much
emphasis during this period was placed on what was referred to as
quality assurance programming.  Typically, quality assurance
programming focused on chart peer review audits and client
satisfaction surveys to identify what people were complaining
about, or what had gone wrong.  The import of quality assurance
reviews continued throughout the 1980's, although service
providers articulated great concern about being expected to be
participants in a process that in reality could never be assured.

Despite the mandates of the 70's and 80's, the fact of the matter
was that there were few compelling reasons for service providers
to be accountable and measure or demonstrate quality.  Monitoring
was frequently ignored as there were few incentives to account
for "doing the right thing" let alone examining the effectiveness
of services.  Quality continued to be extolled as an idealistic
goal that was too difficult to measure, let alone define.
However, after the mid 1980's, the attitude toward quality began
to change.  The economic difficulties associated with deficit
spending and the diminished resources within many service
delivery sectors (education, health care, manufacturing) created
environments in which the incentives to survive overshadowed
doing the right thing.  As these sectors experienced budget cuts
and policy changes, many argued that quality would be severely
impacted, although there were only minimal data to support this
contention.  The ultimate results were major shortcomings for
consumers who experienced and absorbed:  1) the impacts of
organizational reengineering; 2) limited or denied access to
services; 3) poorer quality; and, 4) the outright elimination of
services.

By the late 1980's, consumers began to realize the impact of what
was occurring. This resulted in a major public outcry and marks
another period of major change in the requirements and emphasis
in the monitoring of activities for service providers.  These
changes shifted the focus of program monitoring to what was
referred to as quality assessment and improvement whereby care is
managed to minimize costs and to maximize the desired outcomes. 
This broadened monitoring concept requires that service provider
agencies include practitioners and consumers as active
participants throughout the evaluation process.  Today, this has
become the norm, and unlike quality assurance, the concept
appears to be more than a passing fancy.  It has been widely
embraced outside of the clinical service delivery system for many
years by manufacturing, professional organizations and service
industries alike.  Whether it is doing things right the first
time or doing the right thing, quality assessment and improvement
and the monitoring of outcomes has become the expected.  The
difficult question to assess and answer has been determining
whether what was done was indeed the right thing to do.

In recent years, increased consumer pressure has become a driving
force behind the quality and outcomes agendas.  This is evidenced
by the increased accountability and performance monitoring
occurring in today's service delivery environments.  The
disability community has certainly been a strong force in this
movement.  Consumers have become educated, demand information,
and are forcing providers to not only define quality and outcomes
but to describe them in performance terms.  As a result, this
decade is already being hailed as the one of accountability and
responsibility.  This is further evidenced within the clinical
service delivery sector by the recent transition between two
competing national public policy agendas.  The shift from a
social-ethical agenda, which has enabled many consumers to access
goods and services regardless of cost, toward an economic agenda
whereby the access to goods and services is rationed through a
pricing paradigm of supply, demand, containment, and cost benefit
has certainly played a major role in furthering the outcomes
movement.  This shift has had a profound effect on the assistive
technology community.  While practitioners were able to drive the
service delivery system for many years, today the system is being
driven by policymakers and payers.

Other forces have also been influential in driving the outcomes
movement.  This is evident in the numerous federal and state
mandates, that have been legislated in recent years, which now
require capturing data that reflect upon provider effectiveness
and quality. Most familiar to the assistive technology community
is the "Technology-Related Assistance for Individuals with
Disabilities Act" (PL 100- 407) of 1988.  In the 1994 amended
reauthorization (PL 103- 218) of this enabling legislation,
Sections 102(e)(6-8) specify that recipients of the discretionary
"Tech Act" grants must conduct annual assessments of their
program to determine:

"(A) the extent to which the State's goals and objectives for
systems change and advocacy activities, as identified in the
State plan under paragraph (6), have been achieved; and

(B)  the areas of need that require attention in the next year."

Accountability and performance monitoring have become a
commonplace requirement in much clinical service delivery
legislation that has recently passed at both the state and
federal level.

One can also look at the modification of standards and the shift
in emphasis that has recently occurred by the major health care
accreditation organizations.  This is most evident in the current
monitoring requirements for quality of care and program
evaluation by both the Joint Commission on Accreditation of
Health care Organizations (JCAHO) and the Commission on
Accreditation of Rehabilitation Facilities (CARF) for acute care
as well as rehabilitation/habilitation settings.  The recent
changes are a major shift from the focus and requirements of five
years ago.  In many respects, the requirement by these
accreditation agencies to establish program evaluation systems
have enabled the various rehabilitation communities to be better
prepared and positioned, in terms of accountability, than other
health care communities.  This is best reflected by the host of
outcome measures that are currently available and being utilized
in rehabilitation.  However, although the functional status
measures have gained prominence in recent years, there is still
no one single measure that clearly satisfies all outcome
objectives and dimensions.

It has been suggested for several years that outcomes in the
rehabilitation clinical service delivery arena can be sequenced
along a continuum within the context of the World Health
Organization's (WHO) International Classification of Impairments,
Disabilities, and Handicaps (ICIDH) scheme.  As such, outcomes
may be classified as the consequences of disease or disorder at
some point along a continuum of measurement.  In recent years,
the World Health Organizations ICIDH scheme has gained acceptance
within the rehabilitation community and serves as the underlying
framework from which its outcome measures have been developed and
used.  Specifically, this has enabled taking the five outcome
measurement dimensions (clinical results/status, functional
status, quality of life, satisfaction, and cost) and placing them
at points along the ICIDH continuum of impairment, disability
and handicap.  For example, the dimension of clinical
results/status is viewed as a measure of impairment and evaluated
by utilizing the diagnostic results traditionally obtained;
functional status measures that are employed are viewed as
measures of disability that evaluate function; and, quality of
life is viewed as a measure of handicap through the use of
quality of life scales or handicap inventories.  The other two
dimensions, cost and satisfaction, span across the classification
scheme and are incorporated at each level along the continuum.

     Functional Status Measures

The one dimension that has received the greatest emphasis in
rehabilitation has been functional status which is viewed as a
measure of disability.  Over the years, numerous functional
measures have been developed.  While the early measures were
limited in scope and focused primarily on physical functioning,
they actually corresponded with the early emphasis of
rehabilitation.  Examples of these early measures include the
Katz Index of ADL (Katz et al, 1963) and the Barthel Index
(Mahoney & Barthel 1965).  However, as the field of
rehabilitation expanded to include cognitive, communicative and
psychosocial domains, the scope of the functional measurement
tools also expanded.  Today, the principal functional status
measurement instruments include the Rehabilitation Institute of
Chicago Functional Assessment Scale III (RIC-FAS III) (Heineman,
1991); Patient Evaluation and Conference System (PECS) (Harvey &
Jellinek, 1979); Level of Rehabilitation Scale III (LORS-III)
(Formations, 1991); Functional Independence Measure (FIM)
(Uniform DataSystem for Medical Rehabilitation, 1993); and
Functional Assessment Measure Revised (FAM) (Forer, 1990).  Each
of these functional status instruments are specific to
rehabilitation and measure a variety of functions.  The precision
and degree of sensitivity by which these functions are measured
also varies widely amongst instruments.  Each of the measures
mentioned above are what can be considered mid-range instruments
with respect to sensitivity and focus on different aspects of
rehabilitation.  There are also functional status instruments
that are not mid-range but on either end of the continuum.  For
example, two instruments that are less sensitive but broader in
terms of the range of functional items measured are the
Assessment of Needs for Continuing Care (ANCC) (Health Care
Financing Administration, 1989) and the Minimum Data Set for
Nursing Home Resident Assessment and
Care Screening (MDS) (Morris et al, 1991).  Both of these are
multidimensional, minimal data set, screening and/or referral
instruments.  They provide a wide scope in terms of the
functional status areas examined but with low sensitivity.  These
are not instruments to demonstrate change or improvement over a
short period of time.  On the other end of the
continuum, there has been an emphasis recently in the development
of discipline specific functional status instruments.  These may
be characterized as unidimensional because they focus on a very
specific area of functional status.  This allows examination
within a very narrow range which in turn can assure a very high
degree of sensitivity with respect to how functional status is
measured.  The Canadian Occupational Performance Measure (COPM)
(Law et al, 1994) and the Functional Assessment of Communication
Skills for Adults (FACS-A) (Frattali et al, 1995) are examples of
this type of instrument.

Functional status measures provide varying degrees of objective
evidence regarding the effectiveness of the delivery of specific
goods and services.  However, it is important to acknowledge that
the majority of these instruments still lack sufficient
information regarding their reliability and validity. 
Furthermore, very few of these instruments take into account the
unique nature or any of the complexities associated with
assistive technology.  Finally, it is still unclear what
relationship and importance functional status has on those
components that are of greatest importance to payers and
policymakers-- namely cost and satisfaction.  Clearly, the
verdict is still out on whether payers and policymakers will
value functional status data to the degree that practitioners do.


III. Developing Outcome Measures For Assistive Technology

The increasing preeminence of assistive technology throughout our
society over the past decade has been unheralded.  The pervasive
presence of the multitude of technological solutions throughout
our society, not to mention their numerous benefits are often
championed as the cause celebre for shaping and easing the lives
of individuals with
disabilities and providers alike.  Yet, despite all of the
significant achievements, consumers as well as providers are
equally quick to point out that the technology, the methods by
which the goods and services are delivered, and the resultant
outcomes have been extremely variable and inconsistent at best.

     Why Outcome Measures Are Needed

Over the past ten years, there has been a proliferation of
anecdotal accounts regarding:  1) the continued difficulty that
consumers have accessing services; 2) the persistent financial
barriers encountered by consumers, practitioners, manufacturers,
and vendors alike; 3) the general consumer dissatisfaction; and
4) the frequent abandonment of prescribed technological
solutions.  As a result, some have quietly intimated that the
technology, the resources being allocated, and the service
delivery methods currently employed may not necessarily be the
answer.  Unfortunately, the validity of this assertion is
difficult to ascertain as the assistive technology community has
only minimal data to support or refute these claims let alone
evaluate the effectiveness and efficiency of its services or the
recommended technological solutions.  Clearly, the assistive
technology community is not excluded from having to participate
in the accountability and performance monitoring agendas, nor is
it exempt from the challenge of having to evaluate the worthiness
of its goods, providers and various delivery systems.

Many reasons for the inconsistencies and the variability of goods
and services delivered have been given over the years. 
Explanations have included:

� the inherent difficulties in accessing what amounts to a
limited number of sites providing a full spectrum of services

� inadequate funding streams to pay for the delivery of the
services

� continued funding barriers leading to the acquisition and
maintenance of the technology

� no uniform standards resulting in extraordinary diversity in
the type, frequency, intensity and quality of services that are
available and being provided throughout the country.

While the advances in assistive technology have moved forward at
a very rapid pace, service providers, policymakers, and payers
have generally been incapable of keeping up with the advances. 
This has often contributed to communication problems between
manufacturers, vendors, service providers, payers and
state/federal agencies which in turn has resulted in many of the
inconsistencies and variables noted above.  In addition, several
other contributing factors have been evident and cannot be
ignored.  These have included: 1) turf battles amongst
manufacturers, vendors, service providers, and payers; 2) the
lack of interagency agreements amongst state as well as federal
agencies; 3) inadequate preparatory training resulting in poor
qualifications of the professionals providing services; and, 4)
consumer shopping when recommendations fall short of
expectations.  All of these problems are further overshadowed by
a national budget deficit and an era of diminishing resources.
This has resulted in a reactive, knee-jerk environment in which
resources are being allocated based upon the short-term prospects
of success that provide the "biggest bang for the buck" without
consideration for the ultimate outcome or long- term payoff.

For many, when framed within the context of the bigger picture,
the assistive technology community has been fortunate because
until recently it has been able to remain on the fringes of the
outcomes movement.  It has been able to do this because of two
factors.  First, many policymakers and payers were so swept away
by the novelty and the "sexy, glamorous, razzle-dazzle" nature of
the technological end product that they tended to overlook the
need for accountability and performance monitoring.  Secondly,
the assistive technology community has been able to hide under
the rehabilitation umbrella.  Only recently did it acknowledge
the need to develop specific performance monitoring tools. While
this may have been fortunate in the short run, this temporary
safe haven has actually turned out to be a liability for the
assistive technology community.  As the realities and competing
agendas associated with accountability and performance monitoring
have come home to confront the members of the community, the real
value of the goods and services that it delivers has become
clouded.  By not having developed adequate monitoring systems,
serious questions have been raised regarding the efficiency of
the assistive technology service delivery system.  Furthermore,
many within the assistive technology community have developed the
assumption that better outcomes are derived simply through
improved technological solutions such as smaller, newer, faster,
more portable and more sophisticated systems.  Consequently,
technological solutions have been looked toward for improved
outcomes without data to support the assumption.  Given the
knowledge that almost one third of all devices are likely to be
abandoned (Phillips, 1992), this view has been shortsighted at
best.  With the excitement toward the high-tech end of assistive
technology moderating, a better examination of the validity and
benefits of the technological solutions is in order.  The various
assistive technology stakeholders are finally beginning to
realize the importance of considering both the benefits as well
as the long-term outcomes associated with not only the
technologies provided but also with the services delivered.  This
in turn is causing the assistive technology community to consider
whether the expenses associated with providing services and
systems justify the benefits gained.

Use of Outcome Measures in AT Service Delivery

The methodical implementation and utilization of either program
evaluation or outcomes management research within assistive
technology has been fragmented and limited at best.  A 1989
survey of 28 health care related facilities throughout North
America providing augmentative and alternative communication
(AAC) services revealed that over 71% of the facilities surveyed
did not have any type of program evaluation in place (DeRuyter,
Kennedy and Doyle, 1990).  Out of the 29% of the facilities that
did conduct some type of program evaluation, 14% used generic
facility- wide patient satisfaction questionnaires, 7% conducted
retrospective charting compliance review audit programs, and only
7% had a prospective outcome measurement program in place that
actually provided some degree of accountability or performance
monitoring.

It can be argued that this survey was biased as it only examined
AAC programs in major health care service delivery settings.
However these programs were selected intentionally because each
setting was held accountable by an accreditation process that
actually required some form of program evaluation.  Other
settings where AAC services were provided (public schools,
universities, private practices) were not being held accountable
by an accreditation process in which program evaluation was a
requirement.  DeRuyter and colleagues surmised that program
evaluation in AAC was even more limited than their survey noted. 
In all likelihood, accountability and performance monitoring in
assistive technology continues to be very fragmented and limited. 
One only needs to examine the attendance at recent workshops on
the topics of how to conduct assistive technology program
evaluations or how to develop an outcomes monitoring system to
realize that accountability and performance monitoring is a very
popular topic.  As the author has conducted many of these
workshops, he speaks with firsthand knowledge when he states that
most practitioners have no clue when it comes to this topic.

There are probably many other reasons as to why the assistive
technology community has been void of program evaluation and
outcome studies.  However, three reasons stand out.  First, as
previously mentioned, the assistive technology community has been
able to hide under the rehabilitation umbrella for several years. 
The pervasive attitude was that performance monitoring was just
another passing fad so why actively participate when it would
become obsolete in a couple of years.  Second, the assistive
technology clinical population and associated technologies are
extremely varied and diversified.  From a logistical perspective,
this makes outcomes research difficult to conduct as very few
programs and/or clinicians providing assistive technology
services have access to a large and diversified population base. 
Third, those programs and/or clinicians that do have access to a
large population base find it extremely difficult to conduct
outcomes research because their primary mission is to provide
direct clinical care.  These clinicians and the viability of
their respective programs are directly tied into the
reimbursement for their services.  In light of factors such as
program cutbacks, financial deficits of a magnitude not
previously experienced, and lower productivity in the provision
of assistive technology services, the possibility for conducting
outcomes research becomes exceedingly difficult.  One only needs
to look at the large number of smaller programs that are no
longer providing services to validate this claim.  Short of a
major research funding effort to conduct long-term outcome and
cost benefit studies, the only other opportunity to perform these
studies is to try to conduct them in conjunction with other
quality assessment and improvement activities. However, this is
only likely to occur within health care settings where these
types of activities are required.

Although there is still a paucity of outcomes information, the
assistive technology community has not been entirely without
outcomes activities.  First, there have been several efforts at a
system level within the assistive technology community that have
begun to address the need to establish some type of the
accountability (Blackstone, 1990; DeRuyter, 1992a, 1992b; NIDRR,
1994; Warren, 1992, 1993).  These efforts have been focused at
several levels.  This has included those that were service
specific (AAC, access, mobility, etc.); organizational specific
(RESNA); and, agency specific (NIDRR). Unfortunately, all of
these efforts began after there was a legislated mandate to
provide services and equipment.  Consequently, the assistive
technology community has been "in the position of having to deal
with the cart being before the horse" (Warren, 1993).

Over the past several years, there have been numerous
presentations at conferences and several articles that have begun
to discuss various types of outcome results related to assistive
technology.  Many of these have been single case studies or small
sample size reports.  The greatest shortcoming of most of these
reports are that they have consisted of retrospective reviews
rather than prospective studies.  These include a follow-up
survey of prototype vocational aids for the blind (Brabyn, 1981);
a follow-up survey of the various devices still being used 16
weeks after device delivery (Caudrey and Seeger, 1983); a
retrospective study of client satisfaction with device function
and comfort five years after delivery (Kohn et al, 1983); a
telephone survey of device usage two weeks after delivery
(McGrath et al, 1985); a follow-up on the utilization of devices
in rural areas (Willkomm, 1988); and, a national survey on
technology abandonment (Phillips & Zhao, 1993).
Although these studies have been informative they have provided
little insight into how to change the manner by which services
are delivered and thereby improve upon the outcomes.

To date, only a handful of long-term, prospective assistive
technology related outcome studies have been reported.  Two of
the studies focused on the application and use of augmentative
and alternative communication systems for individual who were
nonspeaking as the result of either traumatic brain injury or
stroke.  In the traumatic brain injury study, the majority of the
nonspeakers regained speech in less than two years with over 65%
doing so within 60 days.  Furthermore, the most common reason for
no longer using an AAC system was related to the system either
being upgraded because of cognitive improvements or the return of
speech.  In the other study, almost two-thirds of those
individuals using an AAC system following a stroke discarded
their system within the first six months and relied on family or
other support systems to facilitate their interactive needs
(DeRuyter & Kennedy, 1990; DeRuyter, Kennedy & Doyle, 1990). 
Both of these findings have a significant impact on the delivery
of services to these populations as they have altered the
traditional manner of simply providing AAC systems to all who
were nonspeaking.  The above studies also identified key
variables related to when systems should be considered.  In a
more recent prospective study, user feedback was documented
through standardized data collection at five different service
delivery centers. These data were used to demonstrate that user
satisfaction and device performance data could be collected and
compared with reliability (Kohn, LeBlanc & Mortola, 1994).

Finally, a preliminary report on a prospective study examining
assistive technology usage in children and adolescents noted that
there are many underlying variables that contribute to the
success in usage (DeRuyter, 1994).  Over 150 children and
adolescents were studied at the time their devices were
delivered, six months later, one year later, and two years
following delivery.  Twenty-four variables relating to the
technology, the client, and the service delivery system were
examined.  Although the relational and correlational studies had
not been completed, the preliminary findings indicated that many
factors contributed to the success in usage.  Each of these
studies which has focused on outcomes has been of paramount
importance for the assistive
technology community because they have influenced and changed the
way that services are provided.  It is these long-term,
prospective type assistive technology-related outcome studies
that are required to effect positive changes in the delivery of
assistive technology services.

Implications For Using Outcome Measures

In light of the national expenditure crisis and the recent
political realignment the demand for assistive technology
services continues to grow.  However, without meaningful outcomes
the assistive technology community will be at great risk of being
unable to ensure delivery of its current level of goods and
services.  There is a strong likelihood that future dollars
available for goods and services will decline.  At best, the
community can hope that the dollars available to meet the demand
will remain flat.  It is no secret that the costs for assistive
technology are significant and are frequently a lifelong expense. 
For no other reason, it is incumbent upon the assistive
technology community to conduct outcomes research to identify
alternative and more efficient ways of providing goods and
services.  The provision of these goods and services must
demonstrate positive outcomes of high value at a reasonable
price.  This will enable the assistive technology community to
come to terms on whether the expenses associated in providing
services and systems justify the benefits gained.  By being
accountable now, the assistive technology community can help
ensure that its consumers will not be denied goods and services
in the future.

The other implication of being accountable and using outcome
measures is that it will clarify for the assistive technology
community who its consumers and stakeholders really are. To many
within the community, it is still only the client parading as the
customer in need of assistive technology goods and services who
is thought of as the consumer.  In reality, most individuals
involved in assistive technology are consumers and all involved
individuals are stakeholders.  Endorsing the concept that only
the client is the consumer is a rather myopic view.  Evaluating
just a single entity prevents any effective examination of
outcomes in the delivery of the various goods and services that
may be provided.  Furthermore, it has been well documented that
clients alone typically have little interest in the issues that
concern or relate to the providers of goods and services and they
measure performance in this capacity largely on an intuitive
basis.  On the other hand, stakeholders are greatly concerned
about the qualitative and quantitative aspects of the goods and
services. Accountability and performance monitoring is of
significant importance to all stakeholders. Therefore, a
consequence of the use of outcome measures will be a
clarification and better understanding of who are the consumers
and stakeholders in the assistive technology community.

Critical Factors Requiring Consideration

There are several issues that can be characterized as being
associated with accountability and performance monitoring in the
development of outcomes measurement and management systems which
will require consideration. These include the dimensions to be
characterized in clinical service delivery; the horizontal and
vertical linking of these dimensions; and, factors that could
negatively influence the respectability of the data.

     Clinical Service Delivery Dimensions

As previously mentioned, there are typically five dimensions
characterized under the umbrella of outcomes management in
clinical service delivery systems.  These are:  1) clinical
results/status; 2) functional status; 3) quality of life; 4)
satisfaction; and, 5) cost. Each of these address a pivotal
aspect associated with judging the merits and best practices of
goods and services, programs, and practitioners by providing
qualitative and quantitative data on the effectiveness,
comprehensiveness, and efficacy of what was delivered.  What
makes the management of client outcomes so complicated in
assistive technology is that each of these five dimensions have
varying degrees of importance to the various stakeholders.  An
important dimension to one stakeholder group may be a "who
cares?" dimension to another stakeholder group.  For example,
functional status is very important to the practitioner but
usually of little relevance to a program administrator; cost is
very important to the payer but usually of little relevance to
the client if that individual does not have to directly pay. 
While it is reasonable to assume that each assistive technology
stakeholder group desires a successful outcome, it is
unreasonable to assume that each assistive technology stakeholder
group desires the same outcome.  This necessitates determining
the information needs and perspectives for each stakeholder group
in order to devise relational outcome information management
systems that correlate not only with the dimensions but also with
the stakeholders.

Vertical and Horizontal Linkage Approach

Correlating the various dimensions and the various stakeholders
poses a major dilemma for those developing outcomes management
information systems.  Even if the various stakeholders could
agree on the same dimension, each would still require different
levels of information detail to match their varied needs. 
Consequently, in order for an outcomes management information
system to be truly effective it requires linkage both in a
vertical and a horizontal manner.  From a design and technical
perspective this may appear to be a fairly simple task.  However,
the reality is that stakeholders will resist having to provide
any more documentation than is absolutely necessary especially
when there is no immediate payoff related to the information
provided.  Systems that are developed therefore, must be kept
simple, provide only the essential information required, and data
must be collected with minimal effort.

A method that has been suggested for vertically linking the
different levels of information required by different
stakeholders is through the use of the measurement tree analogy
(Nelson & Batalden, 1993).  By viewing the outcome information
management system as a "trunk--branch--limb", it is possible to
provide different levels of information detail to match the
differing needs of the various stakeholders.  For example, the
client, practitioner, and administrator/payer may all be
interested in the dimension of satisfaction. However, developing
these different satisfaction measures to meet each stakeholders
information needs would be highly inefficient.  Instead, by
employing the analogy of the measurement tree, and placing each
stakeholder on the tree, it is possible to develop a single
satisfaction instrument that could provide outcome information on
different levels of performance to each stakeholder.  Information
necessary for the administrator/payer at the "trunk level" would
relate to overall satisfaction.  At the "branch level" would be
information important to practitioners such as the drivers of
satisfaction (i.e. courtesy, promptness, etc.). Finally at the
"limb level", information important to clients, would be an
evaluation of those specific features and actions related to the
drivers of satisfaction such as being told how to take care of
the device or who to call for assistance when equipment failed. 
By vertically linking the stakeholders and different types of
information required, it becomes possible to develop an
instrument that provides all of the necessary outcome
information, in this case satisfaction, to all of the players. 
This vertical linking can also be done with the other dimensions
(DeRuyter, 1995).

Just as vertical linkage is important, the same is true for
linking the dimensions horizontally.  The importance for doing
this is to begin examining how the different dimensions correlate
with successful outcomes.  For example, one might assume that a
successful outcome was attained because a lower cost electric
wheelchair with joystick controller was selected that enabled the
client to functionally interface with the communication device,
computer and environmental control unit.  Although the client may
have been satisfied with the outcome in the clinical setting, one
would have to question how successful the outcome was if the new
wheelchair prevented the client from driving his/her van or if
the new wheelchair could not be used throughout the home because
of protruding footrests.  Clearly, the overall functionality of
the system and the client's quality of life would be severely
impacted by this particular technological solution.  What
appeared as a successful outcome in some dimensions and
environments was not in other dimensions and environments.  It is
incumbent to develop outcomes systems that link all dimensions
(DeRuyter, 1995).  In the final analysis, successful
accountability and performance monitoring in assistive technology
will be the result of those outcome management information
systems that are capable of both vertical and horizontal linkages
across the five dimensions.

Factors Affecting the Respectability of Data

Another factor to be considered relates to issues that have the
potential to negatively influence the respectability of the data
collected.  These issues may include:

     � the time intervals at which performance monitoring takes
place

     � the utilization of standardized vs nonstandardized
measurement    tools

� the reliability and validity of the instruments.

Because the provision of assistive technology is frequently a
lifelong event, accountability and performance monitoring must be
a long-term activity.  At a minimum, one should probably obtain
baseline performance data; data following the delivery and
training of a specific assistive technology system; and, some
type of follow-up data.  However, it is unrealistic and
unnecessary to collect outcomes data following every
client/provider contact. Instead, data collection should be
predicated by the reasons and the types of data to be collected. 
For example, while one can argue that cost data should probably
be collected at all times, satisfaction data could be
successfully collected after specific assistive technology goods
have been delivered or services have been completed.  The same
could be said for functional, clinical status, and quality of
life data.  The data collection timelines should be determined by
factors that relate to both the purpose of the accountability and
performance monitoring system and the type of data to be
collected.

Trying to determine whether standardized or nonstandardized
measurement tools should be used is still a somewhat moot issue
as there are no standardized instruments available that encompass
the various components of assistive technology.  Consequently,
until such time as these instruments exist, the assistive
technology community will have to use nonstandardized measurement
tools.  This does not preclude, however, the use of portions of
measures that have been standardized.  Instead, one must just use
caution in how the findings are interpreted and the results
reported.

The issues of reliability and validity are equally important
factors in outcomes management because they signify the
appropriateness, meaningfulness, and usefulness of the measure
being used and the inferences that may be made relative to that
measure.  There are many types of validity to be considered when
developing and choosing outcome measures (i.e. construct
validity, content validity, predictive validity, concurrent
validity, criteria- referenced validity).  In addition to
validity, reliability or the extent to which the ratings are
reproducible when administered under similar conditions must also
be considered.  Just like validity, there are many specific types
of reliability to be considered (i.e. test-retest, inter-rater,
interdisciplinary, inter-informant).  Any further discussion,
other than mention of the above, goes beyond the scope of this
paper.  However, suffice it to say that the measures developed
and chosen in measuring outcomes within assistive technology will
have to be scrutinized for reliability and validity.

There are numerous other factors that have the potential to
influence the respectability of any data collected.  These
include client comorbidities; how to acknowledge the small
increments of change often observed in assistive technology; the
expertise and training of the individuals collecting data; and,
comparability of the data across providers, systems, and sites. 
It is incumbent upon the assistive technology community to
consider all factors in order to minimize failure in the
development of accountability and performance monitoring systems.

Barriers to Implementing Outcome Activities

There are many barriers that may be identified as contributing to
the failure of both developing and implementing accountability
and performance monitoring activities.  These include:

     � resistance to program evaluation

     � failure to acknowledge that service delivery is in
fact a business     with associated costs

     � inadequate personnel preparation

     � regulatory criteria which preclude rapid system change

     � professional turf.

One of the most common reasons for failure is outright resistance
to program evaluation.  Of paramount importance to the success of
any performance monitoring program is ensuring that stakeholder
involvement takes place in both the development and the
implementation phases of the program.  Resistance to program
evaluation can occur at the individual level, the technical
level, and/or the organizational level (Lorber and Lundstrom,
1981).  Through either overt or subtle resistance, improvements
to any service
delivery system are almost impossible.  However, by directly
involving all stakeholders in the development process from the
outset, it can be easily realized that performance monitoring has
the potential to enhance the service delivery process and thereby
the commitment to succeed can be developed.  Through the direct
participation of various stakeholders, realistic goals and
expectations can be set and the technical quality of the system
can be more comprehensive and objective.  Resistance can be even
further minimized by developing performance monitoring systems
that are flexible, provide immediate feedback, and demonstrate to
stakeholders that the system will serve multiple purposes rather
than just serve as an instrument to measure accountability of
individual stakeholders.

Another factor is the failure of many stakeholders in the
assistive technology community to accept that service delivery is
a business arrangement.  As such accountability and performance
monitoring are critical elements for the survival of any business
(DeRuyter, 1995).  In the assistive technology community, the
majority of stakeholders tend to focus on just the functional and
clinical aspects with little regard or appreciation for the other
important dimensions--especially that of cost, satisfaction and
value.  The realities of today's service delivery environment is
that one can no longer expect to access assistive technology
goods and services without giving consideration to the associated
costs.  All stakeholders need to understand that in its simplest
form, service delivery is an agreement between two parties--a
consumer and a provider resulting in the delivery or provision of
some specific agreed upon commodity or service in exchange for
payment.  Typically, the consumer (payer, client or agency)
employs the provider (vendor, practitioner) in some capacity to
deliver goods or services.  As a part of the transaction, both
parties have certain expectations regarding the end product.  It
is the perceived value and/or outcome of that end product as well
as how it was delivered from which accountable information may be
derived.  In a true marketplace, where there are multiple
providers of a particular good or service, both parties place a
very high value on quality and satisfaction because of the shared
interest.  However, when there are only few providers or choices
of a particular good or service, as in assistive technology,
consumers become disadvantaged.  Consumers find themselves in the
position of caveat emptor but often lack the knowledge,
resources, or willingness to question whether the end product was
of the highest quality and greatest value.  To providers, cost,
quality and satisfaction are important albeit for different
reasons. Providers view service cost, quality and consumer
satisfaction as benchmarks from which competitive advantages may
be gained.  By providing higher value at a more reasonable price
(or lower cost), thereby exceeding the consumer's expectation, it
is possible to distinguish oneself from others.  But who
determines value remains the central question. In order for all
assistive technology stakeholders to voluntarily accept
accountability, consensus must be reached to recognize service
delivery for what it is--a transaction between two parties, and
that what follows are different perspectives of what are the
value and outcomes (DeRuyter, 1995).

For those who provide service, this business aspect is rarely if
ever discussed during academic preparation.  This is another
contributing factor.  The failure by many assistive technology
stakeholders to recognize the business and cost aspects
associated with service delivery falls largely upon the personnel
preparation programs.  These programs have been designed to
provide students with the knowledge and competency base in order
to become service providers.  Most programs however have been
inattentive when it comes to providing a dose of real world
experiences that deal with the day to day administrative,
financial and ethical aspects associated with service delivery. 
It is incumbent upon personnel preparation programs to understand
that they have an ethical obligation to adequately train and
prepare students for real world experiences and should be held
accountable for ensuring that this occurs.  As Yoder (1995) so
explicitly pointed out, this may be one of those situations when
the academic training programs in assistive technology "might
need to think of a self-regulatory requirement (obligation) ...
[to] ... always evaluate and measure the end product."

Another barrier relates to regulatory criteria which precludes
rapid systems change. This is notable in the assistive technology
service delivery system because of the multidisciplinary nature
of service delivery as well as the multiple delivery sites where
services may be provided.  There are no consistent standards
regulating assistive technology across the disciplines or site. 
For example, those providing services within a health care
setting are much more likely to be held to accreditation and
licensing standards that
mandate program evaluation and specific outcome studies than
those in private practice, universities, or public schools. 
Another example are the inconsistencies with respect to the
utilization of support personnel found in the professional
licensure requirements in different states.  The standards
regarding the use of support personnel also vary widely amongst
professional organizations.  The uniqueness of assistive
technology and the regulatory requirements from different
agencies, organizations, and states will continue to have a
significant impact upon the development and implementation of
effective accountability and performance monitoring systems.

A final barrier with the potential to contribute to the failure
of outcomes activities relates to ethical practice issues.  As
the assistive technology community moves forward in identifying
and determining expected outcomes it will be confronted for the
first time with having to make several ethical and moral value
decisions. Specifically, identifying expected outcomes will
require: 1) determining what the basic level of adequate service
will be; and 2) what goes beyond that level.  This will require
establishing benefit and success levels. This means recognizing
that the assistive technology community cannot be all things to
all people.  Identifying expected outcomes and developing benefit
and success levels will need to be critically monitored as it is
well known that service providers are basically optimists and
therefore the possibility of benefit will be higher than the
probability of success.

Some have suggested that the concerns associated with
establishing benefit and success levels can be mitigated by
developing preferred practice patterns or practice guidelines. 
Developing these, however, will bring the assistive technology
community face to face with another dilemma.  The majority of
policymakers and payers view preferred practice patterns and
practice guidelines as very self serving.  They consider them as
a series of inbred policies derived by the special interests of
groups serving as providers.  Indeed preferred practice patterns
and practice guidelines may look at service delivery factors but
they do not necessarily look at or take into account the
effectiveness or efficiency of what is being done.  It will be
important to weigh the wisdom of challenging those who are
driving the accountability agenda with what to many may be
clinically appropriate.

IV.  Conclusions and Policy Options

Demand abounds for objective measures of the value and outcomes
of the delivered service or product.  However, subjective
measures, or how the consumer perceives the quality of the
service or product, are a reality and are inherent within
outcomes management research.  It cannot be easily ignored.  In
many respects, the objective and subjective parameters are
diametrically opposed and compound the evaluation of quality and
outcomes.  Therefore, it is important to acknowledge some of the
issues that may influence the development of expected outcomes. 
For instance, consumers are usually poor evaluators of the
objective aspects and providers are usually poor evaluators of
the subjective aspects. It is usually easier to evaluate the
goods than the services.  One cannot always "kick the tires"
before a service is delivered and it is difficult to return a
service to a complaint department.

In order to prevent these opposing parameters from clashing in
the development of expected outcomes and during the
implementation of an integrated system, common denominators must
be identified for both aspects.  It is important to link the end
product with the associated goods or services.  For example, a
common denominator could be value, defined as quality for a
reasonable price.  The quality of a service could be measured
relative to its value according to a financial outcome by the
provider or from a perceived satisfaction outcome by the
consumer.

Finally, identifying expected outcomes will require the assistive
technology community to better understand the ethics of imposing
its clinical standards upon others.  Clinical decisions, whether
they be the result of clinical reasoning or clinical judgment,
are discretionary and the outcomes of such need to be further
understood.

     Policy Options

Mandate the collection of outcome measurement data for all
federally-funded research related to assistive technology service
delivery.  Require all granting agencies (NIDRR, NCMRR, ADD, HHS,
OSEP, RSA, etc.) to include outcome measurement in the evaluation
criteria for review.

Support the development of a standardized outcome measurement
tool for assistive technology through a competitive grant process
or through an interagency initiative at the federal level that
involves all stakeholders.

Establish a research funding effort to conduct prospective,
long-term outcome and cost-benefit studies for the variety of
settings in which assistive technology service delivery takes
place.

Support the development and dissemination of an assistive
technology outcome measurement curricula for personnel
preparation training programs that focuses on the administrative,
financial and ethical aspects of accountability in AT service
delivery.

Hold a national invitational workshop to examine issues and make
recommendations with regard to accreditation standards for AT
services in settings such as universities, private practice and
public schools.


References

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Programs," ISAAC Research Symposium Proceedings (McKee City, NJ: 
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Preliminary Report," RESNA Annual Conference (Washington, DC:
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DeRuyter, F., and Kennedy, M.R., "Augmentative Communication
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Following Traumatic Brain Injury, D.R. Beukelman and K.M.
Yorkston (eds.) ( Austin, TX: Pro-Ed Publishing, 1990).

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Rehabilitation Conference (Boston, MA: 1990).

Forer, S., Functional Assessment Measures--Revised ( Santa Clara,
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Frattali, C., Thompson, C.K., Holland, A.L., Wohl, C.B., and
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Nichols, T.A. and Unruh, A., "Assistive Devices:  Utilization by
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Trauma Rehabilitation 7:57-67, 1992.

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Set for Nursing Home Resident Assessment System and Car Screening
(MDS):  Training Manual and Resource Guide (Natick, MA: Eliot
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Abandonment," Assistive Technology 5:36-45, 1993.

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Yoder, D., Letter to the Editor, Assistive Technology, 7:9- 10,
1995.

----------
Technology and Aging

William C. Mann, OTR, Ph.D.

I.   Introduction

This chapter explores issues related to the use of assistive
technology by older persons. Elders are not a homogeneous
population, and their use of assistive devices varies with a wide
number of factors including their level of functional
independence, interests, motivations, health, social supports,
education, age and income.  Many elders, as well as younger
persons who have mild physical or cognitive impairments or who
experience some pain, find that an assistive device is helpful
for completing a task. More severely impaired elders whose
activities are restricted would be considered disabled; about 8
to 10 percent of elders living at home have disabilities and may
require one or more assistive devices to assist with some tasks.
While this chapter discusses assistive devices useful to a wide
range of elders, the focus is on elders with disabilities.

There are many definitions for "the elderly" or "older persons."
They are typically tied to eligibility requirements for programs
like Social Security. Some definitions include people as young as
age 50 (membership in the American Association of Retired
Persons), while others reach up to age 70 (past mandatory
retirement age for professors). Most definitions suggest age 60
or 65 as the entry point for becoming an "older person."

Less than 100 years ago, only 1 in 25 Americans was over the age
of 65. By 1988, 1 in 8 were over 65 years old. In 1989 there were
31 million Americans over age 65, representing 12% of the
population. For those elders living in the community, about 13
percent have difficulty with one or more Activity of Daily Living
(ADL) task or with mobility.  Bathing and walking are the two
most frequently reported activities with which elders have
difficulty (Special Committee on Aging, 1991).

The National Institute on Disability and Rehabilitation Research
(NIDRR) supports the Rehabilitation Engineering Research Center
(RERC) on Aging at the University of Buffalo. An ongoing
longitudinal study of the RERC-Aging, called the Consumer
Assessments Study is providing an analysis of the use of, and
need for, assistive devices and environmental interventions by
older persons with disabilities. This study is following a sample
of elders over a period of five years, using interviews and
observations in their homes and neighborhoods. This chapter draws
on the work of the RERC-Aging, combining a focus on both
assistive technology and environmental interventions.

The term assistive device was defined by the Technology- Related
Assistance for Individuals with Disabilities Act of 1988 and
reported earlier in this book. The term environmental
interventions refers to home modifications, from simple removal
of throw rugs to adding a ramp or lift to a home. Environmental
interventions also include modifications in the yard, driveway
and sidewalk, and elevators in apartment buildings. In the
community, environmental interventions include adaptations in
such places as public transportation systems, stores, places of
worship and theaters. To maintain independence elders require an
approach that considers the environment as well as task specific
assistive devices. Gitlin and Levine (1992) relate three recent
developments that underline the importance of use of assistive
devices in the home:

� early hospital discharge under the Medicare prospective payment
system has resulted in people requiring assistive devices during
recovery at home

� passage of the Tech Act encourages the use of assistive devices
by persons of all ages, and will increase awareness of the
availability of assistive devices

� more disabled elderly persons are living at home, with family
members providing 80% of all elder care services.

There are clear differences between a home setting and an
institutional setting such as a nursing home. Nursing homes have
significant numbers of "helpers," making it unnecessary for an
elder to cook, to clean - even to independently bathe, dress or
eat. Home settings of elders, however, may also have "helpers" -
spouses, children, neighbors, formal personal care aides. Many
elders with disabilities, at home and in nursing homes, require
personal assistance with daily life tasks. One unfortunate
consequence in these situations is that an atmosphere of "help"
and dependence develops, and often many tasks that an elder could
do with little or no assistance, with or without an assistive
device, are taken over by the helpers. Professional assessment is
essential in ensuring the appropriate level of personal
assistance, as well as the appropriate assistive devices and
environmental interventions.

     Consumer Perspective

The most important factor in providing assistive technology and
home modifications for elders is the perspective of the person
who will receive these interventions. Elders need to be informed
fully about their disability in order to participate in the
selection of the most appropriate devices. Service providers need
to consider the priorities of elders - what do they want to be
doing, and do they really want or feel the need for recommended
devices. Have they been fully informed about options for
different types of devices?

The RERC-Aging Consumer Assessments Study asks elders with
disabilities what activities they can no longer do but they would
like to be doing; this question sought to determine if these
"missed" activities might be possible if the elder had an
appropriate assistive device (Mann, Hurren, Karuza and Bentley,
1993; Mann, Karuza, Hurren and Tomita, 1993). Table 1 summarizes
the results from these reports, categorizing and ranking their
responses. It is clear that the most missed activities are
primarily leisure activities. These activities reflect one aspect
of the "consumer perspective"
-    what is important to the person who might use an assistive
device. Unfortunately, most research and most services for elders
with disabilities focus on ADLs and to some extent IADLs, and may
not start with the consumer perspective on what is important. Yet
there are assistive devices to assist elders with many of the
leisure activities they miss.

[Insert Table 1 about here]

II.  Aging

There are two important factors in considering the needs of
elders - factors that differentiate elders from younger persons
with disabilities. First, there are changes that occur with aging
that are part of a natural developmental process - changes that
reflect declines in vision, hearing, strength, endurance and
balance. Second, as we age we experience more and more chronic
diseases and conditions; the older we are the more likely we are
to have multiple chronic conditions.

Chronic Diseases and Conditions of Older Age

     Arthritis

Arthritis is a serious disabling condition of the joints,
affecting an estimated 37 million people in the United States and
with the prevalence greatest among the elderly (Abyad and Boyer,
1992). Results of the Longitudinal Study on Aging indicate that
approximately 55% of elders have arthritis (Yelin, 1992).

Arthritis has a significant impact on activities of elders. 
Using the Longitudinal Study on Aging, Yelin and Katz (1990)
determined that for those elders who had arthritis and no other
chronic condition, 66% experienced limitations in physical
activities with 25% reporting limitations in ADLs or IADLs.  For
those elders who had arthritis and at least one other chronic
condition, 82% had limitations in physical activity, and 41% were
limited in ADLs. Examining these same individuals two years
later, the percentage of individuals with ADL/IADL limitations
increased significantly for both groups. Using data from the 1984
Supplement of the Aging of the National Health Interview Survey,
arthritis was determined to be the second most important cause of
restricted activity days among elders (Kosorok, Omenn, Diehr,
Koepsell and Patrick, 1992).

Verbrugge, Lepkowski and Konkol (1991, p. 71) concluded that
elders with arthritis had more difficulty in physical functions,
personal care, and household care than elders without the
disease. Disability was greatest in the areas of walking,
reaching, stooping and other physical functions, especially those
that require endurance and strength. The symptoms of arthritis -
joint pain, stiffness, reduced range of motion - contribute to a
reduction in activity.  Eventually, reduced activity can result
in loss of physical function.

Assistive devices for persons with arthritis can help in
preventing significant reductions in activity level.  Assistive
devices can also help in providing "joint conservation" -
preventing progressive injury to arthritic joints due to stresses
from overuse. There are many examples of simple devices, such as
electric can openers, built up utensils, and enlarged key
holders, that assist in activities and provide joint conservation
(Mann, Hurren and Tomita, in press).

     Alzheimer's Disease

There is a high rate of mental disorders - between 15 and 25
percent of older persons (Roth, 1976). The leading cause of
cognitive impairment in the elderly is Alzheimer's disease
(Mortimer, 1983). One out of every 10 noninstitutionalized older
persons has Alzheimer's disease or some other organic mental
disorder; this increases to almost one out of every two people
over the age of 85.

Assistive devices offer the potential to help people maintain or
regain independence, and for the elderly, may prevent or postpone
institutionalization. The use of assistive devices in controlling
or monitoring wandering behavior has been studied (Person,
Johnson and Coombs, 1989; Blasch and Martino-Saltzman, 1989), and
we now find increased use of these devices (Provider, 1989).  The
use of memory aids have also been shown to be helpful for persons
with Alzheimer's disease, particularly in conversing with
familiar partners (Bourgeoris).  Research on specialized memory
aids for the elderly has received funding from the National
Institute of Health under the Small Business Innovation Research
grant program (Kirkpatrick, 1992). While assistive devices offer
potential for increased independence for persons with Alzheimer's
Disease, one study has shown that these elders use fewer
assistive devices, and have a higher rate of dissatisfaction with
their assistive devices, than elders with physical or vision
impairments (Mann, Karuza, Hurren and Tomita, 1992).

     Stroke

Stroke is defined as "rapidly developing clinical signs of focal
(or at times global) disturbance of cerebral function lasting
more than 24 hours or leading to death with no apparent cause
other than that of vascular origin" (Aho, Harmsen and Hatano,
1980).  Stroke often results in weakness or paralysis of the
extremities on one side of the body.  Other common symptoms
include (prevalence in parentheses):  dysphasia or aphasia (51%),
memory impairment or disorientation (47%), and loss of or altered
sensation (36%) (Mayo, 1993). While stroke is the third leading
cause of death in the United States and Canada (Statistics
Canada, 1990), more than half of those individuals who experience
a stroke live beyond one year, and cause of death after one year
is typically from other causes (Abu-Zeid, Choi, Hsu and Maini,
1978).

The Consumer Assessments Study determined that elders with stroke
living at home own a large number of assistive devices - on
average almost 16 devices per person (Mann, Hurren, Tomita and
Charvat, 1995).  These elders find that assistive devices are an
important component in coping with their disability, and they use
and are satisfied with most of the devices they own.  This study
also found that home- based elders with stroke experience the
largest number of environmental problems in the bathroom and
kitchen - rooms where basic ADLs and some IADLs are carried out. 
There are solutions for these problems - for example if cabinets
are too high or deep, placing a lazy Susan in a lower shelf can
make accessing items easier; using a hand-held shower and a bath
bench eliminates the need for standing in a shower or tub.

     Vision Impairment

Vision impairment in older persons has been documented and
described by numerous authorities (Kirchner and Scott, 1988;
AARP, 1991). Older persons represent a heterogeneous population,
which makes it difficult to determine the exact number of persons
who are blind or who have a severe visual impairment; however,
one recent study estimates that 82 older persons out of 1000 have
a serious visual impairment (NCHS, 1990).  One out of 5 elderly
persons has difficulty with reading because of visual impairment,
and 1 out of 20 persons over 65 cannot see words or letters on a
page (Census Bureau, 1986).  Most older persons with visual
impairments are not totally blind, but have some functional
vision; this residual vision is called low vision.  Low vision is
characterized by loss in the peripheral field or in central
vision.  Loss of peripheral vision is sometimes called tunnel
vision.  The major causes of vision loss among elders are
glaucoma, macular degeneration, cataracts, and diabetic
retinopathy.

Assistive devices are playing an increasingly important role in
improving the functional performance of visually impaired
persons.  Enlarged images can be provided through such
traditional devices as magnifying glasses, and newer, high- tech
devices such as closed circuit television systems called "print
enlargement systems." Environmental interventions are also
helpful: increasing lighting and decreasing glare where the
person is working; providing good color contrast on controls,
moving objects closer to the person (Mann, Hurren, Karuza and
Bentley, 1993).

     Hearing Impairment

One third of all elders experience at least some hearing
impairment, and for those over 85 years old, almost half have
hearing loss (Hotchkiss, 1989).  It is one of the five most
common chronic conditions of aging.  While hearing loss is common
among elders, many accept it as a natural process of aging and do
not seek professional help or use assistive devices.  This is
unfortunate, as hearing loss can result in decreased
communication, and is often associated with isolation and
depression (Glass, 1986). Hearing loss can also impact on health
and safety, such as not being able to hear instructions from a
physician or pharmacist, or not being able to hear fire alarms or
traffic in the street.

Presbycusis is the most common form of hearing loss among elders. 
The major symptom of the early stages of Presbycusis is inability
to hear high pitched sounds.  As the disease progresses, middle
and lower pitched sounds also become difficult to hear.  A second
very common hearing disorder among elders is tinnitus.  The major
symptom is a continuous ringing or buzzing sound in the ears,
even without any external stimuli.

For persons with hearing impairments, there are amplification
aides, alarm systems, speaker phones, closed captioning for
television, and vibrating paging devices - just to name a few. 
Environmental interventions include attention to acoustics in the
design, construction, and renovation of buildings used by persons
with hearing impairments.  In homes of elders, carpets and drapes
can be used to absorb background noise.  Placement of furniture
should take into account the need for persons with hearing
impairment to be close and to be able to see clearly others with
whom they are speaking.

     Other

There are many other chronic diseases and conditions.  The
RERC-Aging Consumer Assessments Study ranked these conditions by
prevalence in Table 2.  It is important to keep in mind that many
elders have multiple chronic diseases and conditions, and require
a combination of assistive technology devices and environmental
interventions. They take a number of medications to treat these
conditions.  The RERC-Aging Consumer Assessments Study found that
elders with disabilities had on average 5.0 chronic diseases, and
used 3.4 medications (Mann, Hurren and Tomita, 1993). In
addition, elders face a decline in social resources and income. 
These combined factors result in a great need for assistive
devices and environmental interventions, but often isolation from
information on assistive devices, and low income, result in
elders not receiving the assistive devices or home modifications
they need (Mann, Tomita, Packard, Hurren and Cresswell, 1994).

[Insert Table 2 about here]

III. Overview Of Assistive Devices For Older Persons

     Devices for Persons with Mobility and or Motor Impairments

     Environmental Control Devices

Environmental control devices (ECDs) are used by persons with
physical disabilities, and may also be helpful for persons with
cognitive or visual impairments.  ECDs assist elders in operating
almost any device that runs on electricity: such as computers,
radios, phone, lights, and security systems.  TV remotes offer an
example of a widely used ECD.  Unfortunately, TV remotes were not
designed with the needs of elders in mind.  Consumer Reports
examined 20 universal remote control devices and concluded:  "far
too few remotes appear to have been engineered for ordinary human
hands, eyes, and brains.  Small keypads crammed with row after
row of identical, minuscule buttons, illogically arranged with
hard to read beige-on-gray lettering, are common failings"
(Consumers Union, 1992).  A recent study demonstrated that elders
preferred larger remote control devices, with large buttons and
good color contrast between the symbols and background (Mann,
Ottenbacher, Tomita and Packard, 1994).

Remote control devices can increase environmental interaction
even among severely disabled elders.  A recent study of nursing
home patients found that a group given hand- held, X-10 type ECDs
used their radios significantly more than a control group who did
not have the ECDs (Mann, 1992).  These X-10 devices are available
in electronic stores for prices under $35.

     Walking Aids

     The cane ranks as the most widely used assistive device in
the United States, with over 60 percent of cane users over the
age of 65 years (LaPlante, Hendershot and Moss, 1992).  There are
a variety of designs for cane handles and bases, and canes have
been fashioned out of a wide variety of materials including wood,
aluminum, and most recently lightweight carbon fiber materials. 
While canes are widely used to assist in support during
ambulation, cane owners report a high number of problems with
their use.  The Consumer Assessments study determined that almost
half of all problems encountered with canes related to difficult
or risky use, which resulted in incidents of tripping or getting
tangled up (Mann, Granger, Hurren, Tomita and Charvat, in press). 
Careful professional guidance in the selection of canes, training
on their use, and continued follow-up, is essential.

There are 1.5 million people in the United States who use
walkers, and more than 3/4 are over age 65.  Walkers can support
more weight than a cane.  Like canes, there are many walker
designs and features.  Some walkers even offer a seat for the
user to rest, and baskets and trays for carrying items.  Like
canes there are also a significant number of walker users who are
dissatisfied with their devices, and the problems they are
experiencing could lead to a fall.  Many people receive their
canes and walkers with no professional guidance in the selection
and training - this is a serious gap in our service delivery
system (Mann, Hurren, Tomita and Charvat, in press).

     Wheelchairs

     Wheelchairs offer another option for independent mobility,
or for assisted mobility.  There are many options for cushions,
armrests, wheels, tires, hand rims, and power.  A careful
professional assessment should precede any wheelchair purchase.

Devices for Persons with Vision Impairments

There are a large number and variety of inexpensive, simple
assistive devices for persons with visual impairments, including
pens that write with a bold line, magnifying glasses, and writing
guides.  Books and other materials in large print are available
in many bookstores and libraries.  Banks can print checks with
large characters.  Games, such as Monopoly and Scrabble are
available in large board editions as well as with Braille.  Most
stores selling phones have models with large buttons and large
numbers.  Clocks, watches, thermometers, and blood sugar monitors
are all available with either voice output or large print
features.

For computer users, there are many software programs that magnify
the image on the computer screen, making it possible for many
elders with low vision to see what is on the screen.  Stand-alone
print enlargement systems incorporate closed circuit TV to
provide a large image of text or pictures placed on the device's
platform.  These devices can also be adjusted to reduce glare -
an important feature for many elders who are sensitive to glare.

Devices for Persons with Hearing Impairments

The hearing aid is the most common assistive device for elders
with hearing impairment.  Unfortunately, the hearing aid ranks as
the assistive device with the highest rate of dissatisfaction.  A
large percentage of the problems relate to poor fit - typically
the result of not having had an adequate audiological assessment
(Mann, Hurren and Tomita, 1994).

Assistive listening devices (ALDs) are systems that include a
microphone for the person speaking, amplifiers to increase the
volume of sounds, and for the person with the hearing loss, a
headset.  Many churches and theaters have installed ALD systems. 
For many elders, these systems have made it possible to
participate in community activities.

A number of other devices are helpful for elders with hearing
impairment.  Electronics and phone stores carry phones that offer
amplified sound, as well as add-on devices to provide
amplification. Closed-captioned television text at the bottom of
the screen on televisions is very helpful for many elders.  All
new televisions now offer the hardware for displaying closed
captioning.  Other devices include smoke detectors, doorbells,
and alarm clocks that provide a flashing light or vibration to
alert the person with a hearing impairment.

Devices for Persons with Cognitive Impairments

Memory loss can be augmented with a simple low-tech solution: 
writing notes on paper and posting them in appropriate places. 
An alternate, more high-tech solution is to use a small
electronic notebook.  Many digital wristwatches can be programmed
to sound an alarm - useful for reminders to take medications. 
Memory buttons for storing phone numbers, or "picture" phones,
are also helpful for many persons with memory loss.  Other
helpful devices include automatic turn-off switches for stove
burners, automatic timers for lights, movement-sensitive light
switches that turn lamps on when a person enters a room, and
alerting systems that can sound an alarm when someone wanders too
far away.

     Home Modifications

Several authors have recommended approaches to adjusting the
environment to meet the needs of older persons with disabilities. 
Faletti (1984) described how the environment can be structured
for elders with physical and sensory impairments.  Zgola (1987,
p. 28) described the need for "a calm, predictable and accepting
environment" in meeting the needs of persons with Alzheimer's
disease Hasselkus (1992,
p.   205), also addressing the needs of persons with Alzheimer's
disease, stressed the need for "prevention of harm" and the
"primary mandate of safety'' as well as ``providing an enriched
environment." Seelman discussed the need for environmental
adaptations for older persons who are deaf or hard of hearing,
recommending adaptations to reduce noise and visual distractions.
Levy and Gordon pointed out the importance of environmental
factors as possible causes of "reduced function" for persons with
vision loss.  Jackson, Longino, Zimmerman, and Bradsher studied
the ultimate environmental intervention - moving from an
environment that does not provide sufficient support to one that
does.  They state, "Residential mobility is a major form (but
only one form) of environmental adaptation.  At issue, rather, is
the balance between physical or dispositional competency to
negotiate one's living environment and the resources that exist
in, or can be brought to, the surrounding environment.

The Consumer Assessments Study found 500 environment-related
problems in the homes of the first 127 subjects interviewed. 
This represents a mean of almost 4 problems per home.  These
environmental problems were grouped under the categories design,
maintenance or social/support.  A lock with a small keyhole is a
design problem for a person with a visual impairment or poor fine
motor performance and can be addressed with a design solution:
change the lock to one the person can operate, such as a magnetic
card lock, or a numeric keypad lock.  Insufficient lighting is
also a design problem, if there are too few fixtures, or if the
fixtures allow an insufficient total wattage.  Design problems
can be addressed by changing the design, which is often
relatively inexpensive.  While we often think of design problems
as those relating to doorways and ramps, and design changes as
expensive, such as widening of doorways, items such as light
fixtures, outlets, thermostats, locks, shelving in closets,
toilet seats, and door knobs often can be replaced or modified at
low or moderate cost, and with a major positive impact for the
user.

Maintenance is another major category of environmental problems. 
Pavement surface, condition of carpets, loose handrails, shaky
stairs, clutter, frayed wires on appliances or light cords,
plumbing problems, are all problems with maintenance.  More basic
and very serious maintenance areas include the roof, doors,
windows, and furnace.  Many elders still own their own homes,
having provided much of the maintenance on their homes in their
younger years.  As they age, and impact of impairments increases,
homes become more difficult to maintain independently.  Many
elders simply accept the problems of poor maintenance and ignore
the problems.  Non-homeowners who rent may receive poor
maintenance services from landlords, or simply don't notify
landlords when maintenance problems arise.

The third category is social/support.  Maintenance and design go
hand-in-hand with a social/support system.  The system may be
simple: a spouse or child who observes environmental problems and
helps in finding solutions for them.  The system may include a
landlord, a home health care aid, a visiting nurse or a
therapist.  When the members of this social/support system are
alert to environmental problems, they assist in identifying and
solving them.  What is surprising and disturbing in the findings
of the Consumer Assessments Study is that most elders have a
social support system, but that its members either do not
recognize, or have not been able to address, significant numbers
of environmental problems.

In summary, at-risk elders face significant numbers of
environmental problems in their homes.  While these individuals
receive other services, their home environment needs are not
adequately addressed.  Pynoos (1992, p. 25) states: "Home
modification and repair need to be seen by professionals, older
people, and public officials as a key factor in supporting aging
in place." More attention must be focused on ensuring that
careful assessment of the homes of the elderly at-risk is a
routine component of service provision.  Routine follow-up must
also be established to address new problems that arise as the
needs of the elder change.

     Assistive Devices For Caregivers

Often a spouse or child provides a considerable amount of
caregiving for elders with disabilities.  These family members
may themselves be older, and facing impairment.  Assistive
devices and home modifications that promote independence can
assist both the elder with a disability and the caregiver.  Other
assistive devices, such as lifts, may be essential for tasks that
require strength or endurance beyond the capability of the
caregiver.

IV.  Systems Problems In Delivering Services

Elders are a politically active group, and represent a powerful
lobbying force.  They are represented by a number of
organizations such as the AARP and National Council on Aging
(NCoA).  Issues of health care are of primary concern.  While
elders, as a group, place high value on programs such as Medicare
and Medicaid, discussion and debate rarely gets down to issues
related to reimbursement of expenditures for assistive devices
and home modifications.  With the exception of some medically
prescribed devices, assistive devices and home modifications are
not reimbursable under these programs.  This may in large part be
due to a lack of recognition among elders of the significance of
assistive devices; also, the 8 percent of elders who are disabled
- those individuals most in need of home modifications and
assistive devices - are less likely to be among those most
politically active.

In considering systems of service for elders, it is safe to say
that there is no single system of services for providing elders
with assistive technology and environmental interventions. 
Services under the medical model provide for acute rehabilitation
typically following the acute phase of disabling conditions such
as stroke and hip fracture.  Upon discharge from the hospital or
skilled nursing facility rehabilitation program, these elders
usually receive a number of assistive devices, and their "case"
is referred to an outpatient or home care program, where the
elder may receive a home evaluation, additional assistive devices
as needed, and some home modifications.

Elders who do not receive acute rehabilitation, but experience a
more gradual decline in functional status, may receive services
under programs established under the Older Americans Act.  These
services may include personal care aides, meals, a home
evaluation, and some environmental interventions.

Third party reimbursement for assistive devices follows the
medical model:  a physician prescription is required, and only
those devices considered a medical necessity are covered.  For
those devices covered, typically only the least expensive model
is reimbursable.  For example, an elder may require a walker for
independent mobility.  Even though this elder might be able to go
grocery shopping in nearby stores if provided with a wheeled
walker with basket (for carrying groceries) and seat (for
resting), only the standard frame aluminum walker with no
additional features may be approved under Medicaid.

Many elders and their caregivers choose to purchase assistive
devices using their own funds. More than half the devices these
elders own were purchased out of pocket, similar to findings of
the method of payment for assistive devices in a national survey
(LaPlante, Hendershot and Moss, 1992). Service providers under
the medical model are often reluctant to make recommendations for
assistive devices that are not covered under third party
reimbursement.  This is unfortunate, as elders and their
caregivers should be given information on all options available,
so they can choose the appropriate device relative to their
needs, income, and third party coverage.

Some assistive devices, such as talking clocks and remote
controls are typically purchased by elders with little or no
professional involvement.  Other devices such as canes, grab
bars, and bath benches are also at times selected by elders
without the assistance of a therapist or nurse.  While there is
no risk in purchasing the talking clock, unfortunately many
elders put themselves at risk by procuring inappropriate canes
and walkers, or by installing grab bars in ways that could be
dangerous.  Lack of information on assistive technology services
is as problematic as lack of information on the devices
themselves.

Case managers attempt to coordinate the service an elder is
receiving.  Case managers are often provided by home health care
agencies and hospital rehabilitation programs.  For the most
part, however, case managers do not receive strong training in
assistive devices, and often fail to recommend an occupational
and/or physical therapy assessment.  Many elders never receive
the assistive devices or home modifications they need because
they have not had a thorough assessment.

     Information

As discussed earlier in this chapter, there is a difference
between helpful assistive devices available in stores, and
devices that require professional assessment, training, and
follow-up.  Professionals such as occupational and physical
therapists are trained to recognize the strengths and limitations
of elders, the relationship of their limitations to their
environment, and are knowledgeable about the range of assistive
devices.  These professionals are a very important source of
information for elders.

Elders also need general information on what assistive devices
are available.  Project LINK is a free information service to
help people learn about assistive devices.  Many people with
disabilities are not aware of the wide variety of available
assistive devices, or they lack information on where to obtain
them.  On the other hand, companies marketing assistive devices
have difficulty reaching people who most need their products, as
listings of people with disabilities are confidential and not
available to companies.  Project LINK bridges the information gap
between companies who sell assistive devices and persons with
disabilities who might buy them.

To join Project LINK a person calls this toll free number: 1-
800-628-2281, and answers a few questions.  Alternatively, a
person can fill out a short questionnaire, and return it on the
pre-addressed and pre-stamped form. This information is stored in
a confidential data base.  Companies who sell assistive devices
can request that Project LINK mail out their product catalogs and
other product literature.  Project LINK does not give the names
of its participants to the companies, but provides a mailing
service for information on their products.  There is no cost to
consumers to register with Project LINK.  They join Project LINK
knowing they will receive free information in the mail on
products that may help them, while having the assurance that no
sales people will contact them.  Any person may cancel their free
membership at any time.  Since the Project LINK data base
includes information on the types of activities with which people
have difficulty, and the types of devices in which they might be
interested, companies can have Project LINK carry out very
targeted mailings.

Project LINK was established in 1993 at the Center for Assistive
Technology at the University at Buffalo in New York.  Project
LINK serves individuals with disabilities and companies who sell
assistive devices from around the United States.

The American Association of Retired Persons (AARP) also has a
series of booklets on assistive devices available for their
members.  You can contact the AARP at 202-434-2277, or write to
them at 1909 K Street NW, Washington, DC 20049.

V.   Conclusions and Policy Options

The following are recommendations for national policy on
assistive technology and environmental interventions for older
persons.

The Technology Related Assistance for Individuals with
Disabilities Act of 1988 (Tech Act) states that assistive
technology information should be made available to persons of all
ages.  While persons over 65 years of age represent the largest
group of people with disabilities, Tech Act programs in most
states have done little to reach elders.  Most states have
directed their Tech Act programs out of State Vocational
Rehabilitation or State Education Departments, where the focus is
on children or working age adults.  Tech Act programs must become
more responsive to the information needs of elders with
disabilities, as well as playing a part in systems change
activities.

The Older Americans Act mentions assistive technology only in the
context of programs funded under the Act providing information to
elders.  The reauthorization of the Older Americans Act should
specifically target resources for assistive technology and home
modification information services, and for some actual services,
based on need.

Reimbursement for assistive technology under Medicare/Medicaid
should be expanded to include all appropriate devices relevant to
improvement or maintenance of functional independence, and should
also include home modifications.  Prescription under
Medicare/Medicaid should be expanded beyond physicians to include
occupational and physical therapists.

Basic professional education and continuing education for case
workers, physical and occupational therapists, physicians, and
nurses should include training on assistive technology and home
modifications for elders.

Research is needed to explore the relative costs involved with
the provision of assistive technology and home modifications,
versus use of personal home health care services or
institutionalization. One study is in progress on this topic at
the University at Buffalo Rehabilitation Engineering Research
Center on Aging, to be completed in August, 1996.  Other research
on the relative effectiveness of different assistive devices, and
the development of new assistive devices is also needed.

Groups representing the elderly, such as the AARP, are already
recognizing the importance of assistive technology.  To achieve
these policy recommendations, these organizations should continue
to help in shaping federal legislation that will ensure
information on devices and services, as well as reimbursement for
devices and services, are available to those older persons who
need them.  Likewise, professional accrediting bodies must
incorporate standards on assistive technology assessment,
provision, and follow-up, particularly in relation to the needs
of the elderly.

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----------
Table 1. Activities Most Missed By Elders with
Disabilities (N=392)


     ACTIVITIES     TOTAL
RESPONSE S (537)
     Doing, Watching Sports   86
     Driving   70
     Walking   67
     Gardening/Housework 59
     Socializing    49
     Traveling 29
     Shopping  24
     Art: Painting, Sculpting 22
     Reading   21
     Work 16
     Other     30
Table 2.  Chronic Diseases Of Elders With Disabilities

DISEASE / CONDITION N / (% of 392 subjects )
Arthritis 286 (73.0%)
Circulation trouble in arms or legs     208 (53.1%)
Heart trouble  172 (43.9%)
Other urinary tract disorders 156 (39.8%)
High blood pressure 155 (39.5%)
Cataracts 138 (35.2%)
Other stomach or intestinal disorders   116 (29.6%)
Skin disorders 90
     (23.6%)
Hearing impairment  85
     (21.7%)
Effects of stroke   73
     (18.6%)
Diabetes  66
     (16.8%)
Emphysema 61
     (15.6%)
Thyroid or glandular disorders     50
     (12.8%)
Macular Degeneration     50
     (12.8%)
Ulcer of the digestive system 48
     (12.2%)
Cancer or leukemia  47
     (12.0%)
Alzheimer's disease 47
     (12.0%)
Speech impediment   43
     (11.0%)
Anemia    35 (
     8.9%)
Glaucoma  34 (
     8.7%)
Asthma    30 (
     7.7%)
Kidney    23 (
     5.9%)
Epilepsy  17 (
     4.3%)
Hip fracture/replacement 16 (
     4.1%)
Effects of polio    15 (
     3.8%)
Knee replacement    12 (
     3.1%)
Tuberculosis   11 (
     2.8%)
Parkinson's disease 9 (
     2.3%)
Multiple sclerosis  7 (
     1.8%)
Liver disease  2 (
     0.5%)
Cerebral palsy/atrophy   2 (
     0.5%)
Other     100 (25.5%)

----------
Development, Evaluation and Marketing of Assistive Devices

Joseph P. Lane, MBPA

I.   Introduction

This paper reviews programs, policies and decision options that
present
opportunities or barriers for the future development and
marketing of appropriate assistive devices.  The time period for
review is from 1982 to the present.  The Office of Technology
Assessment's (OTA) 1982 report is the benchmark -
-    the first concerted attempt to examine disability and
technology issues from a national perspective.

Readers of this 1995 paper are urged to read the 1982 report. 
The report's author's did their homework:  they characterized the
state of the practice; they identified critical problems; and
they offered Congress a menu of policy options to address the
problems.  Although the Office of Technology Assessment did not
recommend any particular action, the author's team assumed that
the options offered could help alleviate the existing problems in
development, evaluation, transfer and marketing. What happened? 
Did Congress implement the policies?  Did others achieve the
desired ends through other means?  This paper draws the following
conclusions about
the current situation resulting from policies over the past
fifteen years, and what actions are still needed at the national
level:

     Federal Government

Current - Unrelated Federal support in four areas:  university
research and development, small business development,
public-private technology transfer, and civil rights for persons
with disabilities, all converged to improve supply and greatly
increase demand within the field.

Need - An absence of overall coordination at the Federal
agency-level, and an absence of incentives to cooperate at the
Federal line-level, prevent the optimum application of available
government resources.

     Marketplace Supply

Current - The private sector is pursuing the government's
incentives for small business programs, to introduce
technological advances into new assistive devices.

Need - Companies still lack national market data based on
functional needs, they lack access to information about
federally-sponsored research and development, and their
development efforts are hampered by the threat of personal injury
liability.

     Marketplace Demand

Current - The consumers have more knowledge about the existence
and value of assistive devices, and through Federal initiatives
are increasingly active in the private sector's needs analyses
and product development.

Need - Many consumers still lack the resources, or the
reimbursement options, necessary to acquire the available
devices, and consumers have no source for comparative data to
assess devices prior to purchase.

II.  Status of Development, Evaluation, Transfer and
Marketing in 1982

     Development in 1982

In 1982, disability-related research and development (R & D)
programs were scattered across private sector internal product
development, federal and state sponsored programs in universities
and medical facilities, and limited grant support from interest
groups within professional associations.  The term "assistive
technology" itself would not be defined in federal legislation
for six more years.

The Federal government spent about $66 million on assistive
technology R&D in 1979.  At the same time it spent $36 billion on
income subsidies for persons with disabilities.  As such, R&D
represented only 0.2 percent of the Federal transfer payments for
income assistance.

The most active federal agencies in the field were the National
Institute of
Handicapped Research (now the National Institute on Disability
and Rehabilitation Research (NIDRR)), the Office of Special
Education (now the Office of Special Education and Rehabilitative
Services encompassing NIDRR, RSA and OSEP), the Veterans
Administration, and the National Institutes of Health. The
National Institute of Handicapped Research (NIHR) allocated
fifty-percent of the grants from all federal agencies for
rehabilitation
engineering ($9.5 million) in 1979. The National Aeronautics and
Space Administration (NASA) sponsored projects transferring air
and space technology to the health and disability fields, but not
through a dedicated program.

OTA's 1982 report did not attempt to characterize or quantify the
private and not-for-profit sectors' level of R&D activity in the
field of assistive technology.  It did acknowledge that these
sectors played a primary role in the development and delivery of
assistive devices.  The report cited multiple instances of joint
research and development involving companies, university and
federal research programs.  These efforts were characterized as
resulting from the dedication of individuals rather than the
presence of formal programs.  The private sector was unable to
fully integrate existing
technologies in their products, because the services and funding
for persons with disabilities came from many different and
uncoordinated sources.

The Federal government recognized the need for a national- level
effort to
systematically identify and coordinate R&D activity.  The limited
resources available to the field, the varied and evolving
applications of technology to disabilities, and the multiple
sectors involved, all made assistive technology an appropriate
place for Federal involvement.  The progress made to the present
is reviewed in this report. Today, the unresolved issues remain:

     Which sector should perform R&D?

     How much should be funded and conducted?

     Who should benefit financially from the complex and
synergistic R&D sponsored by public, private and not-for- profit
entities?

The 1982 report recognized that emerging technological advances
in micro-circuitry, materials and bio-medical knowledge, all
promised an "explosion" of innovations.  The following decade
would fulfill that promise.  The report foresaw that the
successful applications of such innovations to the field of
assistive technology, required an emphasis on appropriate methods
of evaluation, transfer and marketing.

     Evaluation in 1982

Assistive technologies address the functional needs of people
with disabilities.  Thus, the evaluation of assistive
technologies requires a broad range of criteria applied to the
full spectrum of human activities.  In 1982: "OTA finds that the
public-private sector partnership is inadequately designed to
support fully useful evaluation efforts and that a coherent,
adequately funded and focused program of evaluation is needed at
all levels of diffusion and adoption of technology for
disabilities." (page 11).

OTA found weaknesses in assistive technology evaluations similar
to those identified in a study of medical technology evaluations:

� No formal or well-coordinated overall system;

     � Existing technologies are evaluated much less
frequently than     new ones;

     � Preventative technologies receive less attention
than therapeutic ones;

     � Inadequate funding for thorough clinical or "life- use"
trials;

� Absence of evaluation input from consumers.

The Food and Drug Administration's evaluation program focused on
medical devices.  The National Institutes of Health's clinical
trials criteria were deemed not appropriate for assistive
devices.  The NIHR (now NIDRR) was the lead evaluation agency for
assistive devices, both for internal and external programs. 
However, even this lead agency had inadequate funding to sponsor
sufficient numbers of evaluation programs.

The expected growth in assistive devices introduced to the
marketplace, magnified the need for sufficient evaluation
programs based on appropriate evaluation criteria.

     Diffusion & Marketing in 1982

The OTA's 1982 report astutely describes how assistive devices
fall under two different models.  The health care model
represents the research, development and evaluation aspects of
assistive devices.  It also represents the social, political and
personal motivations for creating assistive devices, and the
public and not-for-profit funding expended to support it.  The
private sector model of diffusion and marketing takes over
somewhere in this cycle.  The private sector model represents the
manufacturing and distribution channels needed to supply the
assistive device in response to perceived demand.

Several products had successfully migrated from federally-
supported R&D to the private sector marketplace by 1982.  They
were noted as exceptions.  The long list of disincentives to
successful product commercialization was discouraging:

     � Market segments are ill-defined and customer
estimates are  inaccurate;

     � Typical customer's economic status falls below the median;

     � Assistive devices offer an insufficient return to attract
investors;

     � Actual and perceived product liability limits new
business  development;

     � Reimbursement approval guidelines make decisions
ambiguous;

     � Reimbursement amounts fail to cover the cost of goods
sold;

     � Consumers are not fully involved in product
design, testing and marketing.

The long list of disincentives is especially discouraging because
it accurately captures the unresolved problems of diffusion and
marketing nearly fifteen years later.

III. Changes in Technology, Regulations, Programs and
Perceptions 1982 - 1995

     Changes in Technology Base as Applied to Assistive Devices

PC's and laser printers; cell-phones and walkmans; Gore-Tex and
Thinsulate.
These ubiquitous products were not commonly found in the
marketplace when the Office of Technology Assessment wrote their
1982 report.  There are many more:  cable & DDS TV; mountain
bikes and rollerblades; CD's and VCR's.  These products now exist
because companies transferred new technological innovations into
consumer products.

Similarly, today we can only anticipate the future applications
of nano-technology, superconductivity, nuclear fusion, smart
materials, biotechnology, virtual reality and artificial
intelligence.  These fields of basic research will yield
applications that are fundamental departures from our current
concepts of products and services.

The field of assistive technology has and will continue to
benefit from these same advances.  In 1982, the most technically
advanced devices available in the marketplace contained
solid-state components and relatively heavy materials.  They were
also fairly expensive compared to today's units.  For example,
for between one and five hundred dollars a consumer could
purchase (a) a TV channel selector to change stations and
activate television; (b) an environmental control unit using
ultrasonic signals that traveled only 30 feet; or (c) a
respirator alarm boasting no mechanical switches.  For more than
five hundred dollars, a consumer could purchase (a) a cordless
telephone operational within 300 feet of base unit; (b) the first
lightweight wheelchair model weighing 27.5 pounds; or (c) a
reading machine employing a vibrating tactile pad (Kreisler &
Kreisler, 1982).

Since the microprocessor was not yet widely introduced for use in
commercial products, the 1982 catalogue contains no computer
access switches, no alternate keyboards, no computer-based
hardware and software devices, and no microprocessor-based tools. 
Even the low tech devices lacked the materials and design
improvements taken for granted today.

Across the inventory of devices both low and high-tech, the
devices of today are lighter, smaller, smarter and less
expensive.  Current assistive devices show evidence of technology
transferred from other applications in defense, energy and
industry.  Technology for fighter pilots to track targets based
on eye position, was transferred to keyboard and icon tracking
technology for computer-users with disabilities. Composite
materials offering low weight and high strength were developed
for advanced weapons systems, then migrated through sports
equipment (bicycles and hangliders) and finally into wheelchairs. 
Developments drop prices in new products, as when the cost of
speech input software for computers dropped from $12,000 to
$2,000 over four years, and is expected to be bundled within
standard software packages next year.

The development of the technology underlying these advances, and
the ability to transfer the technology from research laboratories
to the marketplace, both owe much to research, development and
technology transfer incentives created at the national level.

     Changes in Regulations

Legislation and regulations regarding technology transfer have
generated increased cooperation between the public and private
sector (FLCTT, 1991).  Key legislation includes:

     � Stevenson-Wydler Technology Innovations Act of 1980
     � Bayh-Dole Act of 1980
� Small Business Innovation Development Act of 1982 � Federal
Technology Transfer Act of 1986
     � National Competitiveness Technology Transfer Act of 1989
     � Defense Conversion Reinvestment and Transition
Assistance     Act of 1993
� Small Business Technology Transfer Act of 1992

Stevenson-Wydler Technology Innovations Act of 1980

The Technology Innovation Act, named the Stevenson-Wydler Act (PL
96-480), required Federal Laboratories to actively participate in
technical cooperation, and to disseminate information on internal
resources.  To this end, the law provided for the establishment
of Offices of Research and Technology Application at major
laboratories, and the Center for the Utilization of Federal
Technology, in the National Technical Information Service.

     Bayh-Dole Act of 1980

The Bayh-Dole Act (PL 96-517) abolished regulations that
previously acted as
disincentives to technology transfer.  The Act gave not-for-
profits (including universities) and small businesses first right
to secure title to any inventions developed with government
support.  The government agency still maintained a non-exclusive,
nontransferable, paid-up license to apply the invention anywhere
for the good of the United States.  The Act also permitted
government owned and government operated (GOGO) laboratories to
grant exclusive licenses to government patents.

Small Business Innovation Development Act of 1982

The Small Business Innovation Development (SBID) Act (PL 97- 219)
created the Small Business Innovation Research (SBIR) program. 
The SBIR program was based on evidence that innovation is the
single most important factor in long-term growth of the U.S.
standard of living, and small companies are the best vehicle for
innovation in the economy.

The SBID Act reserved 1.25 percent of the federal government's
outside
research and development budget to support new technology
development efforts by small businesses, related to the
sponsoring agency's mission.  The funding for start-up ventures
and small business owners, represents an opportunity to share the
cost of higher risk development efforts with the U.S. government.

The SBIR program operates as a competitive grant program.  An
inventor
receives a Phase I award of up to $75,000 over six months
($50,000 until 1992), to test an idea's technical feasibility and
application merit.  A Phase II award of up to $750,000 over two
years ($500,000 until 1992) to reduce the idea to a functional
prototype.  To qualify for Phase II, an inventor has to
demonstrate interest from a third party capable of moving the
device to market (Phase III funded by private sector).  Of
course, given the tenuous stage of development, most third
parties will only provide the most conditional commitments.

A ten year program review of the SBIR program by the General
Accounting
Office documented that $1 billion in awards had generated over $1
billion in new products and development funding, expected to grow
to a $3 billion return over the next five years (GAO, 1992).  The
review was sufficiently favorable to re-authorize the SBIR
program through the year 2000, increase the set-aside to 2.5
percent of research and development budgets, and increase the
award amounts.

SBIR funds support product concept development, reduction to
practice and
eventual commercialization through a business or a partner.  The
SBIR program has proven to be a useful prototype development
resource for the field of assistive technology.  The eye-tracking
computer control system mentioned above, moved from military to
civilian applications with support from the SBIR program.  A
small business developed a new type of hearing aid that converts
sound waves into tactile vibrations. The user can learn to
identify these vibrations with their corresponding sounds or
words.  A follow-up study with SBIR winners would best determine
the actual contributions to product development within the
assistive technology field.

Assistive device related projects are funded primarily through
the U.S. Department of Education (USDE), National Institutes of
Health (NIH) and National Science Foundation (NSF), with
occasional disability spin-off applications coming from
Department of Defense or Department of Energy funded SBIRs. 
Given the higher risks of developing experimental applications of
advanced technology, a high failure rate should be expected in
Phase I.  However, the best intentions of agencies and inventors
still have not overcome the information limitations concerning
what is already available and what has been unsuccessful.  As a
result, many Phase II projects do not move on to Phase III -
-    product commercialization.

     Federal Technology Transfer Act of 1986

The Federal Technology Transfer Act (PL 99-502) made the broadest
changes to the guidelines for public/private research and
development.  The Act authorized government owned and government
operated (GOGO) laboratories to pursue agreements with industry
to commercialize government technology.  Previously, such
collaboration was prohibited.  Involving government employees in
the private sector sale of devices based on federal technologies
was viewed as a conflict of interest.  All federal laboratory
scientists and engineers were made responsible for technology
transfer, to the extent that technology transfer activity be
considered in employee performance evaluations.

The Cooperative Research And Development Agreement (CRADA) is the
contractual vehicle for collaboration under the Act.  Within the
CRADA, a GOGO laboratory director is authorized to negotiate
licensing agreements for inventions from their laboratories, to
exchange personnel, equipment and resources with their partners,
and to grant or waive rights to GOGO intellectual property.  The
CRADA establishes the role of federal and private sector partners
in the development, manufacturing and marketing of specific
technologies.

     National Competitiveness Technology Transfer Act of 1989

The National Competitiveness Act (PL 101-189), permitted
government owned and contractor operated (GOCO) laboratories
essentially the same rights to formulate CRADAs, as granted to
GOGOs in 1986.  The law also authorized all laboratories to
protect from disclosure information and innovations involved in
CRADAs.  This protection was important to private sector partners
concerned about sharing their proprietary knowledge with
government-sponsored laboratories.

The CRADA is an important contractual mechanism permitting
cross-sector
collaboration.  However, the CRADA is a means not an end.  A
CRADA is an
agreement to collaborate, so counting the number of CRADA
agreements initiated does not indicate laboratories' success in
transferring government technology.  Actual commercial product
improvements, and the private sector CRADA partner's interest in
additional collaboration, are two measures for assessing the
effectiveness of technology transfer.

     Defense Conversion Reinvestment and Transition Assistance
Act of
     1993

The Defense Conversion Act of 1993 (PL 102-190 & PL 102- 484),
established
programs for national laboratories to implement working
relationships with small businesses.  The Technology Reinvestment
Project (TRP), is a multi-agency program administered by a
council chaired by the Department of Defense's Advanced Research
Projects Agency (ARPA).  The Technology Reinvestment Project has
two objectives:  to integrate a common base of technology for
dual-use -- applications of the same technology in both defense
and commercial products, and to more closely link technology
innovations to manufacturing processes.

Sponsoring agencies can fund dual-use projects if they serve both
the primary
mission of the sponsoring agency (e.g., defense, energy) and a
parallel application in the commercial marketplace.  The
commercial application must be funded by the private sector
partner.  Besides ARPA, the Department of Energy, the National
Institute of Standards and Technology, the National Science
Foundation and NASA are involved in the TRP program.  The
Technology Reinvestment Project funds several programs that
increase opportunities to transfer technology from
federally-sponsored research
(laboratories and universities) to the field of assistive
technology.

Access to Resource Information:  The Department of Energy
supports a TRP
grant to Knowledge Express Data Systems, a four year old private
company in
Pennsylvania.  The company maintains multiple databases on
technology research and development, licensing opportunities, and
program opportunities. This system is useful to the field of
technology and disability because its databases are relevant to
technology development, transfer and commercialization.  For
example, it includes abstracts on technologies available for
licensing from high technology companies, from universities or
from national laboratories sponsored by federal agencies;
information on products from 35,000 high technology developers
and manufacturers; descriptions of on-going SBIR projects; and
compilations of relevant information from news sources and
federal publications.

The Knowledge Express software permits a single query, Boolean or
natural
language, to search multiple databases.  The TRP funding provides
fee subsidies to 400 universities and federal labs, and to 2,000
small companies.  A temporary subsidy from public funds appears
justified to expand the user base and increase the likelihood of
future information sharing.

Support for Partnerships:  Another TRP program demonstrates broad
partnerships made possible by prior legislation.  Technology
Access for Product Innovation (TAP-IN) is a joint venture between
the Federal Laboratory Consortium (FLC) and NASA's Regional
Technology Transfer Centers.  TAP-IN links technology
development, technology deployment and business service
organizations, to increase access to government technology by
manufacturing and product development business.  Batelle Memorial
Institute is the program manager, the U.S. Chamber of Commerce is
applying its electronic network (ChamberTech) to link businesses
to the FLC's Locator system, and two big six accounting firms
provide market analyses and financial planning services
(NEWSLink, 1993).

Assistive Device Development:  Another TRP-sponsored program is
the New Mexico Technology Deployment Pilot project, a joint
venture of Sandia Laboratory, University of New Mexico and Laguna
Industries, Inc., a small, defense contractor.  This project is
funded to seek unresolved functional limitations for persons with
disabilities, define a technological solution to address the
limitations, and identify relevant technology and expertise
within the federal laboratories.  A development effort is
initiated only if the expected product meets conditions of
dual-use, time to market and return on investment.  If so, the
project team identifies private-sector partners to extract and
deploy that technology and expertise within the assistive
technology application.  The New Mexico Technology Deployment
Pilot project is considered a "pilot," because the level of
success achieved will determine if this extraction and deployment
approach for assistive technology can be expanded to include all
federal laboratories (Adamson, 1993).

The project is currently developing three products in partnership
with government and private sector partners:  an active cushion
to help wheelchair users avoid the formation of pressure ulcers;
a monitoring and alerting system which detects physiological
signs of stress in the wearer; and a transfer aid to lift users
to and from a commode (Weaver & Carter, 1995).

Small Business Technology Transfer Act of 1992

The SBIR's overall success in stimulating start-up ventures and
developing new technology applications, led to initial funding
for a related program, Small Business Technology Transfer
Research (STTR).  Five federal agencies are participating in this
pilot program.  The STTR's requirements are similar to those for
the SBIR.  However, while the SBIR concentrates on
commercializing ideas generated in the small business community,
the STTR program funds small businesses to commercialize ideas
originating in universities, federal laboratories and
not-for-profit research centers.  The STTR program mandates
including a research institution or federal laboratory as a
partner, and the partner must conduct at least one third of the
project's work.  The partnership involves joint research and
development, appropriate technology transfer, and private sector
commercialization of federally-sponsored technology.

Programs Encouraging Assistive Technology Supply

Programs operated by federal agencies or supported with federal
resources
implement the legislation and regulations encouraging technology
transfer and private sector enterprise.  The primary programs
operated by Federal agencies are:

     � Department of Education - National Institute on Disability
and
Rehabilitation Research (NIDRR)

     � Department of Veteran's Affairs - Rehabilitation Research
and
     Development Services

     � National Institutes of Health - National Center for
Medical and
Rehabilitation Research (NCMRR)

     � National Science Foundation

     � National Aeronautics and Space Administration (NASA)

The primary programs supported by Federal resources are:

     � Federal Laboratory Consortium for Technology Transfer

� NASA Regional Technology Transfer Centers

     � National Technology Transfer Center


     Programs Operated by Federal Agencies

Federal agencies support assistive device development and
technology transfer directly through budgeted programs.  The
three primary examples are the U.S. Department of Education, the
National Institutes of Health, and the Veteran's Affairs.  Other
agencies have a limited role in the field, but the role at least
acknowledges the field as important.  The Department of
Education's prominence in the field grew dramatically since 1982. 
It has followed-up on many of the policy options presented in
that report.  At present, the USDE's NIDRR coordinates the
rehabilitation related research programs for all federal agencies
through the Interagency Committee on Disability Research.

U.S. Department of Education:  Most of the Federal-level
responsibility to implement programs concerning assistive
technology, fall under the purview of the U.S. Department of
Education.  The U.S. Department of Education operates multiple
programs which are increasing end-user awareness about assistive
devices, and about regulations supporting their acquisition and
appropriate use.  This awareness translates into increased
customer demand.

U.S. Department of Education - National Institute on Disability
and
Rehabilitation Research:  The National Institute on Disability
and Rehabilitation Research, operates under the Office of Special
Education and Rehabilitative Services within USDE.  This is the
new name of the National Institute on Handicapped Research,
frequently cited in the 1982 report.

NIDRR funds the sixteen active Rehabilitation Engineering
Research Centers (RERCs).  They promote technological solutions
to problems faced by persons with disabilities, and promote the
exchange of information on all related topics.  These centers are
operated by or in partnership with universities, to conduct the
primary research and development work on assistive devices
outside the private sector (Hammer, 1993).

The RERCs each have a particular technology focus, such as
mobility, vision, hearing, robotics, electronic access,
communication, prosthetics, housing.  Each has contributed to the
background research and prototype development for products
currently in the marketplace.  For example, the Smith-Kettlewell
center developed these products:  Light Probe, the TeleBraille
for persons who are deaf-blind, the Auditory Oscilloscope for
people who are blind, Talking Elevator Modules and Talking Signs
to orient blind travelers, educational games and computer access
systems.  They have prototypes for another dozen devices to
assist persons who have low vision or who are blind (Brabyn,
1994).

The RERC on Technology Evaluation and Transfer to some extent
fulfills the
recommendation in OTA's 1982 report to create an entity capable
of facilitating the evaluation, development and commercialization
of new assistive devices.  This RERC program operates out of the
Center for Assistive Technology, University at Buffalo.  This
RERC program coordinates a national network of research centers,
business incubators and consumer agencies.  Collectively they
evaluate the utility of new inventions, and work to move those
showing promise to the marketplace.  As suggested in the 1982
report, the RERC has established a not-for-profit entity, run by
and for persons with disabilities.  This entity will gradually
assume overall responsibility for this evaluation and
commercialization activity.

In the meantime, the RERC program is working with about fifteen
inventors with devices showing promise for use by persons with
physical, sensory, developmental and cognitive disabilities. 
Some devices will reach the marketplace through licenses to
distributors, others through small business development, and
still others by prompting modifications to products already
available for sale.  The RERC is also providing consumer
evaluations of existing products for companies on a
fee-for-service basis.

NIDRR funds other programs focused on the functional needs of
persons with disabilities.  The thirty-six Rehabilitation
Research and Training Centers (RRTCs) conduct research generating
knowledge to improve methodology and service systems, stabilize
disabling conditions and promote independence, and institute
teaching and training programs to disseminate and promote the use
of research findings.  The fifty-four state and territory
Technology Related Assistance programs, are consumer-driven state
plans for the dissemination of information concerning the
availability and delivery of
assistive technology devices and services.  NIDRR also funds
other research,
development and education programs on assistive technology.

NIDRR has worked to continue many of the initiatives started in
the 1970's and early 1980's.  The ABLEDATA project was cited in
the 1982 report as a source of information on available assistive
devices.  ABLEDATA (available in IBM and MAC formats and
accessible via hardcopy, diskettes, CD-ROM and e-mail) now
contains information on 23,000 products and over 3,000 companies.

NIDRR also funds other programs relevant to assistive technology,
including regional centers providing technical assistance on
complying with the requirements of the Americans with
Disabilities Act; a national program to translate research
information into forms accessible to non- researchers, and an
electronic clearinghouse for information on activity in the field
of assistive technology.

Through NIDRR's efforts, the public has unprecedented access to
such
information.  Consumers are making more informed decisions on a
wider range of devices, resulting in higher levels of function in
school, work and family life.  The NIDRR is playing a key role in
technology and disability, despite relatively meager funding. 
Assume that between 35 and 43 million people have one or more
conditions that result in a limitation of life activities.  Also,
assume that the number of persons will increase dramatically with
the aging of the baby boom generation.  Further, assume recent
estimates that the annual economic costs of these limitations
exceed $170 billion dollars (Pope & Tarlov, 1991).  Given these
assumptions, the NIDRR's $110 million budget for 1994 -- between
$2.50 and $3.50 spent per disabled American -- seems insufficient
now and certainly more so in the future.

Department of Veterans Affairs - Rehabilitation Research and
Development
Services:  The Department of Veterans Affairs operates four
Research and Development Centers.  These R&D Centers operate the
Technology Transfer Section, with the mission of improving the
quality of life for veterans with disabilities (Jaffe, 1994). 
The Technology Transfer Section screens pre- commercial products
for their application to the stated priority needs of veterans. 
The program has access to the VA's national network of medical
centers to conduct the clinical trials needed to validate a
device's utility.  The evaluation results, if positive, provide
the private sector developer or manufacturer with documentation
showing the VA as a potential customer, and showing non-VA
applications for the product.  The program is seen as improving
the entrepreneur's ability to bring a useful assistive device to
market, and accelerating the review and acquisition process
within the VA's massive system (Sherados, Cupo & Ford, 1994).

As one example, a scientist from the VA R&D Center in Palo Alto,
worked with clinical researchers in practice to develop a
computer-based visual communication system for use by persons
with global aphasia.  Although the VA funded the work, the
government turned all patent rights over to the developers,
maintaining a royalty-free, paid-up license for government
applications.  The developers found entrepreneurs willing to
establish a company to produce and market the device.  They
brought the device to market and obtained a patent all in less
than one year.  The VA provided a market opportunity for the
product by including it on the list of reimbursable prosthetic
devices for eligible veterans in 1992 (RRDC, 1994).

As another example from the VA R&D Center in Palo Alto, a
research team
developed the Desktop Vocational Assistance Robot (DeVAR) and
simultaneously pursued clinical trials within the VA and
technology transfer options with the private sector.  Although
the device is not yet sufficiently robust or flexible in tasks to
be a medical device, prescribable within the VA system, the
private sector partner is continuing development to meet these
specifications (Van Der Loos, 1995).

National Center for Medical and Rehabilitation Research (NCMRR): 
The National Center for Medical and Rehabilitation Research,
operates under
the U.S. Department of Health and Human Services, Public Health
Service, National Institutes of Health, National Institute of
Child Health and Human Development.  The NCMRR, created in 1990
(PL. 101-613) supports research on restoring, replacing or
enhancing the functional capability of children and adults with
disabilities, resulting from an injury, disease, congenital
disorder or the natural aging process.  NCMRR has access to the
National Institutes of Health's array of grant and program
funding mechanisms.  It has a memorandum of understanding with
the NIDRR to share information on grant priorities and
applications prior to funding (NIH, 1993).

The NCMRR currently supports several post-doctoral research
fellows, working within assistive technology research centers,
and is funding Small Business Innovation Research grants to
develop assistive technology devices.

National Science Foundation:  The National Science Foundation
sponsors an advanced technology program with potential
application to the field of assistive technology.  The NSF's
Engineering Directorate administers the Industry/University
Cooperative Research Centers (I/UCRC) program.  Begun in 1973
with MIT's Polymer Processing Center, fifty-three centers now
work in fourteen areas of advanced technology.  These areas
include nano/micro fabrication, materials, electronics, computing
and health care technology.  NSF provides seed funding for five
years.  Support from industry and other sources is already
fifteen times that amount.  The I/UCRC's conduct
interdisciplinary research, maintain collective industrial
support, and directly transfer ideas from universities to
industry.  About one half of these centers are already
self-sufficient (NSF, 1994).

The National Science Foundation's Directorate for Engineering,
Division of
Bioengineering and Environmental Systems supports senior student
engineers at over twenty universities to construct
custom-designed assistive devices (Enderle, 1992).  The Senior
Design Projects to Aid the Disabled program, started in 1989,
funds these university programs under competitive review at
extremely modest amounts of about $30,000 annually.  Each device
project starts with the actual need of a person with a disability
and ends by delivering a device to meet that person's need.  This
capstone design and engineering program generates hundreds of
devices annually.  However, the focus is on meeting an
individual's need and advancing the student's education.  The
focus is not on developing innovative devices, nor on designing
devices for the broader marketplace.  The student's inventions
may replicate products in the marketplace, and the user depends
on that single program for on-going repair and maintenance. 
Participating faculty are seeking ways to integrate the program
within the assistive technology field, to increase the program's
relevance and the device's potential value to the marketplace.

National Aeronautics and Space Administration:  Here is one
example from a NASA laboratory. A young woman lost her lower left
arm to a crocodile attack in Zaire, Africa.  Her father
approached personnel at a federal laboratory directed by the
National Aeronautics and Space Administration (NASA).  NASA's
charter includes technology transfer and the Space Act of 1958
authorizes programs that address the needs of persons with
disabilities.  As a result, laboratory scientists and medical and
engineering volunteers in the region established a program to
develop prosthetic devices from scrap laboratory materials.  They
developed and delivered a prosthetic limb along with an array of
attachments for use by the young woman.  Another team at the
laboratory worked with a private corporation to develop the first
epoxy resin/graphite and titanium racing wheelchair in 1993
(Lessels, 1994).

     Programs Supported by Federal Resources

Federal Laboratory Consortium for Technology Transfer:  Federal
laboratories receive about 35% of the federal investment in
research and development, and employ about 100,000 scientists and
engineers -- about one out of every six in the country (FLCTT,
1992). The Federal Laboratory Consortium has over 600 member
research laboratories and centers sponsored by sixteen federal
departments and agencies. The mission of the FLC's members is to
move federally-sponsored research and development into the
mainstream economy.  The FLC operates offices in six geographic
regions.  Membership in the FLC is voluntary.  The FLC operates
an information and referral clearinghouse called the FLC Locator. 
The Locator, accessible through the regional coordinators or
directly via fax or mail, matches outside needs to the required
expertise or resources within the federal laboratories.  The
Locator identifies the parties who are then free to establish
working relationships.

The FLC began in 1974, evolving from the DOD consortium of
laboratories
initiated in 1971.  The Stevenson-Wydler Act of 1980 increased
interest in federal technology transfer, which stimulated growth
in the FLC's membership.  The Federal Technology Transfer Act of
1986 established a formal charter for the FLC, developed a
funding mechanism to support it, and further defined its role,
duties and authority.

NASA Regional Technology Transfer Centers:  The Space Act of 1958
acknowledged the potential commercial value of spin-off
technologies, authorizing technology transfer programs.  NASA's
Office of Advanced
Concepts and Technology directs the Commercial Development and
Technology Transfer program.  The program operates six Regional
Technology Transfer Centers (RTTCs) to provide U.S.  firms and
industry access to NASA's research and development resources. 
The six RTTCs are organized in the same six geographic regions as
the FLCs.  The RTTCs and FLC regional programs work together to
share resources needed across regions, and to provide support
resources unique within each region.

National Technology Transfer Center:  The Senate Appropriations
Committee, in 1989, designated the NTTC as a new entity necessary
to enhance the technology transfer process.  The NTTC commenced
operation in 1991, through a five year cooperative agreement
between NASA and the Wheeling Jesuit College in West Virginia. 
The NTTC's mission is to help turn government research results
into practical, commercially relevant technology for U.S. 
companies, primarily by negotiating the organizational maze
within laboratories, and communicating between applied research
and commercial enterprise.

The NTTC is compiling a comprehensive database of federal
technologies.
Business Gold is their electronic bulletin board and searchable
database on laboratory resources, available technologies and
programs.  The NTTC is working with the FLC and the NASA's RTTCs
to ensure that all programs coordinate their resources to promote
complimentary activities and avoid duplication.

The NTTC made a specific commitment to the field of assistive
technology, by
sponsoring forums in 1994 and 1995 on issues relating to
technology transfer.  The forums are identifying the resource
partners for a broad network of government, university and
business entities.  NTTC also initiated a study to examine how
existing resources can be applied to respond to the USDE'S
mandate to partner with a technology transfer organization, to
increase consumer involvement in product development (May, 1994).

     Summary on Programs Encouraging Supply

The field of assistive technology is benefiting from synergy
between multiple
policies at the federal level.  Policies supporting small
business development,
technology transfer of government sponsored research and
development, and dual-use applications of defense technology,
each show value for the field.  The following example shows how
such policies can link to address a specific technological need
-- in this instance, collaboration between a defense contractor,
medical facilities and several federal agencies. The orthotic
professionals in the rehabilitation field need a strong,
lightweight material for manufacturing external braces.  A
defense contractor responded by applying composite materials used
in ballistic missile systems.  Defense agencies funded the
proof-of-concept work, resulting in a 65% weight reduction over
steel braces, and a 100% increase in strength.  The U.S.
Department of Education funded development of a post-formable
version permitting modifications by the orthotist.  Private
insurance companies funded all subsequent development and
evaluation, with final clinical trials of the full brace
scheduled for 1996.  The defense contract has since transferred
its advanced materials expertise to orthopedic implant and
prosthetic applications with products due out next year (White,
Crowson & Dignam, 1994; White & Hammer, 1989).

If the field of assistive technology can articulate other
technological needs with the same precision as that defined for
external braces, the links between existing programs can provide
an adequate solution.  However, these links and programs can be
viable only if they continue to receive funding and policy
support.

     Federal Programs Encouraging Assistive Technology Demand

     Mass Market Products

Demand for products in the mass marketplace largely occurs
without federal
involvement.  Soft drinks, blue jeans and frying pans are mass
market products.  The media presents advertisements, retail
outlets are conspicuous and numerous, and some publications
provide product evaluations and comparisons.  The consumer of
mass market items is in the power position.  The consumer expends
discretionary income, and selects from among competing products
when seeking a particular purchase price or set of desired
features.  The products themselves are manufactured out of
standard components, engineered for reliable if average
performance.  The performance is backed by the retailer's
satisfaction guarantees, manufacturer's warranties -- possibly
extended by credit card companies, and the knowledge that the
unhappy consumer will spend elsewhere.

     Specialty Market Products

By comparison, assistive technology consumers enjoy none of the
beneficial features of the mass market.  The assistive technology
marketplace is akin to
markets for highly specialized products, such as old magazines,
audiophile electronics, or exotic plants.  For such products, the
popular media carries no advertisements, and even the specialized
literature does not provide thorough evaluations.  Further,
retail outlets for specialty products are limited to major
metropolitan areas, and no one outlet is likely to carry the full
range of products.  Some specialty products may not even be
available in the U.S., or may only be imported at additional
costs.  Maintenance and repair services are extremely limited, as
are warranties, for specialty products.  This
analogy to specialty products holds for most assistive technology
products.

     Hybrid Market Products

Eyeglasses, as a product category, represent an analogy toward
which the assistive technology field should strive.  They are
essentially assistive devices because they are a product that
provides the functional capability of sharper vision, yet they
fall somewhere in between the mass and specialized markets.  They
are like a specialty product market because eyeglasses do require
sophisticated assessments, they contain high technology
materials, and they are not needed by everyone.  They are sold in
specialty stores, prescribed and dispensed by highly trained
professionals.  Although a specialized product, the eyeglasses
distribution system functions like a mass market.  The demand is
large enough to support stores in virtually every neighborhood. 
Clerks
and support staff help customers select from among a wide variety
of options (e.g., plastic, colors, contact lenses, frames
styles).  The number of customers keeps prices per unit down, and
many insurance plans pay for the device.  Competition is strong
enough that new stores promote their convenience (one hour
delivery) along with their products.

     From Orchids to Eyeglasses

Although assistive devices will never have the market presence of
soft drinks, the population demographics of the aging baby boom
-- along with their technical aptitude and discretionary income
-- will shift their market presence from the specialty niche of
orchids to the hybrid niche of eyeglasses.  More products will be
considered mass market items, as they become available through
national chains of department, hardware and drug stores.  In the
interim, national policies and regulations are generating the
necessary demand, by making consumers aware that such products
exist, and providing a means to evaluate and acquire them.

Federal legislation associated with assistive technology demand
includes:

     � Education and Vocation Demand
     -    Rehabilitation, Comprehensive Services and
Developmental
     Disabilities Amendments of 1978 (PL 95-602)
     -    Technology Related Assistance Act of 1988 (PC 100-407)

     � Business and Industry Demand
     -    Americans with Disabilities Act of 1990 (PL 101- 336)

     � Senior Citizen Demand
     -    Older Americans Act of 1990 (PL 100-175)

     � Unmet Emerging Demands
     -    Survivors of Injury and Illness

     Education and Vocation Demand

Public laws updated in the 1990's gave children in school and
adults at work, the right to public assistance in acquiring
assistive technology.  The Individuals with Disabilities
Education Act of 1991 (PL 101-476) mandated assessments for
children with disabilities to determine if they required
assistive technology devices or services to access a free and
appropriate public education.  Further, that devices and services
deemed necessary through the individualized education plan, be
provided regardless of the availability of funds.  The
Rehabilitation Act Amendments of 1992 (PL 102-569), presumed
vocational eligibility for persons with disabilities to receive
services and devices, and increased State involvement in
assistive technology provision.  Providing the means to succeed
at school and work is the basis for the American Dream. 
Successful people, in turn, contribute much more to the economy
in the long-term than they take out in the short term.

Rehabilitation, Comprehensive Services and Developmental
Disabilities Amendments of 1978 (PL 95-602):  These 1978
amendments to the Vocational Rehabilitation Act of 1973 (PL
93-112), established the funding mechanism for the Independent
Living Centers program.  As implemented, the Rehabilitation
Services Administration (under USDE/OSERS) provides funding to
States to maintain Independent Living Centers (ILCs).  There are
now over 600 Independent Living Centers in the U.S.  Over four
hundred of them belong to the association, National Council on
Independent Living.

Most ILCs are consumer-run, community-based organizations.  Prior
to receiving funding as ILCs, many of these organizations had
been community agencies focused on advocacy for a particular
disability or age group.  However, the funding regulations, as
further amended throughout the past decade, now require all ILCs
to provide a broad range of services to consumers of any age and
with any disability.  Within this framework, ILCs provide a range
of counseling, instruction, information and support services. 
Many Independent Living Centers actively promote the existence
and value
of assistive technology, via demonstration centers, training
workshops and referrals to providers.  Since each independent
living center is in contact with several hundred to several
thousand consumers annually, they are a strong source of new
demand for assistive devices and services.

Technology Related Assistance for Individuals with Disabilities
Act of 1988: As previously described, every state and territory
is funded through a lead organization selected by the governor. 
Every Tech Act program (PL. 100-407)
provides information on assistive technology devices, and
referral to assistive
technology service programs for consumers, family members,
service providers and organizations.  The fifty-five programs
disseminate information to thousands of organizations and
hundreds of thousands of people annually.  In 1994, these
programs provided assistive technology information and referrals
to 201,833 people.  Another 130,000 people attended training
programs or product demonstrations (TAP Bulletin, 1995).  That is
a tremendous amount of demand stimulation for a marketplace the
size of assistive technology.  Those receiving the information
have a better idea about who provides assessment and
distribution, what technology is available, where they can find
it and who is obligated under law or regulation to support the
acquisition and use.

The Tech Act programs are designed to be consumer- responsive, so
they are
providing the kind of information and referrals that consumers
want in the manner they want them.  They are also mandated to
pursue systems change -- to alter the very structures and
mechanisms designed to deliver assistive technology to the
end-users.  In the 1994 re-authorization, every State Tech Act
program can only receive a maximum of ten years of funding. 
During the second five year funding cycle, these centers are
charged with migrating their programs to self-supporting status.

The 1994 re-authorization to the Tech Act (Section 212), requires
the Secretary
of the Department of Education to, "enter into an agreement with
an organization whose primary function is to promote technology
transfer from, and cooperation among, Federal laboratories . . .
under which funds shall be provided to promote technology
transfer that will spur the development of assistive technology
devices" (Tech Act Amendments, 1994).

This requirement led to direct collaboration between the NIDRR
and the National Technology Transfer Center.  As a result, the
two entities are forging links between the repositories of
state-of-the-art defense and energy technologies, and the end
consumers of assistive devices.  Their common interest is
information exchange to improve the quality of assistive devices
available in the marketplace.  The consumers are linked through
their respective State Tech Act programs, with one State Tech Act
program as the point of contact.  The Federal laboratories are
linked through their Federal Laboratory Consortium, which in turn
is linked to the National Technology
Transfer Center.  The technology base in the Federal laboratories
is being matched to the assistive product needs of the consumers,
through the RERC on Technology Evaluation and Transfer.  That
RERC is the point of contact to the other fifteen RERCs
conducting research and development on application specific
technologies, and to the manufacturers and suppliers of assistive
technology devices through professional associations such as
RESNA and the National Association of Medical Equipment Suppliers
(NAMES).

     Business and Industry Demand

The Americans with Disabilities Act (ADA) of 1990 requires
"reasonable accommodations" to make facilities and transportation
systems accessible, and to help people gain or maintain
employment.  This legislation brought business and industry into
the consumption sphere for assistive technology.  Low technology,
such as building modification and signage, plays a major
role in accessibility, while computer-related high technology is
most relevant to employment.

The typical reasonable accommodation for providing building
access is not
expensive.  Installing ramps, adjusting the height of facilities,
adding Braille signs and purchasing a text telephone encompass
most needs.  More expensive accommodations are found in the
workplace (e.g., adapting computers and adjusting work spaces),
although they typically result in continued productivity for a
valuable employee.  A major U.S. corporation recently estimated
their costs to accommodate employees with disabilities from 1978
- 1992.  Seventy percent of accommodations required no reportable
cost, twenty-eight percent cost under $1,000 per employee.  The
average cost per accommodation was $121 (Blanck, 1994).

     Senior Citizen Demand

The senior citizen community and the disability community have
traditionally kept their distance.  Each did not like to be
reminded of the possibility of joining the other.  Further,
federal policies and legislation placed artificial distinctions
between them.  Fortunately, the demographics of the aging baby
boom show that these communities will soon be the majority.  This
majority carries fewer social stigmas regarding age or
disability.  The social acceptance of assistive devices is
increasing as people view them as
"tools for living." The preceding report on technology
for older persons documents both the increasing demand and the
accepted value of assistive devices.

The outcomes of maintaining independence and sustaining an active
lifestyle are beginning to outweigh concerns about the devices. 
The American Association of Retired Persons (AARP) recently
included a feature report on the Americans with Disabilities Act
and assistive technology (Shapiro, 1994).  Such reports will
accelerate the rate of acceptance for new technologies in
people's daily lives.  These technologies provide an opportunity
for seniors to prolong independent living.  The existing devices
require substantial redesign.  As an example, the majority of
seniors using hearing aids and canes are dissatisfied with the
performance and/or appearance of these products.

     Unmet Emerging Demands

Beyond the assistive technology needs of people born with
disabilities and
people aging into disabilities, are the needs of the increasing
number of people acquiring functional limitations by surviving
disease or injury.  The Federal government has not yet had the
opportunity to address many of these needs, which only arose in
the past decade.  These consumers represent entirely new
categories of need that did not exist when the 1982 report was
prepared.

The designation of regional trauma centers throughout the country
began in the early 1980's.  These trauma centers maintain life in
people with injuries so serious they were previously fatal. 
Victims of vehicular accidents and gunshot wounds comprise a
substantial portion of the trauma center's caseload.  Intensive
care, neo-natal and burn treatment units are all succeeding in
stabilizing an increasingly fragile percentage of accident and
illness victims.  The survivors move through the medical system
and gradually transition out of rehabilitation and back to
independent living.  They face functional deficits of a physical
(paralysis, amputation), cognitive (traumatic brain injury, CVA)
and sensory (vision, hearing, speech) nature.

Regardless of the origin, the resulting functional limitations
can be mitigated
through assistive technology.  Accident victims may receive
payment from insurance claims or tort actions.  Illness survivors
may receive employment compensation benefits.  Any one of us can
join the disability community at any time.  Those fortunate to
have the needed resources, represent the continually renewable
source of new demand for assistive devices.

Despite the advances in medical science, emerging medical
conditions are
increasing the number of people with functional limitations.  As
recounted elsewhere in this report, incidences of AIDS, Chronic
Fatigue Immune Deficiency Syndrome, Environmental Illness and
even Tuberculosis are escalating drastically, with no known cures
or fully effective treatments.  These medical conditions create
physical, sensory and cognitive functional limitations in
previously able-bodied persons.

IV.  Marketplace Supply and Demand in 1995:  Key
Problems

The progress over the past thirty years, and especially the past
fifteen, is
encouraging.  The Federal government is working directly and
indirectly to meet the needs of persons with disabilities, their
family members and service providers.  Despite the progress, some
significant problems remain.  The good news is that most of these
remaining problems can be addressed by modifications in existing
policies or regulations, and by further linking separate programs
in various Federal agencies.  The key problems are:

     � Confidentiality Barriers
     � Product Liability
     � Product Information
     � Selling in the Marketplace
     � Buying in the Marketplace
     � Access to Information and Resources
     � Federal Funding to Disability and Technology Programs
� Competitiveness in the Global Marketplace

     Confidentiality Barriers

It is difficult and expensive for manufacturers and suppliers to
identify and
contact their customers to either inform them about products or
obtain feedback on the products.  It is equally difficult for
consumers to obtain information on specific products and their
functional value.

Privacy laws preclude the distribution of personal information
collected by
service agencies, including agencies serving persons with
disabilities and elderly persons.  These laws protect people from
unwanted or predatory intrusions into their daily lives. 
However, these same laws prevent the broad dissemination of
useful information to consumers about assistive technology. 
Every not-for-profit agency in the disability field maintains
mailing lists of their members.  Every State Tech Act program and
every health care professional maintains information on their
clients.

One program is solving the confidentiality barrier by performing
the role of
information broker.  Project LINK circulates a simple
questionnaire to consumers by having agencies and businesses mail
them to their customers.  Customers volunteer to receive
information about assistive devices by contacting Project LINK. 
Project LINK, in turn, contacts and screens companies to
determine if they have useful products and are interested in
mailing information to potential customers.  Project LINK
receives the company's material and mails it out for them.  The
consumer's confidentiality is protected and their identity is
only revealed to the company if they purchase products.

     Product Liability

Assistive device development, pilot testing and commercialization
assumes a
level of risk for personal injury.  A consumer may be injured by
device malfunction, user negligence or even factors unrelated to
the device.  The mere association may be sufficient for a
consumer or representative to pursue a personal injury lawsuit. 
Further, jury awards in personal injury lawsuits have no
practical limits.  A large award will either exhaust a small
business's resources in payment or in court appeals.

Device developers (supply side) and consumer agencies (demand
side) hesitate to participate in pilot testing, and device
developers hesitate to move prototypes to the marketplace.  Both
fear associating with an activity that may lead to a lawsuit. 
This fear, real and imagined, reduces options for development and
evaluation, and suppresses opportunities for true innovation.

For small business owners, the cost of liability insurance to
indemnify them
against lawsuits is becoming unaffordable.  If small companies
cannot afford to introduce new products, the customers will lose
an important source of innovations.

     Product Information

Manufacturers and suppliers lack adequate standards for use as
development
benchmarks for product comparisons.  They also lack quality
incentives.  Assistive devices do not carry the same satisfaction
and warranty protections as do mass market products.  Twelve
states have passed, and others have pending, consumer protection
legislation for assistive devices, although the terms and
conditions vary considerably from state to state (26).

Consumers lack comparative information on the performance and
function of various assistive devices.  Despite frequent
discussions about the need for a
"Consumer Reports" on assistive devices, no tangible product has
resulted.  The "Consumer Reports" does now include a criteria on
accessibility for many mass market products, but there is no
parallel system for rating and reviewing assistive devices.

     Selling in the Marketplace

Investors and companies are reluctant to enter the assistive
technology
marketplace, because of the limited profitability.  Profit
margins are limited by product development and approval costs,
third-party reimbursement rates, marketing to a fragmented
customer base, and no economies of scale in production or
distribution.

The marketplace includes a substantial number of entrepreneurs
motivated by their contributions to people's lives.  The private
sector is demonstrating a willingness to leverage capital where
those opportunities exist; for example, collaborating with the
Rehabilitation Engineering Research Centers and pursuing the SBIR
grants, both sponsored by the U.S. Department of Education.  Any
new monetary incentives would be welcomed, such as investment tax
credits, regulatory relief, or funding subsidies for orphan
devices.

     Buying in the Marketplace

Reimbursement for assistive devices is essentially limited to
medical necessity. Devices that permit people to communicate, to
control their environment, to go to school, to work, to recreate
and to be a parent, do not qualify for reimbursement.  Since the
majority of persons with disabilities lack the resources to
purchase devices directly, they need assistance from third-party
payers to acquire devices enabling them to go to school, to work
and participate in family life.

Consumers could also defray the device costs through income tax
regulations.
Congress already provided such support to businesses to help fund
the ADA mandate.  Amendments to Omnibus Budget Reconciliation Act
of 1990 (PL 101-508) included regulations permitting small
businesses to deduct as tax credits, expenses for interventions
necessary to achieve reasonable access under the ADA.

Access to Information and Support Resources

Information and service referral programs regarding assistive
devices are
fragmented.  Consumers receive information from various sources,
and are eligible to receive support for assessment and equipment
purchases, based on their age and disability type.  Not all
sources provide the same information or fund equipment across
ages or disabilities.  The ways consumers access information and
service referrals is also fragmented, based on the consumer's
age, ethnicity, education and language.  Even the disability type
influences information access.  For example, people with visual
impairments are less likely to seek information from printed
periodicals, while deaf persons will not gain much value from
non- captioned television broadcasts.

Information about assistive technology is not yet comprehensive
across different types of print and electronic media, nor is the
same information disseminated by all sources.  Further, support
resources to acquire devices are defined in ways that create
artificial barriers for consumers.  For example, children and
elders may both have functional limitations in mobility or
vision, yet both groups cannot receive support from the same
agency.  As another example, an adult with a head injury cannot
access the same resources as a child with a learning disability,
although their functional limitations may be addressed by the
same assistive technology.

Federal Funding to Disability and Technology Programs

Federal justifications for funding programs are based on the
treatment of medical conditions, and either fund short-term
remediation or long-term care.  The limited resources available
for short-term remediation, force programs to choose between
providing large numbers of people with small amounts of support,
or providing few people with large amounts.  For example, a
vocational rehabilitation agency may have to choose between
spending an $15,000 allocation, by either providing computer
systems with voice output for five eligible clients at $3,000 per
system, or by providing a computer system with voice input and
output for one eligible client at $15,000 for the system.  The
budget limitations forcing such choices will discriminate against
clients with marginal disabilities or against those with more
severe disabilities.  There is simply not sufficient funding to
assist everyone who is eligible.

Worse, service programs for very young children and for the
elderly typically
have no funding for assistive devices, because there is no
immediate educational or vocational goal associated with the
funding.  Current policies do not consider the full cost of not
providing assistive technology devices and services to persons
with disabilities of all ages.  Several independent studies
reinforce the need to broaden the cost/benefit equation:

"Information is needed as background for decisions on financing
policy and in particular on the relationship between assistive
technology and the need for and use of services.  The role of
assistive technology should be reviewed in relation to:

     � Income maintenance versus employment;
     � Hospitalization/nursing homes/institutional care
versus living  at home in the community;
     � Full-time home health and personal assistance
services versus     intermittent assistance or
assistance that phases down; and
� Short-term versus long-term outcomes" (28).

The cost/benefit analysis should not stop with the outcomes of
treatment.  The analysis should recognize the prevention value of
assistive devices.  A $3,000 expense on assistive devices and
home modifications (one month charge to Medicare in a skilled
nursing facility) may prevent accidents and sustain functions
that keep an elderly person independent for two additional years. 
The net savings to the government for this single intervention
would be $69,000.  As another example, a reasonable accommodation
in the workplace costing $1,000 may enable a person with a
disability to be both an employee and a tax-payer.  A landmark
study in 1986 showed that sixty-six percent of persons with
disabilities surveyed were not employed.  Of those, two thirds
said they would like to work (29).  Imagine the cost savings and
tax benefits of employing those millions of people.

Assistive technology provides functional abilities.  These
functional abilities reduce the impact of disabilities and lessen
the chances of acquiring secondary disabilities:  "The beneficial
effects of assistive technologies in reducing and preventing
disability and secondary conditions needs to be recognized in
determinations of medical insurance coverage, which should not be
restricted on the basis of medical necessity or convenience. 
Similarly, the beneficial effects of personal assistance services
and durable medical equipment need to be recognized ..."(30, p. 
227).

Competitiveness in the Global Marketplace

The United States is losing a competitive advantage in the
assistive technology marketplace.  Further, the U.S. is missing
an opportunity to expand the market for domestic companies in the
international arena.  The European Union addressed the economic
and social value of the field by creating the Technology
Initiative for Disabled and Elderly People (TIDE).  TIDE is a
research and development initiative designed to increase
cross-national cooperation between European countries at the
pre-competitive stage.  TIDE is encouraging a single European
market for assistive devices by stimulating technology transfer,
defining user requirements, and establishing technical standards
and performance norms for assistive devices.  Through a major
eighteen month study, the HEART project (Horizontal European
Activities of Rehabilitation Technology) managed to define, study
and report the service delivery systems in sixteen European
countries, with the objective of stimulating cross- national
collaboration for improved service delivery (31).  The founders
of TIDE recognized the need to share the limited expertise and
resources available, and to foster collaboration between private
industry, research universities and government programs (32).

The TIDE program does recognize the value of cooperation with
advanced
programs such as those in North America and Japan.  The TIDE
program has
established a formal working agreement with Canada, that
authorizes joint funding for collaborative projects.  Several
specific TIDE projects have made an effort to share their
findings with the assistive technology community in North
America.  For example, the Usability Requirements Elaboration for
Rehabilitation Technology (USER) project, is a joint effort of
the United Kingdom, Norway and Italy.  The USER project is
combining the results of multiple focus groups in Europe and
North America, with feedback from other TIDE projects, to develop
a handbook of usability methods and tools.  This handbook will be
widely distributed (33).

The United States is still a recognized leader in the assistive
technology field.  By pursuing international business
relationships, companies can share available resources and adopt
innovations from other nations.  Consumers can benefit from the
advances made through collaborations at the pre-competitive
stage, and by the product improvements resulting from increased
competition in a global marketplace (34).

V.   Conclusions and Policy Options

A retrospective analysis evokes the truism that the more things
change the more they do indeed stay the same.  Consider these
quotes from the 1982 report's Introduction:

...It is far more expensive to continue handicapping America than
it would be to begin rehabilitating America.  Keeping disabled
people in dependency is costing us many times more than would
helping them to independence.  -- Frank Bowe (page 1);

This report was prepared during a time of uncertainty regarding
Federal block grants to the States for disability and other
social programs . . .  (page 5);

In fact, all decisions about the development and application of
such technologies are ones of resource allocation. (page 11)

The 1982 report concluded:  "OTA's examination of the current
system of
disability-related research, development, evaluation, diffusion,
and use finds that the system suffers from a number of
significant weaknesses" (page 11).  This 1995 report shows that
many of the weaknesses identified in 1982 have been strengthened. 
Congressional action has indeed influenced consumer awareness of
assistive devices, and the public's awareness of the need to
accommodate persons with disabilities within the community. There
is, however, little evidence of direct Congressional action to
support the development, evaluation and marketing of assistive
devices.  The changes in the marketplace described in this
report, resulted largely from serendipity.  Policy and program
changes in other public and private sector arenas, such as small
business assistance and technology transfer initiatives, provide
the base for additional advances in assistive technology.  If
only Congress had taken more direct action a decade ago, the
field could already be leveraging those related programs.  As it
stands, the programs only represent future potential to improve
the field.

The Federal government performs a critical function for the field
of assistive technology, by supporting and coordinating the
related programs and resources at a national level.  By
implementing policies of the 1982 report, as updated in this
report, Congress can resolve the remaining issues in the
development, evaluation and marketing of assistive devices.  No
other entity can perform this necessary function serving the
educational, vocational and daily living needs of over forty
million Americans.

     Policy Options

     Confidentiality Barriers

As suggested in 1982, Congress could mandate the collection of
market-related demographic data by an interagency group led by
the Bureau of the Census.

Congress could support information brokering activity on a
national
level.  Authorize an agency (USDE) to fund a program to provide
information brokering services.  This could be implemented
through an existing program (ILCs, State Tech Act) or could be
proposed as start-up funding for a not-for- profit enterprise.

     Product Liability

Congress could reduce the impact of personal injury lawsuits
involving
the voluntary use of assistive devices.  Current tort reform
legislation is addressing the burden of proof needed to file a
product liability lawsuit, reduce the scope of those named in the
suit, or limit the amount of awards made.

     Product Information

Congress could make comparative evaluation information available
to
consumers.  Authorize a government agency (USDE, Department of
Commerce) to establish evaluation protocols and conduct
evaluations on assistive devices.  Organize evaluations by
ABLEDATA category and make results available through the multiple
paper, electronic and consumer networks.  Extend liability limits
to this evaluation program.

Congress could require assistive devices to carry adequate
warranties
to protect consumers.  Enact a national "lemon law" to cover
assistive devices.  Establish a feedback mechanism to report
devices exceeding a problem threshold to the evaluation system
described above.

     Selling in the Marketplace

As suggested in 1982, Congress could amend current legislation to
create a consistent and comprehensive set of fiscal and
regulatory incentives, designed to encourage private industry to
invest in assistive technology products.

     Buying in the Marketplace

Congress could support full access to devices that sustain or
restore
functional capabilities lost through disability, by expanding the
Medicare (Part B) Durable Medical Equipment reimbursement
guidelines, to encompass a wider range of assistive devices.

Congress could establish tax credits or deductions for consumers,
to
offset the cost of devices not covered, yet required to perform
activities performed by the non-disabled community.

Access to Information and Support Resources

Congress could simplify regulations that define access and
eligibility criteria.  Simplify regulations by defining
eligibility according to functional limitations, not by
disability category or age.  Support the migration of fragmented
programs to a single point of access to devices and services in
existing community-based, cross-disability programs (e.g.,
Centers for Independent Living), for persons of all ages with all
types of disabilities.

Congress could support the multi-media dissemination of
information on
assistive devices.  Congress could ensure that the National
Information Infrastructure be fully accessible to all people with
all types of disabilities, and be ubiquitous and affordable to
encourage use by information producers and consumers (27). 
Congress could also support the U.S.  Department of Education,
Office of Special Education and Rehabilitative Services' efforts
to provide consumer- responsive services through their
Rehabilitation Services Administration's Independent Living
Centers program and to provide information and referral through
their National Institute on Disability and
Rehabilitation Research's State Tech Act programs.

Federal Funding to Disability and Technology Programs

Congress could justify funding assistive technology program
funding on the cost/benefit analysis of outcomes and prevention. 
The net savings to the government from reducing social service
payments to the unemployed and increasing income tax collections
from the newly employed is potentially significant.

Competitiveness in the Global Marketplace

     Congress could authorize the relevant agencies (Commerce,
Education, Health) to pursue a unifying strategy designed to
establish the United States as a participant in the single,
global market for assistive devices.  This single market concept
is already implemented in Europe, with formal working links to
Canada and Japan.


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