We wish to thank the Jason Cruickshank, Bob Gray, and the Cleveland Clinic Athletic Trainers for their support and assistance with data collection. This study was supported by the Edward F. and Barbara A. Bell Family Endowed Chair to JLA.

The protocol outlined below follows the guidelines of the Cleveland Clinic human research ethics committee.
1. Administering the C3 App
<ol>
	<li>Administer the C3 app to all student-athletes at baseline prior to the start of the given athletic season. Administer follow up assessments in the event of a concussive injury. Follow up assessments are reserved for the evaluation of recovery once the individual reports no more than minimal symptoms, so as to prevent symptom provocation as a result...

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P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=National+Athletic+Trainers'+Association+position+statement:+management+of+sport+concussion.">National Athletic Trainers' Association position statement: management of sport concussion.</a> Journal of athletic training. 49 (2), 245-265 (2014).</li><li>Harmon, K. G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=American+medical+society+for+sports+medicine+position+statement:+concussion+in+sport.">American medical society for sports medicine position statement: concussion in sport.</a> Clinical Journal of Sports Medicine. 23 (1), 1-18 (2013).</li><li>Giza, C. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Summary+of+evidence-based+guideline+update:+Evaluation+and+management+of+concussion+in+sports:+Report+of+the+Guideline+Development+Subcommittee+of+the+American+Academy+of+Neurology.">Summary of evidence-based guideline update: Evaluation and management of concussion in sports: Report of the Guideline Development Subcommittee of the American Academy of Neurology.</a> Neurology. , (2013).</li><li>Alberts, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Multidisciplinary+Approach+to+Concussion+Management.">A Multidisciplinary Approach to Concussion Management.</a> The Bridge. 46 (1), 23-25 (2016).</li><li>Alberts, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+Accelerometer+and+Gyroscopic+Measures+to+Quantify+Postural+Stability.">Using Accelerometer and Gyroscopic Measures to Quantify Postural Stability.</a> Journal of athletic training. 50 (6), 578-588 (2015).</li><li>Alberts, J. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+the+Balance+Error+Scoring+System+with+Portable+Technology.">Quantification of the Balance Error Scoring System with Portable Technology.</a> Medicine and Science in Sport and Exercise. 47 (10), 2233-2240 (2015).</li><li>Burke, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Characterizing+Information+Processing+With+a+Mobile+Device:+Measurement+of+Simple+and+Choice+Reaction+Time.">Characterizing Information Processing With a Mobile Device: Measurement of Simple and Choice Reaction Time.</a> Assessment. , (2016).</li><li>Rudick, R. 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L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quantification+of+postural+stability+in+older+adults+using+mobile+technology.">Quantification of postural stability in older adults using mobile technology.</a> Experimental brain research. 232 (12), 3861-3872 (2014).</li><li>Alberts, J., Linder, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+utilization+of+biomechanics+to+understand+and+manage+the+acute+and+long-term+effects+of+concussion.">The utilization of biomechanics to understand and manage the acute and long-term effects of concussion.</a> Kinesiology Review. 4, 39-51 (2015).</li><li>Simon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Reliability+and+Concurrent+Validity+of+Select+C3+Logix+Test+Components.">Reliability and Concurrent Validity of Select C3 Logix Test Components.</a> Developmental Neuropsychology. , 1-14 (2017).</li><li>Bernstein, J. P. K., Calamia, M., Pratt, J., Mullenix, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessing+the+effects+of+concussion+using+the+C3Logix+Test+Battery:+An+exploratory+study.">Assessing the effects of concussion using the C3Logix Test Battery: An exploratory study.</a> Applied Neuropsychology Adult. , 1-8 (2018).</li><li>McCrory, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Consensus+statement+on+concussion+in+sport:+the+4th+International+Conference+on+Concussion+in+Sport+held+in+Zurich,+November+2012.">Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012.</a> British Journal of Sports Medicine. 47 (5), 250-258 (2012).</li><li>Foundation ON. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Concussion Care and Recovery Pathway. , (2018).</li><li>Vander Vegt, C., Register-Mihalik, J., Ford, C., Rodrigo, C., Guskiewicz, K., Mihalik, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Baseline+Concussion+Clinical+Measures+Are+Related+to+Sensory+Organization+and+Balance.">Baseline Concussion Clinical Measures Are Related to Sensory Organization and Balance.</a> Medicine and science in sports and exercise. , (2018).</li></ol>

Drs. Alberts and Linder have filed intellectual property protecting the Cleveland Clinic Concussion mobile application. The remaining authors have nothing to disclose.

The development and implementation of the concussion carepath served numerous purposes in our health system&#39;s transformation toward value-based care1,2,3. The algorithm of care was critical in guiding clinical decision-making, and was supported by standardized, biomechanical outcomes in the form of the C3 app, which was used by all members of the interdisciplinary concussion team. These standardized outcomes provided qualifi...

The practice of medicine and the delivery of health care are undergoing a fundamental transformation from volume to value1, driven by payers, hospitals, clinicians, and patients. Health care delivery is challenged by the lack of standardization, interoperability of systems, communication of information, and the coordination of services. These deficiencies complicate effective continuity of care that often result in unnecessary services and have been identified as primary sources of rising health care costs1,2. By contrast, coordinated disease- or condition-specific care has been shown to optimize outcomes while minimizing costs2. In a coordinated care model, patients with a given condition are managed by an experienced, interdisciplinary team according to best practice guidelines, and are referred to the right provider at the right time2.
In efforts to transform clinical practice from a primarily volume-based to a value-based model, the Cleveland Clinic embarked on an enterprise-wide initiative to standardize clinical practice along disease lines through the development and implementation of clinical carepaths3. A care pathway is defined as a standardized approach for the mutual decision-making and organization of care processes for a well-defined group of patients over a well-defined time4. The underlying tenet of a care pathway is standardization of care. The expectation is that with evidence-based care pathways and interdisciplinary care teams, standardization and best practice will be achieved over time, venue and provider resulting in improved efficiency, effectiveness, and value2. With the inclusion of validated outcomes, there is a built-in mechanism for iterating the carepath over time to further refine and improve patient care.
Concussion was identified as a condition in which the potential to streamline care and optimize patient management was significant. While concussive injuries are typically not life-threatening, their effects can be severe and debilitating, with direct and indirect costs estimated at $83 billion annually5. It is estimated that 80-90% of individuals with concussion recover within 7-14 days of injury6,7. However, consensus on the management of the 10-20% of individuals with persistent symptoms is lacking, and evidence supporting or refuting the efficacy of rehabilitation, medical interventions or the diagnostic value of imaging in individuals with post-concussive symptoms is sparse. Multiple consensus statements indicate that an interdisciplinary team approach is optimal to treat concussion6,8,9,10. In 2011, work on the Cleveland Clinic Concussion Carepath11, shown in Figure 1, was initiated. Our primary goal was to create a standardized, evidence-informed approach to the identification, evaluation and management of individuals with concussion. An interdisciplinary team of providers collaborated in the development of the carepath, building consensus based on available evidence in the literature and expert clinical opinion. Physician groups that were represented included: sports medicine, neurology, neurosurgery, rehabilitation medicine, neuroradiology, emergency medicine, primary care, pediatrics and family medicine. The carepath team also included athletic trainers (AT&#39;s), physical therapists (PT&#39;s), speech therapists, occupational therapists, nurses, and neuropsychologists. Finally, computer scientists and research scientists provided technical guidance and software development. The carepath algorithm, documentation template, and outcomes were developed over a course of 15 months from 2011 to 2012. To ensure appropriateness of outcome measures, the C3 application assessment modules were simultaneously being validated12,13,14,15,16.
The evidence-based Cleveland Clinic concussion carepath depicted in Figure 1 was developed to identify individuals with concussion on a trajectory of typical and delayed recovery, and specifically for the latter group, to create clear and objective criteria for referral to specialty services. Standardized outcome measures were established and proposed to be collected across disciplines. In an effort to facilitate utilization and compliance with the standardized evaluation and documentation requirements of the carepath, the Cleveland Clinic Concussion (C3) app was developed, tested, and deployed. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) to demonstrate the integration of technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) to present preliminary data on the responsiveness of the C3 app in detecting change in neurological function post-concussion. We hypothesized that utilizing the C3 app would improve interdisciplinary communication aide in clinical decision making.

<table border="0" cellpadding="0" cellspacing="0" style="width:680px;" width="681">
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		<tr height="63">
			<td height="63" style="height:63px;width:216px;">Foam Balance Pad</td>
			<td style="width:159px;">Airex, Sins, Switzerland</td>
			<td style="width:139px;"></td>
			<td style="width:167px;">dense foam balance pad used during balance testing</td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;">iPad Digital Table</td>
			<td style="width:159px;">Apple</td>
			<td style="width:139px;"></td>
			<td></td>
		</tr>
	</tbody>
</table>

development and implementation of a multi-disciplinary technology enhanced care pathway for youth and adults with concussion

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project is to 1) describe the development and implementation of the Concussion Carepath, 2) demonstrate the process of integrating technology in the form of a mobile application to enable the carepath and guide clinical decision-making, and 3) present data on the utility of the C3 app in facilitating decision-making throughout the injury recovery process. A multi-disciplinary team of experts in concussion care was formed to develop an evidence-informed algorithm, outlining best practices for the clinical management of concussion along three phases of recovery &#8211; acute, subacute, and post-concussive. A custom mobile application, the Cleveland Clinic Concussion (C3) app was developed and validated to provide a platform for the systematic collection of objective, biomechanical outcomes and to provide guidance in clinical decision-making in the field and clinical environments. The Cleveland Clinic Concussion app included an electronic incident report, assessment modules to measure important aspects of cognitive and motor function, and a return to play module to systematically document the six phases of post-injury rehabilitation. The assessment modules served as qualifiers within the carepath algorithm, driving referral for specialty services as indicated. Overall, the carepath coupled with the C3 app functioned in unison to facilitate communication among the interdisciplinary team, prevent stagnant care, and drive patients to the right provider at the right time for efficient and effective clinical management.

To investigate change in neurologic function following concussion, baseline and follow-up C3 assessments were analyzed in 181 student-athletes injured during the 2013-2014 athletic seasons. Detailed demographics of the 181 injured athletes are shown in Table 1. Data were stratified into two groups: those who recovered within three weeks of injury (N=92) and those who were still symptomatic three weeks after injury (N=89). When comparing the first post-injury assessments, ...

Watch this Scientific Journal Video about Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion at JoVE.com

Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion

A multidisciplinary carepath to standardize disparate concussion care was developed and implemented at the Cleveland Clinic. The Cleveland Clinic Concussion (C3) mobile application was used to enable the carepath through biomechanical outcomes characterizing cognitive and motor function. Patient outcomes improved while cost of care was reduced following implementation.

The evidence-informed standardization of care along disease lines is recommended to improve outcomes and reduce healthcare costs. The aim of this project ...

This technology enables the objective quantification of the multiple symptoms of concussion, and allows multiple providers to use this technology to share information about the neuro performance of an individual. One of the advantages of this technology is it allows us to objectively quantify the multiple symptoms of concussion. For example, balance which typically is evaluated in a very subjective manner can now be quantified using the accelerometer and the gyroscope within the I-Pad.Demonstrating how to use the C3 application is Susan Linder, a research physical therapist from my laboratory. To assess postural sway, use a custom belt to affix the digital tablet onto the participant's sacrum. And inform the participant that their balance will be tested.Instruct the participant to remain in the designated stance for the entire 20 second trial with their eyes closed and ask them to begin with the feet together. Instruct the participant to return to the correct position as quickly as possible if they lose their balance. When the participant is in the proper stance, press Start to begin the five second countdown that signalizes the start of the 20 second trial and record the number of errors committed.Immediately after completing the first trial, begin the next trial. To assess the participant's static vision holding the digital tablet five feet from the participant at eye level, instruct the participant to read the five letters displayed on the table from left to right and record the number of correct letters that the participant is able to read. To assess the dynamic vision, play a sample metronome tone and rotate the head right to left with approximately 20 degrees of cervical rotation in each direction to demonstrate the proper head movement.Ask the participant to demonstrate the proper head rotation keeping with the metronome and initiate the trial confirming that the participant is rotating their head properly while the opto types are presented and instructing the participant to read the five letters displayed from left to right while continuing to rotate the head left to right to the beat of the metronome. For a simple reaction time assessment, display the instruction screen and instruct the participant to place their dominant index finger onto the touch and hold button. When the stimulus turns from yellow to green, instruct the participants to release the button and to touch the green light as quickly as possible.Observe the participant completing the practice trial, confirming that they understand the directions and are able to complete the task within the allotted 100 to 500 milliseconds. Then have the participant complete 25 valid trials without errors within the allotted period. For choice reaction time assessment, have the participant place both index fingers on the touch and hold buttons, and have the participant lift the digit that corresponds with the side on which the green light was presented.Tapping the green light as quickly as possible without moving the finger on the side of the scion destructor light. Observe the participant completing the practice trial, insuring that they understand the directions, and are able to complete the task within the allotted 100 to 750 milliseconds. Then observe the participant complete 25 valid trials without errors within the allotted time.For the processing speed test, initiate the test, and instruct the participant to read the instructions provided on the sample testing screen. And to use the symbol key on the top of the screen to complete the test below the symbol key. Inform the participant that a new row of symbols will appear once the existing row is completed, and that they should continue to enter corresponding digits until prompted to stop for the entire two minutes of the trial.After reminding the participant that they cannot correct an incorrect response, and to complete each response as quickly and accurately as possible, press the begin test button to initiate the test. And confirm that the participant is performing the test correctly. For trail-making Test A, instruct the participant to read the instructions on the screen, describing the test as a connect the dots test in which 25 circles corresponding with digits one through 25, must be connected using the provided stylus.After having the participant complete a practice trial, press begin test to begin the trial. And confirm that the correct procedures are followed. For trail-making Test B, instruct the participant to read the instructions on the screen, describing the test as a connect the dots test in which 25 circles corresponding with digits and letters must be connected with the stylus.And instruct the participant to begin with the number one followed by the letter A, alternating with consecutive numbers and letters until all 25 dots have been connected. At the end of the practice trial, press begin test, and observe the participant completing the test, confirming that correct procedures are followed. When all of the trials have been completed, a radar plot of all of the Cleveland Clinic Concussion application modules can be generated.Here, detailed demographics of the 181 injured participants from this representative trial are shown. The data were stratified into two groups, those who recovered within three weeks of injury, and those who were still symptomatic three weeks after injury. When comparing the first post-injury assessments, a significant difference was observed between the two groups for the simple reaction time, choice reaction time, trail-making test B, and for two of the six balance error scoring system stances for quantifying postural sway.Suggesting that participants who remained symptomatic performed significantly worse on the C3 modules, measuring information processing, executive function, set switching, and postural stability. Importantly, the participants performed comparably on all modules at baseline, and difference were only observed at follow-up suggesting that the modules are effective in detecting changes in neurologic function as a result of concussive injury. It's important to understand where each student athlete is struggling, so we can refer them to specialists who can actively work on improving their symptoms and deficits.Several of these tests service screening tools to prevent stagnant care, and insure that we can get these student athletes to their right providers in a timely manner. The advantage of this system is that it brings multiple providers, and the patient and their family onto the same page using data. These objective data help guide return to play decision making, as well as next steps for those individuals who may not be recovering.

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6.4K 조회수.  Cleveland Clinic Foundation. 이 기술은 뇌진탕의 다중 증상의 객관적인 정량화를 가능하게하고, 여러 공급자가 개인의 신경 성능에 대한 정보를 공유하기 위해이 기술을 사용할 수 있습니다. 이 기술의 장점 중 하나는 우리가 객관적으로 뇌진탕의 여러 증상을 정량화 할 수 있다는 것입니다. 예를 들어, 전형적으로 매우 주관적인 방식으로 평가되는 균형은 이제 I-Pad 내의 가속도계 및 자이로스코프를 사...