June 2009

Data Connectivity Challenges in Telemedicine : Lieutenant Colonel Salil Garg & Squadron Leader Mudit Mathur

INTRODUCTION

We live in a divided world: between rich and poor, healthy and sick, literate and ignorant, democratic and authoritarian, and between empowered and deprived. All the technologies and policies that we developed in the past for harnessing human development have not wiped out these glaring disparities.

While many categorisations of countries have been developed (such as developed, developing, emerging and transition economies etc.), a new labela sign of the timesis the ‘digital divide’, which describes the development of countries (and groups within countries) in terms of their capacity to harness the power of ICTs. Whether we can overcome the digital divide and provide basic and advanced medical care to even the most destitute of people is a question that remains unaddressed!

Of late, people are taking active interest in the development of telemedicine infrastructure. This is because medical services have become very expensive and costs are spiraling out beyond the means of the common man. In such a scenario, will telemedicine be able to provide a solution by enabling transfer of high-quality images and data at economical rates and bring down the cost of service? Is telemedicine is going remain to hallowed portals of high tech medicine or will it be able to provide succor to the man on the street? Marrying the two ends is where the future of telemedicine may lie!

Transfer of Data

Wireless telemedicine: In today’s world, how does telemedicine work? As we have already brought out in our previous articles, there are three particular aspects – patients dealing with doctors, doctors dealing with other experts from remote locations and data sharing between various doctors/experts. All three require different levels of technological adaptations.

The first level is possible either through telephony (voice-based) or through Internet (transfer of data and images). The remotely located doctor analyses the oral/verbal/image-based data and gives a reasonable treatment advice that maybe sufficient in itself or may help in tiding over the crisis and the patient may seek further help at a more convenient time.

Even at the second level, where doctors and paramedical staff working in remote locations need to consult with experts in other locations, a simple access to a telephone or an internet connection maybe a great achievement. Any transmission of data and any response from the other end are more than welcome.

At the pinnacle of telemedicine practice, is the contact between various high end hospitals and specialists, who maybe discussing and dealing with very sophisticated decision making and management practices just at the click of a button.

We need technologies that can make slow connections a history and through which doctors and patients will be able to communicate with each other easily. The earliest of these are nearing implementation in the form of 3G telecom technologies, which is going to be followed in next few years by 4G, 5G and 6G technologies.

In telemedicine, data transfer involves transmission of select, usually quantifiable, biochemical and physiological parameters of organ or system function to a central point for storage, analysis and immediate feedback instructions to the patient concerning treatment. Trans-telephonic assessment of cardiac pacemaker signals is also a form of data transfer. Data transfer may be direct, accomplished by automated measurements and periodic downloading through a special device, such as a biosensor or specially designed palmtop. Conversely, data transfer may be indirect, with manual measurements being performed by the patient and then communicated via telephone or Internet to a central receiver. Indirect data transfer demands thorough patient or caregiver training to avoid errors that could lead to wrong diagnosis.

A Telemedicine System over Internet

A modern patient oriented web-based telemedicine system to promote the idea of e-medicine should have the following features:

  • Provide the efficient and convenient methods for patients and doctors to communicate with each other through the Internet and to fundamentally alter the personal face-to face relationship that has been the model for medical care for generations.

  • Design less expensive and more realistic methods for testing
    the effectiveness of alternative clinical practice.

  • Provide a circumstance for “Case Diagnosis” and “Case Consultation” on the remote situation.

  • Build computer-based patient records and other electronic information systems that provide relatively easy and fast access to large databases and that permit the application of powerful statistical methods for analyzing and displaying those data.

  • Allows patients to see doctor specialist in web and send their medical data/image by Internet.

  • Formulate strategies for proving information to patients, clinicians, and others in ways that promote informed decisions and stimulate desired changes in behaviors and outcomes.

  • Potentially allows easier access to more information about a patient that the user either requests or needs.

  • Automatically produce a payment including types of telemedicine services and would be divided into professional and facility components.

  • Providing secure web payment.

  • Authentication procedures to ensure that messages are received from the stated source exactly as they were sent.

  • Should be able to maintain patient confidentiality, medical ethics and be covered on medicolegal issues.

Wireless Communication in Healthcare systems

Limitations of technologies
The advantages of using wireless technologies far outweigh their disadvantages. However, handheld devices and wireless technologies have some issues which would pose a challenge in the healthcare industry and its applications. Some of these potential threats are:

Small Screens
Due to small screen sizes health professionals cannot view large tables / electronic health records in a single screen. However, this may change in the future with wider screens, more availability of wireless connections and ability to connect to bigger screens for better viewing.

Insufficient Memory
To minimise costs handheld devices and mobile devices come with very small memory footprints and the processing speeds of these devices are slow compared to personal computers or laptops. This aspect is again likely to be rectified by technology.

Less Bandwidth
Bandwidth plays a vital role here as the pervasive and QoS related issues are very high in terms of serving patients who are in need for immediate healthcare service. This is the most important limitation and if we can circumvent it, it will ensure a quantum leap in our telemedicine abilities.

Slow Data Entry
Handheld devices are small in size and therefore, data entry becomes a tough process especially while on the run. It becomes a very time consuming process if long notes are required to be taken.

Security issues
Handheld devices can be easily hacked, lost or stolen. Hence, some form of security like biometric entry and usage must be built into the devices. The other potential threat would be the entry of remote users into the hospital’s expert system or mainframe computer. This poses as a threat to patient’s privacy and well being.

As we all know the transition from the present day technology to 3G and onto 6G is going to be a long drawn and a tedious process. Though it may take time, it is bound to happen and we have to be there when it does, because if we miss the bus, we may not get another chance.

The Limitations
Today, doctors and the patients are limited by technology. The entire data cannot be transmitted and the transmitted data may not be accessed at the place of reception. Let us take a few examples –

Suppose a patient presents himself with chest pain. The doctor requires to know the symptoms – the same may be transmitted by telephony or the patient may be seen by videophony (though a 3-D image maybe more preferable). The ECG requires to be transmitted. If transmitted on a mobile phone it may not be large enough for the doctor to analyse and a larger screen may require connection with a computer which may not be possible at the time. A similar limitation maybe there with X-ray images. During coronary angiography, in case advice from another expert is needed, and this may require split second decisions, it may not be available. The angiographic images are heavy radiological images and it is still very difficult to transmit them. Similarly, in cases of stroke, it maybe very difficult to transmit CT scan images or MRI images to the neurophysician. Not only they take long time to upload, they may not be even clear to the viewer on small screens. At present, very few ICU’s or radiology laboratories are equipped with data transmission facilities.

3G Technology

3G is the third generation of telecommunication hardware standards and general technology for mobile networking, superseding 2.5G. It is based on ITU family of standards under the IMT-2000. 3G networks enable network operators to offer users a wide range of advanced services including wide-area wireless voice telephony, video calls and broadband wireless data, all in a mobile environment. Additional features also include HSPA data transmission capabilities to deliver speeds up to 14.4 Mbit/s on the downlink and 5.8 Mbit/s on the uplink.

4G Technology

4G (also known as Beyond 3G), an abbreviation for Fourth-Generation, is a term used to describe the next complete evolution in wireless communications. A 4G system will be a complete replacement for current networks and be able to provide a comprehensive and secure IP solution where voice, data and streamed multimedia can be given to users on an “Anytime, Anywhere” basis, and at much higher data rates than previous generations. A vital requirement for telemedicine procedures is the reliable, uninterrupted delivery of information.

Heterogeneous 4G networks will allow users to access a wide range of location dependent services like increased data rates and streaming media. Consider an ambulance equipped with wireless telemedicine devices and initially under the coverage area of an Wireless LAN hotspot with data rates up to 54 Mbps. Under the coverage area of the hotspot, the ambulance will transmit the telemedicine traffic streams at the available data rates. However, on the move the device will handoff to the next best available network (e.g. GPRS), which offers data rates only up to 13.4 Kbps. Thus the connection could be maintained albeit at lower data rates. Furthermore, if the ambulance travels into areas that do not fall under GPRS coverage, the device can handoff to the wide-area satellite network. Even though it may not be possible to transmit high-quality multimedia streams at all times, 4G networks offer more reliability by allowing healthcare professionals to roam freely between urban and rural areas, and still remain connected to the main site through the best available network service.

However, successful implementation of 4G involves resolving a number of issues. The convergence of networks with disparate characteristics results in many complexities at both the application and network level, particularly during conditions like vertical handovers. Although the channel quality improves during a downward vertical handover, (when the MH moves from a macro cell to a micro cell) it can degrade considerably during an upward vertical handover, which may result in connection loss. To maintain an acceptable level of Quality of Service (QoS), it is vital to hide these complexities from applications while roaming among networks.

Apart from this, maintenance of a balanced flow of multi-class traffic across a wireless channel under varying network conditions and reconfigurability of terminal devices and network elements for dynamic selection of best available service are a few among the numerous issues that researchers are striving to discover optimum solutions for and form a truly ubiquitous heterogeneous 4G network. Yet, despite the numerous challenges involved in the development of a ubiquitous heterogeneous network, the fascinating idea of seamless connectivity anytime, anywhere makes it an attractive field of research.

4G is being developed to accommodate the quality of service (QoS) and rate requirements set by forthcoming applications like wireless broadband access, Multimedia Messaging Service (MMS), video chat, mobile TV, HDTV content, Digital Video Broadcasting (DVB), minimal service like voice and data, and other streaming services for “anytime-anywhere” objectives of the 4G wireless communication standard:

5G (Real wireless world) (completed WWWW: World Wide Wireless Web):

The idea of WWWW, World Wide Wireless Web, started with 4G technologies. The following evolution will be based on 4G and will be completed by forming a ‘real’ wireless world. 5G should be a more intelligent technology that interconnects the entire world without limits. The differences between 3G and 4G are with respect to data rate (speeds) and services, for example – global roaming, interface with wire-line Internet, QoS and security. 4G will be supported by IPv6, OFDM, MC-CDMA, LAS-CDMA, UWB and Network-LMDS. They can be arranged in different zone size. IPv6 can be designed for running in the widest zone, called World cell. OFDM, MC-CDMA and LAS-CDMA can be designed for running in the wide area, called Macro cell. Network-LMDS is in Micro cell, and UWB is in Pico cell. In the 4G wireless networks, each node will be assigned a 4G-IP address (based on IPv6, 128 bits), which will be formed by a permanent ‘home’; IP address (32 bits) and a dynamic ‘care-of’ address (32 bits) that represents its actual location. The care-of address will be informed to other devices by directory server for directly transmit purpose using mobile IP interface with wire-line network and wireless network. 5G will be the completed version of WWWW, World Wide Wireless Web, to form a real wireless world with no more limitation with access and zone issue.

STOPPING POINT

In spite of the security issues in wireless technologies, incorporating wired and wireless technologies in healthcare systems proves to be a viable and last mile solution for serving the needs of the patients at the shortest possible time. Applying wireless technologies into healthcare benefits not only the healthcare professionals but also the patients. Considering the coverage, performance and service factors, as discussed above, an effective wireless technology can be designed. Thus, properly designed and developed wireless technologies may ensure smooth communication between the patients and healthcare professionals, by providing coverage, performance and service, thus helping the healthcare professionals to serve the patients effectively. Expert systems should be used in healthcare combined with Artificial Intelligence to ensure faster communication between the healthcare professionals and the patients. The following diagram gives an expected schedule for meeting with our objectives. And if we are not there on schedule some doubting Thomas may certainly be able to say –

“Doing it right is no excuse for not meeting the schedule.” (Plant Manager, Delco Corporation)

The challenge is how to make newer technologies to overcome the present limitations. A seamless transmission of data and images as in the cases of transmission of X-rays, angiographic films or CT scan images and MR images would result in the same images being reviewed by experts in real time with the ability to advice corrective measures. Maybe the holographic projection of images will be able to solve the problem of viewing images in proper size and a 3- D perspective.

As our medical services and living conditions improve our life expectancy will go up. The future may have a higher geriatric population. There will be more patients with metabolic and lifestyle diseases and more people will be alive and living with these diseases. So, you may have a 90 year old gentleman with all the diseases including arthritis who may still be enjoying his golf and who needs to consult once in three months. This he may do via telemedicine, thus saving transportation charges and other difficulties including a visit to the doctor who himself maybe 90 year old. Maybe doing it right and doing it on schedule maybe the answer.

(This work provides the overview of the field of Telemedicine practices done by various experts and institutes. Author(s) take no claim in either designing the models or its concepts, however, direct integration of isolated works in the field of Telemedicine practices has been done in this article. Suitable cross references are marked.)
References :

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  5. Bibbi Thome, Anna-Karin Dykes, Ingalill Rahm Hallbert, ‘Home care with regard to definition, care recipients, content and outcome: systematic literature review’, Journal of Clinical Nursing 2003; 12: 860872
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