Telemedicine: Remote Remedies
By Jenny Bieksha, Bishop & Associates Inc.

There are many factors driving the need to develop tools and solutions to improve health care delivery, including a shortage of health care professionals, an aging population, increased chronic medical conditions, and rising health care costs. Telemedicine could be a powerful tool to improve efficiency in the delivery of health care. Multiple products, services, and industries are in development to serve various telemedicine applications, including information technology vendors, medical device manufacturers, pharmacies, hospitals, and nursing homes.

Telemedicine is the remote provision of health care services and health education, mediated by technology. There are two primary modes of telemedicine:  

1. Real-time (synchronous) telehealth sessions are live and interactive, and frequently use videoconferencing technologies. Often, a nurse or technician operates special telehealth-enabled instruments, such as an electronic stethoscope, at the consulting provider’s direction to remotely perform a physical examination.

2. Store-and-forward (asynchronous) telehealth, involves data (such as digital photographs) that are captured locally, then temporarily stored for transfer at a later time, via a secure web server, encrypted e-mail, specially-designed software, or electronic health record. The consulting provider then reviews the stored data and makes diagnosis, treatment, and planning recommendations. These are electronically transferred or faxed back to the referring provider.

A hybrid approach, utilizing both transmission capabilities is becoming more common. But regardless of the approach, telemedicine requires medical devices that connect to these methods of transmission and allow effective clinical examination and evaluation of the patient for diagnosis.

Connected health care is a tremendous challenge for the industry, because you have two devices that are wirelessly enabled, but you also must have the infrastructure and the business model behind it to make it a realization. There are tools for in-home care and they must address the issue of interoperability with diagnostic tools, records tools, and patient information tools. Specialized application software, data storage devices, database management software, medical devices capable of electronic data collection, storage, and transmission are all key components of the telemedicine infrastructure.

Telemedicine Services and Delivery Mechanisms
The use of medical products with electronic exchange capabilities allows for the provision of a wide range of telemedicine-related services.

• Networked programs link primary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas. The links may use dedicated high-speed lines or the Internet for telecommunication between sites.

• Point-to-point connections utilize private networks used by hospitals and clinics to deliver services directly or contract out specialty services to independent medical service providers at ambulatory care sites.

• Primary or specialty care to the home connections link primary care providers, specialists, and home health nurses with patients over single-line phone-video systems for interactive clinical consultations.

• Home to monitoring center links are used for cardiac, pulmonary, or fetal monitoring, home care, and related services that provide care to patients in the home. Standard phone lines and the Internet are used to communicate directly between the patient and the center.

• Web-based e-health patient service sites provide direct consumer outreach and services over the Internet. Under telemedicine, these include sites that provide direct patient care.

Telemedicine Products
Many medical devices capable of collecting and electronically transmitting information can be digitized for use in telemedicine applications. These include blood glucose meters, pulse oximeters, blood pressure cuffs, CT scanners, and MRI machines. Some of these devices are targeted towards home health care and the patients interested in closely monitoring their health status, while others facilitate the exchange of information between hospitals, clinics, and physicians.

Opportunities for connector manufacturers exist across the infrastructure and a wide range of remote monitoring devices that exploit advances in bandwidth, networking, mobile telecommunication, RF technologies, and miniaturization. There are a variety of devices (peripherals) used to expand the capabilities of a telehealth system, including:

• Telehealth-enabled physician’s examination instruments, such as a video otoscope (ear), dermascope (skin), or electronic stethoscope (heart, lung), can be connected to a digitizer or videoconferencing endpoint for remote examination.

• Medical diagnostic equipment with standard video outputs, including ultrasound, ocular imaging equipment, and endoscopes.

• Network-enabled biomedical/physiological monitoring devices, including ECG, EEG, EMG, vital signs monitors, glucometers, weight scales, and Spirometers.

• Consumer electronics. Cameras are common in many of these applications. Technologies include composite video, S-Video, LED, fiber optic lighting sources, USB, and FireWire-B digital interface (IEEE1394.b). Industrial cameras integrating the AIA GigE Vision open standard allow real-time delivery of high bandwidth streams of non-compressed imaging data to host PCs over CAT-5e and CAT 6 cables up to 100 meters without specialized interface hardware or frame grabbers.

Potential Benefits of Telemedicine
Benefits that can be realized by an increased use of telemedicine range from increased compliance in taking medications, improved health care delivery in rural and underserved areas, improved delivery of health care services outside hospitals and clinics, and better utilization of health care professionals. Telemedicine maximizes the use of existing health care professionals by allowing them to remotely diagnose, monitor, and recommend treatment for patients located in rural areas. Despite these potential benefits, there are a number of barriers to overcome in order to accelerate the development and application of telemedicine.

Challenges to Overcome
There are numerous challenges involved in the advancement of telemedicine. One obstacle is finding ways to incentivize doctors who make money by seeing patients in the office, not for using Internet-based monitoring systems. Cost is not the only concern for telehealth products. These devices transmit massive amounts of data from the patient to a health-monitoring center or even a physician's office, and usually requires broadband access, something still geographically restricted in the U.S. However, the FCC recently announced a plan to expand access to high-speed Internet connections to nearly 100 million Americans by 2020. Through the Universal Service Fund, it makes money available to health care providers to help defray the cost of telecommunications services, such as broadband, in rural areas.

Availability of systems and infrastructure possessing sufficient capacity to gather and exchange data, images and other health information is necessary for effective use of telemedicine services. The seamless exchange of information and data between medical devices, communication systems and infrastructure is essential. Efforts to standardize device protocols have been underway for years. Joint standards addressing interoperability are published and controlled by ISO, IEEE, and the European Committee for Standardization. The ISO/IEEE 11073 standard defines the sections of a system, methods to exchange and evaluate vital signs data between different medical devices, and the remote control of the devices. The specifications define the relationship between a device and the gateways between the device and the larger health care system.

Information technology and the use of networking and data communications is revolutionizing the way the medical community interacts with each other and with patients. A high-speed data communication network can bring people together in a way never before possible. Telecommunications corporations are capitalizing on the growing use of their products in the health care industry. With increased focus on technology connecting patients to different modes of care and the push for interoperable electronic health systems, these companies are positioned to strengthen their share of the health care business.

Consumer telehealth will be an extension of the current home medical device market, with manufacturers offering additional Internet-based services to consumers who purchase monitors. Services such as an examination of readings, as well as dietary and nutritional advice, will become more prevalent. These services are likely to be subscription based and will coincide with the popularity of Internet health products such as Google Health or Microsoft's Health Vault. The Continua Health Alliance aims to make all home-use medical devices with telehealth features interoperable, so it is also likely that consumer devices will be able to work with innovative new health records.

Home Medical Device Market
In 2009, medical devices made up 82 percent of the global medical equipment market, with $228 billion in sales, according to a February 2010 report by Medical eTrack Global Data. The use of home diagnostics for blood glucose monitoring alone is a $4 billion market. The market forecast for remote patient monitoring is $260 million in 2010, while revenues from remote patient monitoring using mobile networks is expected to reach $1.9 billion globally by 2014.

Clinical devices traditionally sold for use in hospitals and doctor’s offices are being redesigned for home use, and consumer electronics with more health-oriented features are appearing on the market. Electronics companies are taking a closer look at the consumer market, offering new products and services and exploring innovative business models to take advantage of this growth. A number of technologies have increased the reliability of home monitoring devices, leading to rapid adoption by patients and health care providers alike. These technological advances are changing the perceptions of consumers and are expected to enhance the acceptance of home monitoring devices among patients in the future.

Incorporation of consumer electronics into the home medical device market is providing added opportunities for the connector industry. What remains unclear is whether the potential applications will be designed in by the consumer electronics manufacturer, due to their expertise in selling commodity products (such as smartphones, netbooks, iPads, or GPS navigation systems) or via the medical device manufacturer. Inevitably, manufacturers must ensure that new devices brought to market are still affordable by the price-sensitive consumer.

The demand for self-medication and home-based treatment is increasing. More patients are handling both the diagnosis and treatment of specific diseases at home. Facilitating this transition has been the miniaturization and cost reduction of electronic medical devices used in basic diagnostic investigation and treatment. Hospital-based patient monitoring systems are being supplemented by portable versions operating in the home. These devices feature integrated telemetry capabilities that allow a physician or nurse to continually monitor blood glucose, blood pressure, and pulse levels.

Blood Glucose Meters
Most downloadable meters enable patients to download their blood glucose readings to the computer and email the test results to your doctor. The meters usually require a connection cable, unless they are designed to work wirelessly with an insulin pump, or are designed to plug directly into the computer. Measurement results are stored with the measurement time and date to the EEPROM or flash memory as a data log that can be uploaded to a computer via RS-232 or USB interface.

A number of meters have been combined with other devices, such as insulin injection devices, PDAs, and even Game Boys. A radio link to an insulin pump allows automatic transfer of glucose readings to a calculator that assists the wearer in determining an appropriate insulin dose.

A continuous blood glucose monitor (CGM) determines blood glucose levels on a continuous basis (every few minutes). A typical system consists of a disposable glucose sensor placed just under the skin which is worn for a few days until replacement, a link from the sensor to a non-implanted transmitter that communicates to a radio receiver, and an electronic receiver worn like a pager (or insulin pump) that displays blood glucose levels with nearly continuous updates, as well as monitors rising and falling trends.

Blood Pressure Monitors
The core subsystems of blood pressure monitors include:

• Processor/Memory: Digital pressure measurement and heart rate are performed by the microcontroller. The measurement results are stored in flash memory as a data log that can be uploaded to a computer via USB.

• User Interface: The user can control the pressure measurement process and read the results on an LCD display.

• Sensor Interface: The processor can control the cuff inflation/deflation and sense blood pressure.

• Power Conversion: Converts input power from the alkaline battery to run various functional blocks

• Software packages providing a blood pressure and pulse graph tracks your values over time. This information can be downloaded or transferred via a wireless transmission to the physician.

Digital Stethoscope
High-end digital stethoscopes offer capabilities such as audio recording and playback. They also provide data to visually chart results by connecting to an off-instrument display such as a computer monitor. This advanced functionality increases the physician's diagnostic capability.

The main elements of a digital stethoscope are the sensor unit that captures the heart and lung sounds, along with auscultation digitization, and digital processing for noise reduction, filtering, and amplification. The sound is commonly transferred with a wired interface, such as USB, or with a wireless interface like Bluetooth® or another proprietary wireless interface.

Some digital stethoscopes have a small, simple display due to the limited space available; others have only buttons and LED indicators.

Most digital stethoscopes use either one or two AAA 1.5 volt primary batteries. Rechargeable batteries can be used.

In summary, telemedicine represents a series of technologies and procedures significantly different from current health care practices. It can use technology to break down distance barriers and remotely connect specialists with patients who need advanced medical treatment, and allow greater exchange of images and health data are just a few of the advantages of widespread deployment of telemedicine. Connected health systems are poised to receive widespread attention and adoption in the next decade, a move driven primarily by cost reduction.

As consumers embrace smarter products in the home, patient care will transition from health care facilities toward patients and families in their homes. An agreed-upon infrastructure is required so that patients and caregivers can access this growing body of information. This common foundation will bring together a diverse set of players: consumers, device manufacturers, software companies, health plan companies, and providers. In order for telemedicine to succeed, they must collectively address the complexity of connected health care and provide a seamless experience for the growing number of device users.