Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice...

Wireless Technologies: The Challenges and Opportunities Facing Telehealth

Henry RosenVice President, M2M Business Solutions

Numerex Corporation

U.S. Healthcare: Too Much Money/Too Little Results

Our spending is out of control vs. rest of developed world:• 17.4% of GDP spent on healthcare (next highest is Netherlands at 12.0%), UK is 9.8%, Canada is 11.4%• U.S. Per capita spending of $7,960 – next highest is Norway ($5,352); Canada ($4,363) and UK ($3,487), and Japan ($2,878)

- World Bank/Organization for Economic Cooperation & Development

Our performance pales by objective metrics:• 47th in world ranking for infant mortality (we are second lowest in developed world and even rank below Cuba!)• 25th in world for life expectancy (we are below Chile & Greece – Japan leads)• We do NOT have the best healthcare system in the world – at least not in cost/benefit terms

- World Health Organization/CIA World Fact Book

Wireless Telehealth – Vital for our Country

The problem in numbers:•60% (over 100 million) of American adults have at least one chronic condition (disease that is long-lasting or recurrent)•77% over 65 have two or more chronic conditions•90% of all health care spending is towards treating chronic conditions.- US Dept of Health & Human Services

Undeniable evidence of the benefits of Remote Patient Monitoring:•89% of agencies reported an increase in quality outcomes•76.6% cited reduction in unplanned hospitalizations•77.2% cited reduction in ER visits•76% reported patients improving self care by proactive disease management- Philips Healthcare

Chaz•56 years old, married, Harvard MBA•Recently received 2nd Pacemaker Implant•Completely dependent on device now for cardiac rhythm management•Still runs marathons and works out regularly•Wants to work closely to monitor own condition•Technophile/early adopter of consumer gadgets•Wants to maintain active lifestyle despite risks

Judith•87 years old, twice-widowed•Generally good health; received replacement heart valve 7 years ago•Lived in same home for 56 years; wants to stay as long as possible •Biggest concern is staying in home•Doctor appointments are a major effort; •Late adopter of computers/email •Active in local “Ageing in Place” organization

Wireless Telehealth - Real Impact for Individuals

Wireless Telehealth: Great Opportunity

“Wireless Medical Devices Herald a New Revolution in Healthcare.”

Gerson Lehrman Group

/ Huge Complexity

“Wireless Telehealth Solutions Face Many Challenges, including . . . Complexity . . . Acceptance . . . Costs . . .

Reimbursement”

Forrester Research

Telehealth has a language of its own 510k alliance analog ansi ata Asynchronous Transfer Mode (ATM) Audio-teleconferencing Backbone Bandwidth Basic Rate Interface (BRI) Bit bis cardiac care ccd cdc cesl chf chin chronic care continuaa

copd CMS Defense Data Network (DDN) dax devices diabetes doj Dedicated Line Demarc Dip

(Dual In-line Package) Switch Distribution Amplifier Duplex Audio ehr emr fcc fda forward ftc hcaho

hcii hie himss hitsp Home Tele-Health (HTH) Hard Wired Half Duplex hl7 hme hmo hpsa icd9

implantable cardiac devices initiative interoperability ip matmo mcot

meaningful use medix mhealth iniative monitoring Monitored Medication

Dispensing Systems (MMDS) Monitoring Center/Station MBPS (Megabits per Second) mua nchsr nhsc

ohih phr point of care post-acute care pots Patient Tele-Monitoring Systems (PTMS) Pendant

Peripherals Programmable ppo ppp pprc protocol reimbursement remote sonet ss7

store & forward t1 t3 tcp telematics telemedicine tia-50

Adding Wireless Increases Complexity of Telehealth Even More

1800mhz 1900mhz 1xrtt 2g 3g 4g adl agps nalog-to-wireless ansi apis bearers bluetooth bridged

bsc bus cdma certifications command converter counter csd ctia debug dialserv dna

dns dota edge ether ethernet etsi ev-do evdo event fast fcc fcm flash fota

gateway ggps ggsn gpio gprs gps gsm hlr hsdpa hspa http iccid imei imsi

incoming indication infrastructure input integrated ip iso-27001 iwf leo lte

management memory mesh messages mobile model module modem msc mt100a2w-g-eu mt100a2w-g-gb mt100a2w-g-nam mt100a2w-nam object plugins power-up ppo

protocols pstn ptcrb receipt registration rf rj-11 rs-232 secure serial

service sgsn shell sim sms standards tcp tftp timer trace translator udp udpapi unsent usb vlr voip wap wifi wimax wireless zigbee

Successful Wireless Telehealth Initiatives Must Solve Many Issues

What’s the best way to configure & activate

devices?

Should I use a module or embedded

modem?How can we optimize the payload to make

it affordable?

What’s the right wireless

network(s) to use?

How do I pick a wireless module?

Can I automate orders and

requests for equipment? How do I manage

support when patients call in?

What is the right rate plan?

How do I protect my data so I am

compliant with all regulations ?

How will we ship hardware so it is “plug and play?

What about international coverage?

How will I handle billing to insure reimbursement?

What if something isn’t working – how

will we handle returns?

Can I integrate into our legacy systems?

How do I manage my devices over the air?

Distilling the complexity into D-N-A helps simplify things

What’s the best way to configure & activate

devices?

What’s the right wireless network

to use?

Should I use a module or embedded

modem?How can we optimize the payload to make

it affordable?

How do I pick a wireless module?

Can I automate orders and

requests for equipment? How do I manage

support when patients call in?

What is the right rate plan?

How do I protect my data so I am

compliant with all regulations ?

How will we ship hardware so it is “plug and play?

What about international coverage?

How will I handle billing to insure reimbursement?

What if something isn’t working – how can will we handle

returns?

Can I integrate into our legacy systems?

How do I manage my devices over the air?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well


Analog to Wireless Conversion as a First Step?

Smart Phone vs. Hubs vs. Stand-Alone Devices?

Embedded Module vs. Modem vs. Hybrid?

Challenges of Designing Solutions for WIreless?

Regulatory / Network Certifications Needed?


When to use GSM vs. CDMA vs. Satellite?

How Much to Pay for Data?

Single Console Management of Multiple Networks?

Complete Network Visibility?

Domestic Footprint – Especially in Rural Areas?

What about Global Coverage?

Network Security, Privacy & Patient Rights?

From 2G to 3G to 4G and beyond?


Device & Network Agnostic Platform?

Administrative Console w/ Device Management (FOTA, etc.)?

Hosted or Self-Managed Data Center?

Application Monitoring Tools?

Easy Integration to Legacy Systems?


Financing?

Electronic Order Management?

Device & Network “Out of the Box” Experience?

Drop Shipping & Fulfillment Services?


Recurring Monthly Billing?

First and Second Tier Customer Support?

RMA’s and Return Management?



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To Cut Development Time & Costs – follow a proven process

Follow a proven, three phase process to design, develop, and deploy successful wireless telehealth solutions.

Design

Phase 1 - Solution Definition

Working sessions & requirements for device, network, application – as well as data integration into existing legacy systems. Deliverables include Phase 2 Statement of Work.

Develop

Phase 2 - Proof-of-Concept

Build a small number of working prototypes of the complete end-to-end solution. Also develop a detailed ROI model that quantifies the benefits and justifies moving to Phase 3.

Deploy

Phase 3 – Initial Commercialization

Implement a carefully constructed early stage deployment which validates the ROI model in real market conditions. This includes sufficient scale for valid results, but limits out-of-pocket.

• Minimal transaction count• Minimal transaction size• Asynchronous communications• Stateless applications• Minimal implementation of transport layer functions

Wireless Application Architecture Is Different

• Polling• Verbose messages (Ascii text)• Sending static/duplicate data• Sending unchanged/unimportant “dynamic” data• Over-reporting• Confirming transactions/excessive handshaking• Synchronizing state between client and server• Synchronizing time between client and server• Using session-based, confirmed delivery transport

Common Wireline Application Issues

• Wireline applications must usually be rearchitected• Assumptions underlying wireline application architecture are invalid• Fundamental system design usually has to change• “Tuning” or “optimization” can improve performance – a little

• Otherwise, high usage-based charges on every device forever

• Good news! – It’s almost always software

Converting Wireline Applications to Wireless



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Consider a Two-Step Process to Wireless Conversion

Examples of Wireless Converter Devices

Conversion Device

Solutions using PPP Pass-through Require Little or No Change



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Smart Phone/Tablet

Glucometer data downloaded to Patient’s Smart Phone or Tablet

+ leverages patient’s existing hardware & network rate plan

- Patient must own a Smart Phone or tablet w/ data plan/app & download data

- Lack of standardization of devices

Hub Device

Smart Hub Device aggregates data from multiple sources

+ Combines multiple medical devices in one location

- Opens possibility of managing multiple diseases & symptoms

- Typically fairly expensive and complex to implement

Stand Alone Device

All-in-One Device (Glucometer PLUS wide area wireless communications)

+ Simplest implementation – allows total control of process

-Lowest cost

-Longest time to market

Three Alternative Device Approaches (Diabetes Examples)



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Embedded Module vs. Pre-Certified Modem

Consider using a modem/module with enhanced capability a la Java (to do heavy lifting apart from PCB) to limit

exposure on FDA approvals



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Wired Connections Wireless WAN Connections

“Free” connectivity Usage-based charges

“Always” connected Connect on usage

Low latency Very high latency

IP and MAC addresses Also MSISDN and IMSI identifiers

Static/known IP client address Dynamic/unknown IP client address

Monolithic Internet Home carrier and roaming

Wireless Is VERY Different from Landline or Ethernet Connectivity

• Minimize transaction count• Exception-based reporting• Batched reporting• Custom transport layer protocol functions• Custom application and presentation layer protocols

• Minimize transaction size• Employing UDP• Custom application and presentation layer protocols• Client application designed for configurability• Client application designed for modular updating

• Other techniques• Data model modification• Time-base management and calibration

Best Practices for Wireless Telehealth Applications



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Standard Regulatory / Network Certification Flow

Typical Regulatory / Network Certification Timetable



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Combine coverage footprint of Tier I (blue) and Tier II/III (orange) carriers to deliver maximum coverage in U.S.

Consider Coverage in Rural Areas



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International GSM cellular coverage:

185 countries (All EU, SingaporeCanada, United States and Spain have country-wide GSM service).

Global Coverage Exists for Wireless Telehealth

World SIM

For Devices & Patients Moving Around the Globe

OR

Where opening new countries w/ low “density” of connections

Single SIM, Simplified RatesOne SIM works everywhere. Simplified rates for >185 countries

Dual IMSI Technology Domestic & international profiles on a single SIM card allows for Single console management of all Connections

Local SIM

For Devices Permanently Installed in a Fixed Location

AND

Where in-country “density” of connections exists (>10,000)

Locally Sourced SIMWith enough in-country density local SIMs provide the most competitive rates

Requires Local Contract With enough in-country density local SIMs provide the most competitive rates

Consider Two International Approaches – based on density



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ISO/IEC 27001: 2005 certified (“ISO 27001”)

11 Security Domains33 Control Objectives133 Security Controls

ISO 27001 facilitates compliance with

HIPAA requirementsFERC/ NERC Security MandatesOther security laws/regulations

Sarbanes-Oxley Compliance

Data Security, Patient Privacy – What to Look For



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2G/2.5G

Most Existing M2M Applications still use this technology or GPRS

Will eventually be “sun-setted” by carriers – lots of consternation

Lowest cost modules in this category

Many different “flavors” of 3G (HSPA, EVDO, etc) – most useful for “data intensive” apps (web sites, etc.)

Modules must be “backward” compatible for non-3G coverage and are larger/more costly

Modules becoming more affordable

4G & beyond

Stands for Long-Term Evolution

No agreement yet (Sprint vs. AT&T/Verizon) on convergence

High speeds not required for Telehealth apps

Modules typically much more expensive (for now)

Wireless Network Evolution

1xRTT



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Each Network Type Has Its Plusses & Minuses



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How Much Data is Needed – What Should it Cost?

Smart Vehicles•Taking Readings Every Second•Accumulating GPS AND engine performance data•Usually sending data 1x per minute (when moving) •<500 KB to 1 Meg/month

Smart Electric Meter•Taking Readings Every 15 minutes•Aggregating usage and unit performance data•Usually sending data 1x per day + exceptions•Point-to-Point Data <50 KB/month

Smart Telehealth •Not as data intensive as vehicles but . . .•Most companies claim to need more data•Probably points to improper architecture/optimization for Wireless



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49

Console Management Of Multiple Cell Networks

50

View and Manage all SIMs & Rate Plans from one screen



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Deep Network Visibility at the summary level

Deep Network Visibility at the SIM level



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Best Practice Wireless DNA Architecture



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Extensive Device Management Tools



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Representative Virtual Architecture - Hardware



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Data Center Must Allow for Deep Application Monitoring



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Easy Integration to Legacy Applications & Interoperability?



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Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice...

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