Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice 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
Wireless Telehealth - Real Impact for Individuals
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
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
Wireless Telehealth: Great Opportunity / Huge Complexity
“Wireless Medical Devices Herald a
New Revolution in Healthcare.”
Gerson Lehrman Group
“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
Dispensing Systems (MMDS) Monitoring
ohih
mhealth iniative
monitoring Monitored Medication
Center/Station MBPS (Megabits per Second)
mua nchsr nhsc
phr point of care post-acute care pots Patient Tele-Monitoring Systems (PTMS) Pendant
Peripherals Programmable ppo ppp pprc protocol reimbursement
store & forward t1 t3 tcp telematics telemedicine tia-50
remote
sonet ss7
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
gps gsm hlr hsdpa hspa http iccid imei imsi
incoming indication infrastructure input integrated ip iso-27001 iwf leo lte
gpio gprs
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
unsent usb vlr voip wap wifi wimax wireless zigbee
udpapi
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 do I pick a
wireless module?
Can I automate
orders and
requests for
equipment?
How do I manage
support when patients
call in?
How will I handle
billing to insure
reimbursement?
How can we optimize
the payload to make
it affordable?
What is the right
rate plan?
What’s the right
wireless
network(s) to use?
What if something
isn’t working – how
will we handle
returns?
How do I protect my
data so I am
compliant with all
regulations ?
What about
international coverage?
How do I manage my
devices over the air?
Can I integrate into our
legacy systems?
How will we ship
hardware so it is
“plug and play?
Distilling the complexity into D-N-A helps simplify things
What’s the best way
to configure &
activate devices?
Should I use a module
or embedded
modem?
How do I pick a
wireless module?
Can I automate
orders and
requests for
equipment?
How do I manage
support when patients
call in?
How will I handle
billing to insure
reimbursement?
How can we optimize
the payload to make
it affordable?
What is the right
rate plan?
What’s the right
wireless network
to use?
What if something
isn’t working – how
can will we handle
returns?
How do I protect my
data so I am
compliant with all
regulations ?
What about
international coverage?
How do I manage my
devices over the air?
Can I integrate into our
legacy systems?
How will we ship
hardware so it is
“plug and play?
DNA is the key to Wireless Telehealth
– but Product Lifecycle Management services are vital as well
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?
DNA is the key to Wireless Telehealth
– but Product Lifecycle Management services are vital as well
Domestic Footprint – Especially in Rural Areas?
When to use GSM vs. CDMA vs. Satellite?
What about Global Coverage?
How Much to Pay for Data?
Network Security, Privacy & Patient Rights?
Single Console Management of Multiple Networks?
From 2G to 3G to 4G and beyond?
Complete Network Visibility?
DNA is the key to Wireless Telehealth
– but Product Lifecycle Management services are vital as well
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?
DNA is the key to Wireless Telehealth
– but Product Lifecycle Management services are vital as well
Financing?
Electronic Order Management?
Device & Network “Out of the Box” Experience?
Drop Shipping & Fulfillment Services?
DNA is the key to Wireless Telehealth
– but Product Lifecycle Management services are vital as well
Recurring Monthly Billing?
First and Second Tier Customer Support?
RMA’s and Return Management?
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
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
Develop
Deploy
Phase 1 - Solution Definition
Phase 2 - Proof-of-Concept
Phase 3 – Initial Commercialization
Working sessions & requirements for
device, network, application – as well as
data integration into existing legacy
systems. Deliverables include Phase 2
Statement of Work.
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.
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.
Wireless Application Architecture Is Different
•
•
•
•
•
Minimal transaction count
Minimal transaction size
Asynchronous communications
Stateless applications
Minimal implementation of transport layer functions
Common Wireline Application Issues
•
•
•
•
•
•
•
•
•
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
Converting Wireline Applications to Wireless
• 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
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Consider a Two-Step Process to Wireless Conversion
Examples of Wireless Converter Devices
Solutions using PPP Pass-through Require Little or No Change
Conversion Device
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Three Alternative Device Approaches (Diabetes Examples)
Smart Phone/Tablet
Hub Device
Stand Alone Device
Glucometer data downloaded to
Patient’s Smart Phone or Tablet
Smart Hub Device aggregates data
from multiple sources
All-in-One Device (Glucometer PLUS
wide area wireless communications)
+ leverages patient’s existing
+ Combines multiple medical
+ Simplest implementation – allows
hardware & network rate plan
devices in one location
total control of process
- Patient must own a Smart Phone or
- Opens possibility of managing
multiple diseases & symptoms
-Lowest cost
tablet w/ data plan/app & download
data
- Lack of standardization of devices
- Typically fairly expensive and
complex to implement
-Longest time to market
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
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
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Wireless Is VERY Different from Landline or Ethernet
Connectivity
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
Best Practices for Wireless Telehealth Applications
• 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
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Standard Regulatory / Network Certification Flow
Typical Regulatory / Network Certification Timetable
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Consider Coverage in Rural Areas
Combine coverage footprint of Tier I (blue) and Tier II/III (orange)
carriers to deliver maximum coverage in U.S.
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Global Coverage Exists for Wireless Telehealth
International GSM cellular coverage:
185 countries (All EU, SingaporeCanada, United States and Spain have country-wide GSM service).
Consider Two International Approaches
– based on density
World SIM
Local SIM
For Devices & Patients Moving
Around the Globe
For Devices Permanently Installed in
a Fixed Location
OR
AND
Where opening new countries w/
low “density” of connections
Where in-country “density” of
connections exists (>10,000)
Single SIM, Simplified Rates
One SIM works everywhere.
Simplified rates for >185 countries
Locally Sourced SIM
With enough in-country density local
SIMs provide the most competitive
rates
Dual IMSI Technology
Domestic & international profiles on
a single SIM card allows for Single
console management of all
Connections
Requires Local Contract
With enough in-country density local
SIMs provide the most competitive
rates
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Data Security, Patient Privacy – What to Look For
ISO/IEC 27001: 2005 certified (“ISO 27001”)
11 Security Domains
33 Control Objectives
133 Security Controls
ISO 27001 facilitates compliance with
HIPAA requirements
FERC/ NERC Security Mandates
Other security laws/regulations
Sarbanes-Oxley Compliance
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Wireless Network Evolution
2G/2.5G
4G & beyond
1xRTT
Most Existing M2M
Applications still use this
technology or GPRS
Will eventually be “sunsetted” 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
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 Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Each Network Type Has Its Plusses & Minuses
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
How Much Data is Needed – What Should it Cost?
Smart Electric Meter
Smart Vehicles
Smart Telehealth
•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
•Taking Readings Every
Second
•Accumulating GPS AND
engine performance data
•Usually sending data 1x per
minute (when moving)
•<500 KB to 1 Meg/month
•Not as data intensive as
vehicles but . . .
•Most companies claim to
need more data
•Probably points to improper
architecture/optimization for
Wireless
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Console Management Of Multiple Cell Networks
49
View and Manage all SIMs
& Rate Plans from one screen
50
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Deep Network Visibility at the summary level
Deep Network Visibility at the SIM level
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Best Practice Wireless
DNA Architecture
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Extensive Device Management Tools
Extensive Device Management Tools
Extensive Device Management Tools
Extensive Device Management Tools
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Representative Virtual Architecture - Hardware
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Data Center Must Allow for
Deep Application Monitoring
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation
Easy Integration to Legacy Applications
& Interoperability?
Wireless Technologies:
The Challenges and Opportunities Facing Telehealth
Henry Rosen
Vice President, M2M Business Solutions
Numerex Corporation