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Telemedicine in the world of mobile phones

One of the most striking technological developments over the last couple of decades has been the amazing growth, not only in the performance of mobile phone handsets but also in the development of mobile phone networks and the huge take-up of mobile phones by all sectors of the population. This has occurred not only in developed countries — in some Western European countries the use of mobile phones has exceeded 100% penetration, i.e. there are more actively used mobile phones than the total population — but also in developing countries. The acceptance of mobile telephone technology by the population at large would suggest that this could be the basis of a system for the communication of medical data from patients to remote clinicians and vice versa, but there are many issues behind such apparently straightforward approaches. This article looks at how one Finnish system, the Health Gateway, has addressed these issues.
by Fabrizio Galbiati

Advantages of home-based monitoring
Costs, coverage problems, and demographic pressures are already overloading the healthcare systems in many countries. And the future does not look promising either. The percentage of the worldwide population that can be considered as “old” has been increasing dramatically. Some studies estimate that the global population of people over the age of 65 is expected to more than double from 375 million in 1990 to 761 million by 2025. In addition, the recent WHO survey on “Obesity and overweight” shows that lifestyle-related diseases such as obesity, diabetes and hypertension are becoming a real problem worldwide. This relatively new phenomenon requires new approaches to medical care, and underlines new priorities such as the prevention of disease and the heightened importance of the patient’s compliance with recommended lifestyle changes.

Healthcare providers should be able to not only offer cost-effective services for all the population they serve, but also promote specific health prevention actions for citizens in a way that they will feel motivated to accept. In practice this means that  health management has to be brought more and more to a personal level and should “empower” the patient to be more in control of his or her own health outcome.

One way to bring health management to a more personal level is to use something that people are already familiar with and they use in their daily life: the mobile phone. With the use of mobile phones, information sharing between patients and doctors can take place virtually at any time regardless of location. The technology should facilitate self-care, mobile care and home care. It has been shown that health management then becomes more effective, faster and also easier since the patients involved feel more involved and hence more motivated.

Figure 1. Mobile phone platforms such as eHit’s Health Gateway system can provide a reliable wireless interface between several patient monitoring devices and an information platform.

Issues involved in designing and implementing new mobile phone-based systems
Even if the above approach sounds like  straightforward common sense, in practice, real life is much more challenging. Perhaps the first issue to be faced is the multitude of different types of users that could potentially use mobile monitoring. Analyses carried out jointly  by independent health care professionals and patients led the Finnish company eHIT and provider of mobile phone -based telemedicine systems to the conclusion that there could not in practice be such a thing as a one-size-fits-all solution.

Different kinds of users have different needs and require different approaches. Today electronic devices are tiny but extremely powerful tools and for instance young people want to get as much as possible out of them. On the other hand, more elderly people are not likely to be interested in using a small keyboard and display screen to navigate through results and personal information. For these reasons eHIT decided to design software that is highly modular and where functionalities can be easily tailored to different needs, so resulting in an end-product  which can be used by a wide range of users.
The outcome is that each active user feels comfortable with a more informative user interface, and also with graphical diagrams of measurements and trends [Figure 1]. A mobile phone-based diary that can be actively consulted is also highly appreciated.
For those patients looking for a more discreet approach, the software can be configured to be almost invisible. Thus, the system starts automatically when the mobile phone is turned on and remains in the background waiting for measurement data coming from the measuring devices. When, for instance the user takes a blood pressure measurement, the result is transferred via Bluetooth to the mobile phone and from there it is forwarded to the healthcare personnel – silently and without any intervention from the user.
However, an easy-to-use and cost-effective solution for seamless remote patient-doctor interaction using mobile phone technology means that an effective and secure service platform is also needed. This imposes the use of recognised standards for connectivity, information sharing and interoperability with existing information systems. Unfortunately, many existing remote monitoring platforms are based on ad hoc technologies and they lack interoperability with other systems. One reason for the existence of such ad hoc solutions has been the lack of proper standards and guidelines for information sharing within the personal care environment. To address this issue, organisations such as the Continua Health Alliance and Integrating the Healthcare Enterprise (IHE) have recently been focussing a lot of attention on defining frameworks and profiles based on existing standards.

Customers and also end-users are increasingly aware of issues related to interoperability and they are more demanding for openness from suppliers. However, in some countries, monopoly or oligopoly market situations make things more difficult, as information system manufacturers frequently have priorities to maintain their position or system. This question can, however, often be overcome by partnerships with other IT manufacturers in order to offer their customers an integrated solution.

When measurement data are safely transferred to the hospital or laboratory system, a new question arises: are the data reliable and can they be compared with measurements that are generated by health care professionals? Even if modern personal care monitoring devices are usually highly precise and reliable instruments, it is always possible that they could be used in an incorrect fashion. For example, erroneous  measuring procedures could lead to invalid results. Most of these issues can however be solved through appropriate training of the patient on the use of the personal care device.  
Nevertheless, measurements taken at home by the patients themselves should always be clearly identified as such, to differentiate them from those taken by health care professionals. In any case, measurements are always downloaded directly from the measuring device with minimal patient intervention so as to avoid  possible typing errors. This in itself is a major step in the construction of evidence-based practice.

Figure 2. Even on relatively small screens such as those on mobile phones, data e.g. blood pressure, can be clearly displayed graphicly.
Figure 3. The Health Gateway system can use not only standard mobile phones, but also so-called ‘smart’ phones and personal digital assistants.

The Health Gateway system
The leading product from the Finnish company eHIT is the Health Gateway system, which is an effective and secure tool for the wireless transfer of data from different measurement devices to the health care service provider via a mobile platform [Figure 2]. The system consists of a mobile platform, which collects the information from the measuring devices, and a server platform, which receives the collected data and forwards them to the existing Information System. The mobile platform can be used on different devices such as mobile phones, smart phones and Personal Digital Assistants (PDA).
A single mobile phone can collect, store and transfer information from different measuring devices. This also makes possible the integration of devices produced by different manufacturers. For instance a blood pressure meter, a scale and a glucometer can be used together to collect and register key information in diabetes care. The mobile device guides the patient and seamlessly collects information from the measuring devices. The patient can also follow his/her progress in the therapy directly from the display of the mobile device.

The information is then automatically transferred to the health care provider by using a secure GPRS/GSM/3G connection. The information received can then either be stored in the Health Gateway server or directly forwarded to an existing information system. In this way the accuracy of the measurement data is always maintained and the data are available to the health care professionals in real-time and in the appropriate format.

Personnel from the health care provider who are authorised so to do can browse the data on reception and can send an almost immediate feedback to the patient using the Health Gateway client application. This bidirectional connection guarantees a faster patient treatment process since the patient can receive a feedback almost immediately. The system is also capable of generating automatic alarms established according to predefined algorithms. These alarms can be addressed to the health care professionals as well as to the patient or his/her relatives. The Health Gateway system interfaces with several measurement devices for monitoring of ECG signal, blood glucose, coagulation factor, peak expiration flow, blood pressure, oxygen saturation, EMG signal, body weight and other parameters. The system is currently used by private and public health care organisations in many different countries.

Practical implementation
Several applications of the Health Gateway system have been successfully implemented by various hospitals, clinics and healthcare centres. For example, in one Finnish university hospital, patients  are being successfully treated for stress urine incontinence (SUI) by carrying out their regular training exercises at home. SUI is the involuntary loss of urine that occurs in during physical activity such as coughing, sneezing, laughing or exercising. As an efficient alternative to surgery, a programme of exercises designed to strengthen the pelvic floor muscles can restore the urethral closing functions. However to be effective, such training programmes should be carried out and monitored for approximately three months. The intimate nature of the symptoms means that the training programmes are followed more closely by women if they are carried out in the privacy of their own home, with the results of the training programme being sent directly to the health care personnel.

The bidirectional capability of the Health Gateway also makes it possible to provide a remote update of the training program. New exercise programmes can be transferred from the health care provider to the patient’s mobile phone and wirelessly uploaded to the training device. At the same time, patients can also receive some feedback from the physician/nurse directly on the display screen of their mobile device.

In another example, a private clinic in Tokyo, Japan uses the Health Gateway to follow up patients with cardiac disorders. A tiny ECG sensor measuring only 36x36 mm transfers real time ECG data to the patient’s mobile phone. The mobile phone performs an analysis of the Heart Rate Variability (HRV) and gives a quick and easy-to-understand feedback to the patient. The entire ECG is automatically sent to the clinic for in-depth analysis and a detailed report is then sent back to the patient.

The modularity and flexibility of the Health Gateway offer many other applications. For instance, it has been used as a self-service health centre kiosk: patients can just step in and take a blood pressure measurement or other body measurement, without making a reservation in advance. The results are automatically transferred to the Electronic Patient Record of the healthcare centre. Patients being treated using the system generally feel much more motivated, since they can follow the progress of their treatment directly on their mobile devices regardless of time and location. The possibility of receiving immediate feedback from the health care provider is also seen as an important aspect that increases patient self-confidence.

In addition to making the treatment faster and more comfortable for the patient, the system has been shown to reduce treatment costs. For example, the introduction of the Health Gateway in the monitoring of the incontinence training exercises described above was shown to result in an approximately 30% saving to the clinic as compared to the standard method of giving training sessions at the hospital. Furthermore, patients saved time and travelling expenses. Insurance companies can thus also benefit from this mobile solution, which potentially reduces direct and indirect costs such those related to absence from work.

The future
The role of remote monitoring is becoming more and more important in health care management. Several applications are already extending the traditional approach and involving the patient in the care process.  But the trend is to move from monitoring patients affected by chronic diseases to preventive monitoring. The earlier the alarm bell can be rung, the more effective will be the treatment.
A tighter integration between technology and automation used in the home (domotics) and telemedicine is also to be expected, particularly in the ageing population. Such technologies can not only improve the quality of life for senior citizens but also reduce healthcare costs. Many elderly people may be allowed to continue live their normal lives at home when remotely assisted by health care professionals. Mobile extensions bring a significant improvement to the quality of life, since people can access healthcare professionals from anywhere and not only from home.

In the more distant future we will probably see the use of electronics to make remote monitoring even more discreet. Tiny implantable bio sensors could constantly monitor our health status and automatically generate alerts well before the symptoms of a disease become apparent. Although this may sound very futuristic it should be noted that many innovative systems are already available on the market today.

The author
Fabrizio Galbiati,
Sales Manager
eHIT Limited,
Microkatu 1, PO Box 1199
70211 Kuopio


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