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Advanced Hardware and mHealth

David J. Whitten / Kathleen G. Charters

INTRODUCTION

Healthcare computing technology depends upon hardware—the silicon, metal, and plastic portion of the “hardware–software–human” triangle. When forwardthinking professionals think about advances in new hardware and create new care models which require them, they can produce healthcare innovations that positively affect patients and the ways nurses use to describe and deliver healthcare. “eHealth”—the practice and use of information and communication technology—is shaped by new hardware, and also helps to drive increases in the sophistication of mechanical devices and electronic systems. Health professionals and the general public develop new services and provide information which inform new models of disease and practice. This activity pushes existing development while leveraging and advancing new ways of using hardware. Since mobile devices such as smartphones are integrated into the daily lives of patients, the practice of healthcare and advanced public health depends upon these mobile devices as foundational to delivering targeted healthcare.

Three key hardware elements work together to enable mobile health (mHealth) to create a more powerful synergistic whole. In order, they are (1) convenient physical device size, (2) ubiquitous wireless network access, and (3) longer battery life. Progress in mHealth has accelerated in recent years, supported by the increasing prevalence of sophisticated infrastructure and the capability and capacity of internal computers in mobile devices. This capability is usually seen in smartphones, advanced tablets, and wearable/implantable/injectable devices. These devices include quicker processing power and memory storage, and more power applications are enabled through large-capacity storage both on the local mobile device and through offline storage of large volumes of information that is made available through cloud computing services. Long-life batteries form the last supporting leg of this triangle.

Hardware

There are three extant trends in computer hardware advancement: (1) readily available, conviently packaged information processors which are able to deliver highimpact programs and are accessible at hand to the care providers, (2) extensive communication infrastructure such as electronic networks and mobile telecommunication systems and the cloud to which the local mHealth devices can be connected, and (3) multiple powerful central processing centers that enhance the local mHealth devices. This combination of local machines, an efficient use of electronic infrastructure and powerful cloud services, allow innovations in software and user interfaces that target the special needs of healthcare and nursing. For example, tablets used to be less powerful than laptop computers, but could still act as a bridge between a stationary desktop computer and the internal computers in smartphones. This linkage allows more information to be provided, and leverages higher density displays to quickly present information in a timely way. Tablets are used to run different programs than laptops or desktop computers but can communicate with computer programs. This means care can be supported by specialized programs on easily carried tablets while distant computers can provide significant computing resources which require more computing power, electrical stability and centralized storage for the information generated.. A smartphone is a powerful hand-held computer with an operating system and the ability to access the Internet. Wearable devices, in multiple physical forms, such as watches, are comparable in size to that of a piece of jewelry. These wearable devices are able to provide specialized equipment used to collect physiological measures such as heart rate and rhythm, respiration, sleep cycles, and even rapid blood analysis (Zhu, 2013), as well as other information that requires physical proximity to the wearer. After collecting the information, the device doesn’t need to have the capability of long-term storage and analysis. That is provided by the computers which collect the data sent wirelessly from smartphones via the Internet. Implantable devices, such as an internal cardioverter-defibrillator, provide methods of intervention, as well as the ability to monitor physiological responses. Since many medical conditions are time sensitive, having these devices implanted lessens the need to have them quickly available externally, and allows more flexibility in patient’s lifestyle and improves quality of life. Injectable microcircuitry is the focus of active research where many privacy, security, and ethical issues are addressed.

Massive amounts of data, available in large-capacity redundant storage, also allows steadily improving faulttolerant designs which are not limited by portability. These machines can be bulky and organized into redundant arrays of independent disks (RAIDs) for replicating and sharing data. The intentional duplication among disks makes it possible to store larger chunks of information than a single storage device can handle, and allows specialized circuits that check that the information is not lost or corrupted. Genomic data and machine learning is facilitated through the combination of accessibility and capacity, as both are essential in recognizing patterns which are only evident when examining large data sets. Multiple patterns in genomics data and historical records require targeted algorithms and neural networks. Organizing these patterns in a way that makes the results accessible through the Internet requires significant multiples of computer processing capacity and storage beyond the limited local storage and computing power within mobile devices. Cloud computing is the short-hand way of expressing a mobile device’s ability to access a large number of computers connected through a communication network and thereby run a program or application on a parallel platform of concurrent computer resources. This allows the user of a smartphone to take photos, edit the photos, and annotate them with clinically relevant context before sharing them. This is a common example of leveraging mobile device access to cloud services without the requirement of leaving the patient to go back to a desktop machine that has the capacity to allow the clinician to edit and share.

A limiting factor for mobile computing is the length of time a mobile device can work independently before being connected to a non-mobile power source. Modern rechargeable batteries enhance the device’s accessibility to the patient’s location, whether at bedside or in a more active care locale. Many people complain about battery capacity as this effectively limits the portability of the mobile device. The enhanced need for background processing in the mobile device to support activities creates problems because when there is a high level of background activity, the internal computer and memory use significant amounts of power, but which isn’t evident to the user. For example, running multiple interactive mobile applications (apps) in the background will each drain power, and will shorten the amount of time the device can be used before having to recharge the battery (Schmier, Lau, Patel, Klenk, & Greenspon, 2017). Use of mobile data and video is rapidly expanding (Moore, 2011), driving research on ways to deliver vastly improved power density (Williams, 2013).

Wireless Communication

The foundation of mobile computing and mHealth is a mobile device’s ability to connect with networks in multiple ways. Technology used to wirelessly communicate with a mobile device includes mobile telecommunications technology, Wi-Fi, Bluetooth, and RFID. Mobile telecommunications technology continues to evolve (Federal Communications Commission, 2012). Fifthgeneration (5G) networks that provide faster performance and more capabilities are replacing fourth-generation (4G) and third-generation (3G) networks. Much like them, a 5G network supports all Internet Protocol (IP) communication. It uses new technology to transfer data at very high bit rat5es, significantly improving both the speed and volume of data transfer than was possible with the previous network technology (Nikolich, 2017). The InternationalTelecommunications Union-Radio (ITU-R) communications sector sets the standards for International Mobile Telecommunications-Advanced (IMT-Advanced) technology. The peak speed requirements for 4G service are 100 megabits per second for high mobility communication (e.g., communications while traveling by car or train) and 1 gigabit per second for low mobility communication (e.g., communications while walking or standing still). Technologies that do not fulfill 4G requirements but represent the forerunners to that level of service by providing wireless broadband access include Worldwide Interoperability for Microwave Access (Mobile WiMAX) and Long-Term Evolution (LTE), a standard for wireless communication of high-speed data for mobile phones. (Although the standards-setting body is international, due to different frequencies and bands used by different countries, only multi-band phones will be able to use LTE in all countries where LTE is supported.)

Wi-Fi is intended for general local network access—generally within a single building or other limited area. The limited area of access is called a wireless local area network (WLAN). Wi-Fi is a technology that allows an electronic device to exchange data or connect to the Internet wirelessly using (in the United States) 2.4 GHz Ultra High Frequency (UHF) waves and 5 GHz Super High Frequency (SHF) waves. Advanced hardware makes this connection through a wireless network access point, or hotspot. Wi-Fi is based on the Institute of Electrical and Electronics Engineers (IEEE) 802.11 standards. To provide a level of security for the wireless connection, various encryption technologies are used, such as Wi-Fi Protected Access (WPA) and Wi-Fi Protected Access II (WPA2) security protocols. To ensure that devices can interoperate with one another, a type of Extensible Authentication Protocol (EAP) is used. Wi-Fi security concerns are covered in the National Institute of Standards and Technology (NIST) Guidelines for Securing Wireless Local Area Networks (NIST Special Publication 800-153) (2012b).

Bluetooth is intended for a wireless personal area network (WPAN). Wi-Fi and Bluetooth are complementary. Wi-Fi is access point-centered, with all routed through the access point which is typically a modem or router which brings the Internet into the building from an Internet service provider. The router allows several computers, tablets, and other devices to connect to the Internet through a single access point—the router). Bluetooth is used for symmetrical communication between 2 to 7 Bluetooth devices. Bluetooth permits the connected devices to transfer information among the connected devices. The devices must be physically close to each other because the connection is low-bandwidth situations. For example, a user might connect a smart phone to the radio in an automobile so coversations take place safely through the (handsfree) radio rather than the user trying to drive and handle a phone at the same time. Typically, several devices are paired with a single device, such as Bluetooth keyboards, mice, activity monitors, and cameras paired to a single desktop, tablet, or smartphone. Protocols covering wireless devices include Wireless Application Environment (WAE), which specifies an application framework, and Wireless Application Protocol (WAP), which is an open standard providing mobile devices access to telephony and information services.Bluetooth is a wireless technology standard for control of and communication between devices, allowing exchange of data over short distances. Bluetooth is used for wirelessly connecting keyboards, mice, light-pens, pedometers, sleep monitors, pulse oximeters, etc. The range is application specific. Bluetooth uses 2.4 to 2.485 GHz UHF radio waves, and can connect several devices. The Bluetooth Special Interest Group (SIG) is responsible for Bluetooth standards. Bluetooth security concerns are addressed in the NIST Guide to Bluetooth Security (NIST Special Publication 800-121) (NIST Special Publication, 2012a).

Radio-Frequency Identification (RFID) is a technology that uses radio-frequency electromagnetic fields to transfer data, using tags that contain electronically stored information. Typically, RFID is used for equipment tracking and inventory control. For example, in an operating room, RFID is used to automatically poll equipment in the suite and cross-reference that equipment with inventories showing the equipment is certified, and the date of the most recent service. Tags contain an integrated circuit for storing and processing information, and modulating and demodulating a radio frequency. Tags also contain an antenna for receiving and transmitting the signal. The tag does not need to be in the line of sight of the reader, and may be embedded in the object to be identified. The reader is a two-way radio transmitter-receiver that sends a signal to the tag and reads its response. Advanced hardware uses increasingly miniaturized RFIDs; some chips are dustsized. The International Organization for Standardization (ISO) and the International Electrotechnical Commission (IEC), among others, set standards for RFID. The standards for information technology telecommunications and information exchange between systems are ISO/IEC 18092 and ISO/IEC 21481. (Although the standard-setting bodies are international, frequencies used for UHF RFID in the United States are currently incompatible with those of Europe or Japan.) Security concerns are addressed by using cryptography. RFID security concerns are addressed in the NIST Guidelines for Securing Radio Frequency Identification (RFID) Systems (NIST Special Publication SP 800-98) (NIST Special Publication, 2007).

Standards and Protocols

A protocol is a method that allows information to be shared on an information channel. Both the sender and the receiver of information must use the same protocol to be able to communicate. These agreements are usually well-established between vendors in the form of standards and best practices. When they are followed, global and easy access to data or records can leverage networks and networked information so that more equipment can use common networking infrastructure in a standardized way. Since the Internet is global in scope and extent, it requires specific networking models and communications protocols. The information is segmented into information packets which are organized using a method commonly known as Transmission Control Protocol (TCP) and the Internet Protocol (IP) or TCP/IP. This suite of standard ways of communicating provides end-to-end connections, between cooperating software and hardware. TCP/IP specifies intricate details about how data are to be formatted, how various Web sites and equipment can be located (through use of a common address method), specialized transmission methods and means for copying data packets from one computer to another, route information so the computers that are communicating can efficiently find each other, error correction schemas with checksums to guarantee that the information that was sent hasn’t been changed (corrupted) as it passes through multiple machines, and finally, that the destination receives all of the information that was sent without loss and in the correct order. To be fast and accurate requires special devices that all share this common agreement about how information should be organized into the TCP/IP protocol.

Historically, these protocols are established by the Internet Engineering Task Force (IETF) which maintains the standards for the TCP/IP suite as well as multiple other standards and protocols (IETF RFC Index, 2019). There are also agreements for all commonly needed protocols for Internet user-interface services and support services. For example, to communicate e-mail messages, there is the Simple Mail Transfer Protocol (SMTP). The methods that computers use to find information on a local network are specified through Network File System (NFS). These methods require the use of File Transfer Protocol (FTP starting with RFC238 from 1971) and HyperText Transfer Protocol (HTTP—RFC1945 from 1996), both of which have secure forms (SFTP and HTTPS). Security is provided using encryption standards developed by the IETF. IETF also provides confidentiality and integrity for data sent over the Internet. Electronic mail depends on privacy enhancements that date back to 1987. Cryptographic network protocols to protect data while it is being transmitted between computers are Secure Sockets Layer (SSL) and Transport Layer Security (TLS). Protocols for encrypting data at rest include Pretty Good Privacy (PGP) and GNU Privacy Guard (GPG). (Note: GNU is a name, not an acronym).

Building on top of six-level network standards, there are standards that ensure health information is properly identified, transmitted correctly, and complete. The seventh (application) level of standard is called Health Level Seven (HL7) (HL7 International, 2018). The FHIR standard with all its deliberations has been accessible to the public free of cost through the Web site https://build.fhir.org/history.html.

The HL7 International (https://www.hl7.org) is an American National Standards Institute (ANSI) accredited Standards Developing Organization that maintains the framework and standards for the exchange, integration, sharing, and retrieval of electronic health information. These standards are the most commonly used in the world for packaging and communicating health information from one party to another using language, structure, and data types that allow seamless integration between systems. A myriad of medical equipment, such as lab testing equipment, pharmacy pill filling machines, patient identification card creators, heart monitors, and imaging equipment, all communicate using the HL7 protocol, both to each other and to electronic medical records systems and electronic health information systems. The HL7 standards support management, delivery, and evaluation of health services and clinical practice (Health Level Seven, 2014).

There are multiple forms of HL7, some of which look like simple text lines, and others such as the FHIR which are organized as JavaScript Object Notation data structures (HL7 FHIR, 2019) and even blockchain records that encrypt transactions to keep a ledger of healthcare activities for a patient.

Clinical Content Object Workgroup (CCOW) is an HL7 standard protocol that enables different applications to synchronize at the user-interface level in real time. This standard allows applications to present information in a unified way. For example, with CCOW enabled, a provider could bring up a patient record in the inpatient electronic record application, and then open the outpatient electronic record in a different application, and CCOW would bring up the same patient in the outpatient application.

Evolution and adoption of existing technologies and standards allow users to benefit from advanced hardware without the need for deep knowledge or expertise. For example, you can watch a feature film on a smartphone without knowing how the underlying hardware and software work. These advances in hardware along with virtualization support new care models.

Drivers of Mobile Healthcare

The 2012 documentary Escape Fire: The Fight to Rescue Healthcare is an urgent call to think differently about healthcare. Clinicians shifting from a focus on disease management to a focus on ending lifestyle disease may leverage the use of mobile platforms. For example, during an outpatient visit, Dr. Natalie Hodge prescribes an app for health self-management in the same way that medicine or any other intervention would be prescribed (Wicklund, 2014, February 13). According to the mHIMSS Roadmap, “patients and providers are leveraging mobile devices to seek care, participate in, and deliver care. Mobile devices represent the opportunity to interact and provide this care beyond the office walls” (Healthcare Information and Management Systems Society [HIMSS], 2012b).

Advancements in technology, federal healthcare policy, and commitment to deliver high-quality care in a costefficient manner have led to new approaches (mHIMSS, 2014b, 2014c). The Affordable Care Act (ACA) leverages innovative technology to bring about “a stronger, better integrated, and more accessible healthcare system” (HIMSS, 2012b). For example, mobile apps allow expansion of telemedicine and telehealth services. The current healthcare focus is on preventive and primary care to reduce hospital admissions and emergency department utilization. Engaging patients in management of their chronic diseases helps them maintain their independence and achieve a high quality of life. Patients may make use of collaborative tools such as Secure Messaging or the Patient Portal to communicate with their healthcare team, and may find support through social interactions on a blog.

Technology in Mobile Healthcare

Under the ACA, innovative technology is seen as an integral component of an integrated, accessible, outcomedriven healthcare system. Mobile technology may be key to providing more effective preventative care, improving patient outcomes, improving access to specialized medical services, and driving system-wide cost reduction. Services to patients and families at home will be personalized and delivered by providers equipped with apps for smartphones, tablets, and laptops (Powell, Landman, & Bates, 2014).

The National Institutes of Health defines mHealth as “the use of mobile and wireless devices to improve health outcomes, healthcare services, and health research” (HIMSS, 2012a). A major component of mHealth includes timely access to clinical information such as the data contained in electronic health records (EHRs), personal health records (PHRs), and patient portals. This information should be securely accessible by clinicians, patients, and consumers over various wireless mediums both inside and outside the traditional boundaries of a hospital, clinic, or practice (HIMSS, 2012b). The iPhone and Android operating systems have accelerated the proliferation of mobile data use. By 2015, mobile data traffic will be some 20 times the 2010 level (Moore, 2011).

The concept of mHealth can be traced to the early 1990s when the first 2G cellular networks and devices were being introduced to the market. The bulky handset designs and limited bandwidth deterred growth. Lack of communication standards impeded interoperability, and batteries lasted less than 6 hours. A major standards breakthrough occurred in 1997, enabling Wi-Fi capable barcode scanners to be used in hospital inventory management. This lowered the need for specialized knowledge by practitioners and supported healthcare organization cost-saving measures (Ray, 2018). Shortly thereafter, clinicians began to take an increasing interest in adopting technologies. At this time, nurses began to use personal digital assistants (PDAs) to run applications like general nursing and medical reference, drug interactions, and synchronization of schedules and tasks. This quick rate of adoption was quite notable for clinicians were often considered technology adverse. Increased processing capabilities and onboard memory created an appetite for more advanced applications. Network manufacturers were beginning to offer Personal Computer Memory Card International Association (PCMCIA) wireless devices, creating an environment where retrofitted hospital computers or new laptops allowed nurses to access the Internet without adding network cabling.

In 2000, the Federal Communications Commission (FCC) dedicated a portion of the radio spectrum to wireless medical telemetry systems (WMTS); this allowed the wide adoption of specialized devices for remote monitoring of a patient’s health. Fiber-optic networks and other specialized communication equipment increased data transmission rates, making it highly feasible for hospitals to run video or voice applications over their local wireless networks. Connection software with the hospital electronic record and Application-Specific Devices (ASDs) can increasingly be integrated with nurse call systems and medical telemetry so that nurses can receive prompt patient-specific alarms, text messages, and alerts tied to their ongoing care. Many vendors are now beginning to offer the same type of nurse call integration and voiceover Wi-Fi capabilities on popular smartphones (HIMSS, 2012b).

Nurses soon became familiar with Computers on Wheels (COWs), which evolved to workstations on wheels (WOWs). More wireless devices were integrated into networks and a greater emphasis was placed on error detection and prevention, medication administration safety, and computerized provider order entry (CPOE). Parallel to Wi-Fi technology evolution has been the growth in cellular technology. In many healthcare organizations, seamless roaming between the two systems is a reality. Nurses now have immediate access to patient data at the bedside.

Infrastructure

mHealth is a broad, expanding universe that encompasses a wide variety of user stories (use cases) that range from continuous clinical data access to remote diagnosis and even guest Internet access. The role of video in healthcare is evolving as quickly as the standards themselves. Telemedicine carts outfitted with high-resolution cameras include remote translation and interpretation services for non-native speakers as well as the hearing impaired. In the past, WOWs were mainly used to access clinical data, but these carts have gained such wide acceptance that they are often found in use by clinicians on rounds or at change of shift. Hospital systems and ambulatory practices have also started using products like FaceTime, Skype, Google Hangouts, and other consumer-oriented video-telephony and Voice-Over Internet Protocol (VOIP) software applications for patient consults, follow-up, and care coordination (mHIMSS, 2014a).

Wi-Fi infrastructure connecting medical devices to centralized record keeping computers has obsoleted specialized overlay networks. These multiple-use networks allow hospitals to leverage economies of scale by using their existing Wi-Fi infrastructure for multiple purposes. This does increase the hospital’s dependency on the Information Technology (IT) department and specialized computer knowledge and personnel to ensure the security of the hospital, clinic, or practice wireless network. It also requires considerable investment in proper planning and design for a robust network, capable of supporting various types of medical devices such as infusion pumps, mobile EKG devices, point-of-care lab devices, mobile X-ray machines, portable ultrasound equipment, and blood gas analyzers on a single cohesive network infrastructure.

This also requires testing and monitoring of those devices to limit infectious disease transmission. Their portability and simplicity make these devices highly effective in performing diagnostics near patients in a healthcare facility. They also speed the diagnostic cycle by providing reduced turn-around time when needed. This lowers mortality and morbidity of infectious disease while limiting the impact of institutional risks such as antimicrobial resistance (Bissonnette, 2017)

An important and often overlooked aspect of mHealth is patient or guest access to the wireless system. Care must be taken to segregate the guest access wireless network from the health professional networks. Wireless guest access provides a way for patients and their families to access the Internet; it can be a valuable tool for hospitals to engage with patients and guests. In a healthcare setting, organizations generally opt to provide free unencrypted access with a splash page that outlines terms and conditions. This allows the hospital to address liability for the patient’s Internet traffic and allows guests and patients to access the network quickly.

Real-time location services (RTLS), a concept dating back to the 1990s, has evolved rapidly over the years. RTLS can be used for location tracking of physical assets using RFID tags as beacons, temperature/humidity monitors, distress alert badges, and they can even be used to track hand washing (mHIMSS, 2014e). A properly configured RTLS system can minimize the task of tracking down medical equipment and show the nurse the current status of the equipment. The wide range of uses for RFID technology enables many innovative practices. Biomedical, pharmacy, security, and other departments in the hospital are using this technology (Table 3.1).

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