Issue: Future Technology Trends
What general trends might affect the future of Telehealth technology and its standards?

Discussion
Along with the evolution of the Next Generation Internet, three trends that will likely influence the near future of the telehealth industry and dictate the need for technical standards are:

• The digitization of information;
• The migration toward wireless communications; and
• The globalization of services.

Background
The digital revolution is underway. Digitized data, voice, still images and motion-video can be mixed, matched, melded, and sent over myriad types of conduits. Advances in digital and compression technology mean that vast amounts of information can be stored on smaller and smaller chips. Important applications of this technology include the creation of digital medical libraries and medical databases, as well as the potential to develop Electronic Medical Record Systems and Smart Cards that can hold medical information on a card the size of a credit card. Currently, however, there are no technical standards that can help easily integrate telemedicine clinical data onto these systems and cards.

Next Generation Internet: The Internet has dramatically changed the way America communicates and does business. Between 1991 to 1999, the number of domain names with an IP address rose from almost zero in 1991 to by 45,000,000 by 1999.¹ From the consumer's standpoint, the Internet offers the ability to interact with health practitioners online and easily access health-related information. It's no wonder, then, that more people use the Internet to gather information about health-related topics than any other subject.

However, there are numerous barriers that might inhibit telehealth growth on the Internet, including growing delays, costs, and lack of security, reliability and availability on a worldwide basis. The development of Internet2 might help address some of these barriers. Internet2 is a joint venture by academia, the federal government and industry. This group is using a new high-speed backbone network with a core subnetwork consisting of a 2.4-Gbps, 13,000-mile research network to test Internet applications (for example, Internet Protocol (IP) multicasting, differentiated service levels, and advanced security). It will also allow researchers to test and resolve problems such as bandwidth constraints, quality and security issues.

Will wireless lead the way? In the telehealth industry, wireless technology is most commonly used for telemetry and emergency medical services. However, in countries that have adapted to digital wireless phone systems faster than the United States, the future of wireless technology is already available. For example, in Japan, Nippon Telephone & Telegraph will provide Internet e-mail access via its wireless phone services to 1 million customers. This year, Japanese companies will also introduce a mobile videophone to its local markets that can transmit live video at 32 kbps. In the Netherlands, Nokia has already introduced the Nokia 9110 Communicator, which can link to a digital camera; store images, and then e-mail them. Nokia's Communicator will be available in the United States within in the next year, but mobile videophones may not be for several years.

Companies in the United States have already have introduced wireless handheld computers, such as the Palm Series and its competitors. More recently, mobile phone providers, such as Sprint PCS , have introduced products with the ability to access limited Web pages for text information but direct access to the Web and its graphics is not yet possible without appropriate technical standards. However, a standard called the Wireless Application Protocol (WAP) is already under development. WAP is a way of converting information on Internet Web sites into a form that can be displayed on a mobile hand-held phone device. The advent of so-called microbrowsers may still be a few years away, because mobile systems currently do not have the capacity to support high-speed connections with the Internet. Once faster speeds are available, WAP proponents believe that consumers will be able to get message notification and call management, electronic mail, mapping and location services, weather and traffic alerts, sports and financial services, address book and directory services, and corporate intranet applications on their hand-held devices.

Mobile satellite communications also promise to extend the global reach of voice, data and other services. Two Low Earth Orbiting Satellites systems, Iridium and Orbcomm, became commercially operational in 1999. The Orbcomm system is used as a tracking service to monitor the location of trucks or other vehicles, travelling long distances. (Iridium recently filed for bankruptcy.) Several more satellite systems will become operational soon, including Lockheed Martin's Astrolink, scheduled to begin operations in 2001, and Hughes Network Systems' Spaceway. Additionally, Motorola and Boeing have invested in an ambitious plan to put up an "Internet in the sky" called Teledesic. Teledesic plans to have 288 satellites in its "constellation" network as opposed to Iridium's 66 "birds," or satellites. According to Teledesic, it will be able to offer affordable broadband Internet access, videoconferencing, high quality voice and other digital data needs.

Unlike terrestrial mobile phone systems, satellite technology may be several years away from offering affordable services. However, these systems will provide several advantages. Larger satellite systems can reach a global audience and at the same time offer data transmission rates three times faster than an ISDN connection. Another way of putting this is to say that satellites can deliver data at speeds up to 45 Mbps-nearly 30 times faster than a T1 line.

Global reach, global service: Adopting international technical standards for the telehealth industry, such as those developed by the International Telecommunications Union (ITU), will become more critical as global services and communications become the norm. For example, the ITU has already developed the "H" standard series for videoconferencing, which has been widely adopted. The World Trade Organization (WTO) is preparing to embark upon health services negotiations this year, after successfully finishing its financial services and telecommunications basic services negotiations. Clearly, telemedicine and distance education will be an important part of these new global trade discussions. In addition to the WTO, the World Health Organization is also hosting treaty discussions around telemedicine.

Conclusion: This Telehealth Update points to general trends that may affect the future of telehealth standards and guidelines. Interoperability, connectivity, scalability and mobility will be key features for telehealth technology in the future. Thus, standards and guidelines with open architecture will be required. Wireless and wireline data transmission standards will also become more and more important as large blocks of information are transferred from central information centers to personal Smart Cards and vice versa. Another important theme is the need for compatible standards between communications systems and medical devices. Internationally accepted standards and guidelines may also be an important trend as global connectivity and interoperability become an issue and telehealth becomes a global service.

What you need to know

• What is interoperability, ISDN and open architecture?
• Where are many technical standards developed?
  • National Technical Standard-Setting Organizations:
    • American National Standards Institute
    • Institute of Electrical and Electronic Engineers, Inc.
    • National Institute of Standards and Technology
  • International Standard-Setting Organizations:
    • International Telecommunication Union
    • International Standards Organization
    • European Telecommunications Standards Institute
• Which Associations or Government agencies track wireless technologies?
  • Cellular Telecommunications Industry Association (not a U.S. Government Web site)
  • Federal Communications Commission
  • National Telecommunications and Information Administration

Other Links

• Internet2 (not a U.S. Government Web site)
• Satellite Information Resources

Next Steps
The Office for the Advancement of Telehealth convened a two-day workshop in September 1999 to develop general technical standard guidelines for its new grantees. A summary of the workshop will be posted in early December 1999.

Telehealth Technical Standards of the Future

Predicting the future of the telehealth industry and the technical standards that will underpin "next generation" technology is a bit like predicting the stock market over the next few years. If we could accurately forecast, we would all be rich. At the most, we can describe some important trends in the telehealth industry over the short term and suggest some possible scenarios for the future.

Background
Over the past five years, significant changes in the telehealth industry have been tied to rapid technology advances and the convergence of the communications, media and computer industries. What has been even more dramatic is the exponentially expanding global reach of the
Internet, which grew out of a community of U.S. academic and military developers to reach a world wide global audience in just a few years.

Along with the evolution of the Next Generation Internet, three trends will most likely influence the near future of the telehealth industry and dictate the need for technical standards: the digitization of information, the migration toward wireless communications, and the globalization of services.

Bits and Bytes: The Future Is Now
Although Next Generation Internet, wireless technology, and the globalization of services may be just around the corner, the digital revolution has arrived. Digitization of data, voice, still images and motion-video has enabled producers and users to mix, match, and meld different mediums and send information over myriad types of conduits: telephone lines, cable, wireless digital cellular systems, and satellite systems. Moreover, advances in digital and compression technology have created countless opportunities to store vast amounts of information onto smaller and smaller chips. Important applications of this technology include the creation of digital medical libraries and medical databases and the potential to develop Electronic Medical Record Systems and Smart Cards that can hold medical information on a card the size of a credit card. Note an April 1998 study called: "Future Trends in Medical Device Technology: Results of an Expert Survey" conducted by the Food and Drug Administration, which identifies six major areas, including computing-related technologies, as an important "trend driver" in the development of future medical devices. According to this survey, computer-related technologies will drive the development of "integrated patient medical information systems, patient smart-cards," among other things.

Currently, however, there are no technical standards that can help easily integrate telemedicine clinical data onto these systems and cards. Perhaps more importantly, many Americans are concerned about the security and privacy of their medical records, especially if this information is centrally stored in an easily accessible format.

Another trend, highlighted in the FDA Survey was an accelerating "emergence of home- and self-care products (the fastest growing segment of the medical device industry throughout the 1990s)." An outgrowth of this study was a joint Catholic University and FDA Workshop on Home Care Technologies for the 21st Century in April 1999.

One of the workshop's eight topical areas (Topic A), co-chaired by Dena Puskin, Sc.D., and Gerald Loeb, M.D., explicitly addressed home telehealth. Puskin and Leob's topical report, highlighted four areas: 1) vision (anticipated, desired); 2) gaps in knowledge; 3) barriers; and 4) recommendations. This group produced three statements that explicitly related to standards, and their anticipated impact on telehealth:

1. Under Vision Statements:
A-5: The government will take an active role through education, regulation, and provision of services that become accepted privately as the standard of care. Consumer-driven demand will lead to products targeted to specific types of consumers. This demand is likely to lead to increasing pressure on government and health care insurers to provide reimbursement for these products. A decision to pay for a product or service will require payers to set standards for what they will pay for and what they won't. Following historic trends, there will be a convergence among payers as to what is an acceptable service or product for payment, especially if Medicare has decided to cover them. This will result in de facto standards that are likely to be accepted by the private market, for as it is said, "He, who pays the piper, calls the tune." In addition, there is likely to be growing concern about the safety or validity of the claims for such products, especially if such products are directed at the elderly, disabled, or infirm. As in the past, this concern could be galvanized into pressure on federal and state agencies to take a more active role in educating the public about, and regulating the sale of such products.

2. Under Barriers:
A-2: Nascent communication standards for medical devices (e.g., IEEE 1073) need to be developed, promulgated, and accepted widely before system integration can proceed efficiently. The lack of standards in the field is a major impediment to telehealth technologies reaching their full potential in terms of market penetration. Health care professionals and administrators are frustrated by health care devices that do not work together or are not easily upgraded. They are reluctant to make large-scale investments in technologies today that will become out-dated legacy systems tomorrow. In the long run, standards facilitate rather than impede technology development. The challenge is to develop standards and effective procedures for updating these standards without stifling innovation.

3. Under Recommendations:
A-4: Develop and promote standards for exchanging and archiving information that address the fluid environment created by tele-homecare. In an increasingly mobile society, we need standards that promote the exchange of information regarding the care of an individual that cut across sectors of the health care field. Such standards would enable rapid exchange of information regarding individuals, no matter where they received health and health-related services. At the same time, these standards must reflect concerns that the privacy, confidentiality, security, and integrity of data are maintained.

Interestingly, each statement differs in focus. The first recognizes that "standards of care" within the health services professions is an important issue, (see also the 1988 Report of the Interdisciplinary Telehealth Standards Working Group (created for the Joint Working Group on Telehealth (JWGT)). The second explicitly addresses medical device telecommunications. At a time when many medical devices have moved to the home environment, the lack of appropriate standards has resulted with few products that integrate medical devices and telehealth, and furthermore, those that are available tend to be expensive legacy systems. This issue is addressed further in the companion discussion paper by Jack Winters. The third summarizes some of the challenges of designing effective technical standards, due to the need to address issues as varied (and often contradictory) as ease of access on the one hand, and confidentiality on the other.

It is interesting that the top two recommendations of the Workshop were to fund research for intelligent processing of large amounts of health data (F1), and to fund large-scale demonstration projects to evaluate tele-homecare interfaces and systems (A1). Both address challenges that relate to futuristic telehealth. Clearly, one of the key themes is how to effectively transfer data. Possibilities include a mass-market teleconferencing approach like the T.120 group for data-sharing, the evolving IEEE 1073 (open architecture Medical Information Bus), or various other means. Another key theme was that of universal design and standardization, so as to enable universal access by all, including older adults and persons with disabilities (this is further addressed in Jack Winters' paper). Taken all together, a message emerges: With so much change on the horizon, government policy in setting up guidelines has the potential to help shape how, when, and why home telehealth is used.

Next Generation Internet: In the future, will IP be the only standard you need?
While many factors may have or will contribute to advances in telehealth, the introduction of the Internet dramatically changed the way a large number of American's communicate and do business, including telehealth. In order to grasp the magnitude of the Internet's phenomenal expansion over the past eight years, it is useful to refer to the Network Wizards' Internet Domain Survey Host Count. Between 1991 to 1999, the survey shows that the number of domain names with an IP address rose from almost zero in 1991 to 45 million by 1999.¹

In the telehealth field, the development of the Internet has created seemingly limitless opportunities to instantaneously transfer medical data, images, and text across vast distances and to many people simultaneously, all in a blink of an eye. Today, the remote diagnosis of radiology images or accessing a vast medical library via the Internet from a desktop computer is becoming commonplace.

From the consumer's standpoint, the Internet offers the ability to interact with health practitioners online and easily access health-related information-more people use the Internet to gather information about health-related topics than any other subject.

Despite the apparently infinite possibilities for telehealth, there are numerous barriers that may inhibit the growth of telehealth on the Internet including growing delays, costs, and lack of security, reliability and availability on a worldwide basis. The development of the Next Generation Internet - Internet2 - may help address some of these barriers. Internet2 is a new high-speed backbone network. The backbone for Internet2, called the Abilene Project, is a subnetwork consisting of a 2.4-Gbps, 13,000-mile research network connecting three businesses and 150 universities, which will test Internet applications such as Internet Protocol (IP) multicasting, differentiated service levels, and advanced security. It will also allow researchers to resolve problems such as bandwidth constraints, quality and security issues.

Although some, like Dr. David Warner, have suggested (half in jest) that the only standard of the future may be IP (Internet Protocol), this idea may not be so far-fetched. As we discuss below, wireless and other technologies are rapidly integrating the Internet into their systems and adopting the IP packet networking standard as their network backbone of the future?

Will wireless lead the way?
In the telehealth industry, telemetry and emergency medical services have been the most common uses of wireless technology. Some examples of medical telemetry equipment include heart, blood pressure, and respiration monitors. With monitors, a patient has the freedom to move around while still being monitored. At the same time, just one health care worker can monitor several patients remotely, thus decreasing health care costs. Emergency medical services have also adopted various uses for wireless technology ranging from mobile phones to more advanced wireless applications that allow emergency physicians at a hospital to remotely view and diagnose a patient in an ambulance equipped with video and wireless data transmission equipment. The telemedicine equipment can be as simple as a laptop computer with desktop video conferencing capabilities that provide simultaneous two-way video, two-way voice, vital signs, cardiac and other data to a trauma center.

In the near future, it is likely that more and more healthcare providers will find medical applications for wireless technologies. For example, The Washington Post recently described how a physician at Beth Israel Deaconess Medical Center in Boston used a wireless handheld computer to verify a diagnosis in the emergency room:

Paramedics said the patient being wheeled into a Boston emergency room last week was suffering from a potentially lethal heart condition, but Steven K. Epstein wasn't so sure. The electrocardiogram was cryptic, and Epstein, the attending physician knew he'd need a little help. Instead of dispatching an intern to pore through a textbook or waiting for a specialist to arrive, Epstein reached into his pocket for a device that's become as useful to him as a stethoscope: His Palm V hand-held computer. With a few taps of the unit's stylus on its card-sized screen, Epstein pulled up a brief summary from a medical database. "I looked at my Palm and then at the EKG and I said, this person is not having a heart attack," said Epstein…"and I never had to leave the patient's side."²

With an increase in the use of hand-held wireless devices with Internet capabilities, there will be a greater need for technical standards that ensure interoperability, reliability, quality and security of medical data transmitted over the airwaves. In July 1999, the Federal Communication Commission recognized the need to allocate spectrum for wireless medical equipment such as telemetry, and called for comments about allocating designated spectrum for telemetry and providing it with primary status, which protects the service from electromagnetic interference.

In the private sector, technical standards for new wireless technologies have been developed, including those for wireless Local Area Network Systems; and for wireless digital hand-held devices, including mobile phones. The development of next-generation IEEE wireless standards for Local Area Networks (LANS) (802.11b Direct Sequence, with speeds of 11 Mbps, and 802.11a with speeds of 20-30 Mbps) means that one can easily move around the office with wireless desktop computers.

Perhaps a more significant development is the June 1999 agreement among major wireless operators to adopt a new standard called 3G or "third generation," for next-generation, land mobile, digital hand-held devices. The new standard will replace several competing standards that have made it difficult for mobile phone users to use the same handset in different countries. Adoption of the new 3G standard will also allow manufacturers to develop sophisticated devices capable of global roaming, and transmitting moving pictures and web pages to wireless hand-held devices.

A standard called the Wireless Application Protocol (WAP) is already under development by a California company. WAP is a way of converting information on Internet Web sites into a form that can be displayed on a mobile hand-held phone device. The advent of so-called microbrowsers may still be a few years away because mobile systems currently do not have the capacity to support high-speed connections with the Internet. Once faster speeds are available, WAP proponents suggest that consumers will be able to get message notification and call management, electronic mail, mapping and location services, weather and traffic alerts, sports and financial services, address book and directory services and corporate intranet applications on their hand-held devices.

In anticipation of these advances, a group of major operators and manufacturers (including AT&T and Nokia) plan to establish common backbone standards, based on Internet Protocol for the next generation of wireless systems. Over time, this IP packet-based network would replace the current circuit-switch network that was originally designed to carry voice traffic.

In countries that have adapted to digital wireless phone systems faster than the United States, the future of wireless technology is already available. For example, in Japan, Nippon Telephone & Telegraph will provide Internet email access via its wireless phone services to 1 million customers. Japan will also introduce a mobile videophone to its local markets that can transmit live video at 32 kbps, this year. In the Netherlands, Nokia has already introduced the Nokia 9110 Communicator, which can link to a digital camera; store images, and then e-mail them.³ Nokia's Communicator will be available in the United States within in the next year but mobile videophones may not be for several years.

Americans have been slower to jump onto the wireless band wagon in part because the wireline infrastructure in the United States is nearly ubiquitous and reliable and because the FCC has allowed U.S.-based wireless phone companies to adopt different competing standards for digital wireless services across the country. With phone lines available everywhere in the U.S., Americans have felt less need to adopt mobile phones than their foreign counterparts. Countries like Brazil, which does not have reliable wire-line networks in many areas (such as the Amazon), have quickly adapted to mobile technology and have high mobile phone penetration rates. Mobile phone systems are cheaper to develop and install, particularly in remote or difficult terrain. Some say the high mobile phone penetration rates in the Netherlands has been the result of no wire-line systems in the summer home areas of Sweden, Finland and Norway.

Standards may also have played a part in wireless deployment. In Europe for example, the European Union (EU) adopted one mobile voice standard: Global System for Mobile Communications, or GSM. One standard allowed mobile phone companies to expand rapidly throughout the EU and offer advanced technologies that were interoperable between different systems, phones and countries. U.S. companies have found it more difficult to introduce technological advances nationwide because competing standards preclude the use of these advances across systems, phones and even regions and countries where standards vary. This makes the introduction of technology more expensive because each system must have its own version and is supported by fewer people.

Mobile satellite communications is another type of wireless communications system that promises to extend the global reach of voice, data and other services. Low earth orbiting satellites systems (known as LEOs), such as those owned by Iridium and Orbcomm, became commercially operational in 1999. The Orbcomm system is used as a tracking service to monitor the location of trucks or other vehicles, travelling long distances. Iridium (which recently filed for restructuring and bankruptcy) has offered a global mobile phone system for international travelers who can make phone calls from remote places like the Himalayas or the Amazon using the Iridium handset and satellite system.

Over the next few years, several more satellite systems will become operational, including Lockheed Martin's Astrolink, which is scheduled to begin operations in 2001; Hughes Network Systems' Spaceway, Alcatel's SkyBridge; and Loral Space & Communication's Cyberstar, which already offers some limited data services over its network.

Craig McCaw and Bill Gates, together with Motorola and Boeing, have invested in an ambitious plan to put up an "Internet in the sky" called Teledesic. Compared to other proposed satellite systems, Teledesic plans to have a large number of satellites in its constellation: 288, as opposed to Iridium's 66 "birds." According to Teledesic, with this constellation system it will be able to offer affordable broadband Internet access, videoconferencing, high quality voice and other digital data needs.

Unlike terrestrial mobile phone systems, satellite technology may be several years away from offering affordable services-but the wait may be worth it. Larger satellite systems can reach a global audience and at the same time offer data transmission rates three times faster than an ISDN connection. Another way of putting this is to say that satellites can deliver data at speeds up to 45 Mbps, or nearly 30 times faster than a T1 line.

Global reach, global service
Adopting international technical standards for the telehealth industry such as those developed by the International Telecommunications Union (ITU) will become more critical as global services and communications become the norm. For example, the ITU has already developed the "H" standard series for videoconferencing, which has been widely adopted. Practicing telemedicine and telehealth in an international arena may be easier than in our local U.S. markets, given U.S. cross-state licensure barriers. In fact, the World Trade Organization (WTO) is preparing to embark upon health services negotiations this year, after successfully finishing its financial services and telecommunications basic services negotiations. Clearly, telemedicine and distance education will be an important part of these new global trade discussions. In addition to the WTO, the World Health Organization is also hosting treaty discussions around telemedicine.

Conclusions
This paper presents some general trends that may affect the future of telehealth standards and guidelines. Interoperability, connectivity to the Web and mobility will be key features for telehealth technology of the future. Thus, standards and guidelines with open architecture will be required. Wireless and wireline data transmission standards will also become more and more important as large blocks of information are transferred from central information centers to personal Smart Cards and vice-versa. Another important theme is the need for compatible standards between communications systems and medical devices. Internationally accepted standards and guidelines may also be an important trend as global connectivity and interoperability become an issue and telehealth becomes a global service.

Footnotes
¹Between 1987 and 1997, Network Wizards counted the number of domain names that had IP addresses assigned to them. As of 1998, the survey counts the number of IP addresses that have been assigned a name.

²The Washington Post, May 30, 1999, p. H1.

3Source: Time Magazine, Aug. 23, 1999, p. 40.

Glossary
Taken from Federal Standard 1037C, a 1996 General Services Administration publication that provides Federal departments and agencies a comprehensive source of definitions of terms used in telecommunications and directly related fields by international and U.S. Government telecommunications specialists: