Connection between Biomedical Telemetry and ...

Chapter 14: “Connection between Biomedical Telemetry and Telemedicine” E.G. Spanakis1, V. Sakkalis1, K. Marias1, M. Tsiknakis1,2 1

Computational Medicine Laboratory, Institute of Computer Science, FORTH Vassilika Vouton, GR-70013 Heraklion, Crete, Greece 2 Biomedical Informatics Laboratory, Department of Applied Informatics and Multimedia, TEI Crete, Heraklion, Crete, Greece

{spanakis, sakkalis, kmarias, tsiknaki}@ics.forth.gr Contents 14.1.

Abstract......................................................................................................................................................... 1

14.2.

Introduction .................................................................................................................................................. 1

14.3.

Biomedical instrumentation ......................................................................................................................... 2

14.4.

Biomedical telemetry and telemedicine: Related work ................................................................................ 3

14.5.

Theory and Applications of Biomedical Telemetry ....................................................................................... 8

14.6.

Integration of biomedical telemetry with telemedicine ............................................................................... 9

14.7.

Novel Wireless Communication Protocols and standards .......................................................................... 11

14.8.

Cross layer design of wireless biomedical telemetry and telemedicine health networks .......................... 13

14.8.1.

Electromagnetic spectrum ................................................................................................................ 13

14.8.2.

Interference management for biomedical telemetry communication networks .............................. 14

14.9.

Telecommunication Networks in Healthcare for Biomedical Telemetry .................................................... 16

14.9.1.

Body Area and Personal Area Networks ........................................................................................... 17

14.9.2.

Medical Device Connectivity ............................................................................................................. 19

14.9.3.

Biomedical telemetry monitoring devices for telemedicine ............................................................. 26

14.10.

Future research directions and challenges ................................................................................................. 33

14.10.1.

Bio-telemetry systems for high rate biomedical signals .................................................................... 34

14.10.1.

EEG Portable Monitoring and Novel Electrode Design ...................................................................... 36

14.10.2.

Bio-inspired approaches .................................................................................................................... 38

14.11.

Conclusion................................................................................................................................................... 39

14.12.

References .................................................................................................................................................. 42

14.1. Abstract

In this chapter we combine our knowledge and expertise on computational medicine, biomedical telemetry and telemedicine, to define and describe the way smart networking environments can deliver seamless, personalized and non-obtrusive health care services. In this context, we will present a number of key technologies including: smart ubiquitous networking environments and unobtrusive devices and instruments (miniaturization, nano-technology, smart devices, sensors etc.), seamless mobile/fixed communication infrastructure, dynamic and massively distributed device and biosensor networks, dependability and security aspects, service oriented architectures adaptively orchestrated to provide personalized health care services. Future research directions and challenges are also discussed and presented.

14.2. Introduction

Recent advances in Information and Communications Technology (ICT) enable the acquisition, transmission and interpretation of different bio-signals, from fixed or mobile locations, at an acceptable cost. This can support better prevention and wellbeing and provide valuable and prompt diagnostic tools in various application domains, ranging from home care to emergency care, or situations in which a second or a specialist opinion is required before taking a clinical decision [Breen et al. 2010]. Important trends in healthcare include citizen mobility and the consequent move towards shared or integrated 1

care in which the single doctor-patient relationship has changed to one in which an individual’s healthcare is the responsibility of a team of professionals in a geographically extended healthcare system. In this new scenario, the possibility of consulting and collecting clinical information from different points is becoming a common need for citizens and physicians. Moreover, the increase in the life expectance has produced an older population that may need continuous assistance especially in cases of serious or chronically ill people that wish to live independently.

In this perspective, with focus to the provision of high quality of care, assuring life independency, the significant new research challenge is the integration of multiple biomedical sensor streams, to extract local and global health-state indicator variables that can be queried and monitored by an unobtrusive system. Using biomedical telemetry, ubiquitous computing, social user interfaces and wireless communication technologies, intelligent e-Health spaces can be created, accelerating the extensive deployment of sensor technology in tomorrow’s telemedicine services. The vision for future biomedical telemetry and telemedicine informatics is to offer seamless e-Health services to people through an environment capable of recognizing and unobtrusively responding to needs by allowing intelligent communication and interaction among users and systems.

14.3. Biomedical instrumentation

2

A medical instrument is any appliance, apparatus, material, device or other, including necessary software for its proper application, used for the purpose of diagnosis, prevention, monitoring, treatment or alleviation of a disease, and which does not achieve its principal intended action in or on the human body by pharmacological, immunological or metabolic means, but which may be assisted in its function. We can distinguish medical instruments and devices into three different categories; general control devices: simple devices with minimal potential for harming the user’s body; special control devices: non-invasive devices including x-ray, f-MRI, wheelchairs, infusion pumps, electronic stethoscopes, spirometers, ECG and EEG devices, SpO2 sensors, blood pressure sensors, surgical drapes, needles and suture material, and more; and lastly those of general and special control with premarket approval or scientific review that ensures device's safety and effectiveness (most of them are life-sustaining or life-supporting devices) such as replacement heart valves, silicone gel-filled breast implants, implanted cerebral stimulators, ventilators, bed side monitors, and many more. Biomedical instrumentation covers this area of research focusing on selecting and properly using instruments for measuring medical variables and indicators for medicine or biomedical research. Biomedical telemetry involves devices designed and connected together in a scientifically appropriate manner to sense (or capture) biomedical signals and process them for human display and/or further processing for control and therapy using intelligent electronic health information and communication systems.

14.4. Biomedical telemetry and telemedicine: Related work 3

It is evident that the delivery of health care and healthcare organizations themselves is been transformed by current advances in biomedical telemetry technologies. These advances are giving rise to a range of reforms in the way in which health-care services are currently delivered. Preventive medical care will be emphasized for individual health management, data will constantly be transmitted to the hospital through built-in sensor and monitoring systems, e.g., in the patient’s watch, accessories, or other items worn daily, and results will be fed back to the patient. Mobile and wireless technologies promise to transform the healthcare industry, supporting the acquisition, integration, analysis and storage of clinical data in all its forms; information tools provide access to the latest findings while communication tools enable collaboration among many different organizations and health professionals. Patients and health professionals are becoming increasingly mobile and the need for support in managing their health is growing. As a result, wireless connectivity is intensively for ubiquitous radio communications [Timmons et al. 2004].

In [Webster 2006] various types of biotelemetry systems from the early 1950’s to the late 1990s are presented. The authors summarize the advances and reviews of the biotelemetry related technologies in this area. A classic reference book in biotelemetry is by MacKay [MacKay 1993], which represents an excellent starting point and includes some ingenious techniques used by early investigators to remotely acquire physiological information. 4

The use of wireless communications in a healthcare environment raises two crucial issues. Firstly, the RF transmission can cause electromagnetic interference of biomedical devices, which could as a result critically malfunction. Secondly, the different types of electronic health (e-Health) applications require different quality of service (QoS). In [Phond et al. 2010], the authors introduce an innovative wireless access scheme called EMI-aware prioritized wireless access. This protocol focuses on guarantying the safety of biomedical devices from harmful interference by adapting transmission power of wireless devices based on the EMI constraints. The landmark paper [Akyildiz et al. 2002] describes major concepts of sensor networks which have been made viable through the convergence of microelectro-mechanical systems technology, wireless communications and digital electronics. It explores the sensing tasks and the potential sensor networks applications, and presents an extent review of factors influencing the design of sensor networks. The design of a complete communication platform (from sensors to remote applications) in [Fernanda et al. 2006] describes the basis for the construction of nano and microsensorbased sleep management system. The innovation of the work presented by the authors is the introduction of a framework and system for hypo-vigilance monitoring and management for cross-sector applications, based on micro and nano sensors.

In [Galarraga et al. 2007] the advances and opportunities that ICTs bring for Personal Health telemonitoring devices are presented in detail. The article identifies the need for standardized, open and robust solutions allowing the development and deployment of 5

cost effective and interoperable telemedicine systems, with the ISO/IEEE 11073 family of standards been the most appropriate international standard for telemedicine applications.

As the population ages and the risk of chronic disease increases, the cost of healthcare rises. Technology for mobile telemetry is expected to contribute to the dual objective of cost-reduction and improvement of the efficiency of care. In achieving these goals, several technical challenges must be successfully addressed, including sufficient system lifetime, high signal fidelity, and adequate security. [Jurik et al. 2009] presents the design, implementation, and evaluation of a Mobile biotelemetric system that addresses the efficiency of treatment and other remote medical monitoring and technical challenges. The system differs primarily for its ability to provide flexible, robust, and precise end-toend communication and to enable tradeoffs in metrics such as power and transmission frequency. A good example of a mobile application is presented in [Nguyen et al. 2009], where a mobile waist-mounted device is used for monitoring a subject's acceleration signal, subsequently used for detecting fall events in real-time with high accuracy and triggering appropriate emergency messages. In [Brunelli et al. 2006] the design and implementation of a bio-feedback system for rehabilitation is presented, based on a dedicated, distributed, wireless body sensor-network. This work introduces the concept of a close-loop system, deploying multiple body-mounted sensors, multi-sensorial signal fusion and intelligent action through the provision of audio biofeedback using personal computer devices and headphones. 6

In parallel, implanted sensors can provide precise measurements and continuous patient monitoring as described in the approach of an artificial retina prosthesis and cortical implant in [Schwiebert et al. 2002] where a complete system for restoring vision to visually-impaired persons from the signals generated by an external camera to an array of sensors that electrically stimulate the retina via a wireless interface. The authors aim to create a smart sensor implant to restore vision to persons with diseased retinas or suffering from other damage to the visual system that is believed to have tremendous potential for improving the quality of the life for people. Other applications include insulin pumps with close loop glucose monitoring systems [Spanakis et al. 2011], and blood pressure monitoring [Fassbender et al. 2008].

The authors in [Cerny et al. 2008] focus on the analysis and design of sensing electrodes by the use of unconventional materials for a long term bioelectric activity measurement with advanced capabilities in a transmission of signal, time-impedance stability and low half-cell voltage. The principle of electrodes is conducting polymers which can be builtup on a textile or other non-primary conducting materials. These types of sensors could be used among other ones in mobile human’s telemetry systems. Lastly in [Khoor et al. 2001] Bluetooth is explored for collecting short and long-term digitized ECGs together with relevant clinical data for patient management. A wireless communication protocol was developed for short-range radio data transmission able to send compressed records though cellular networks. [Panescu 2006] provides a review of Microelectro-Mechanical 7

systems (MEMS), a technology developed to create miniature sensors and actuators, and fabrication technologies, materials, and power supplies in order to better understand their design. The paper discusses some of the applications of MEMS in medicine and biology such as pressure sensors, accelerometers, human retinal prosthesis, tactile sensor skin and MEMS-based renal replacement systems.

14.5. Theory and Applications of Biomedical Telemetry

Biomedical Telemetry refers to the use of ICT for the transmission of biological or physiological data, using any kind of biomedical instruments and devices, from a remote location to a location that has the capability to interpret the data and affect clinical decision making to provide effective diagnostic, therapeutic, and prosthetic tools in physiological research and pathological intervention. Biomedical telemetry systems, used when direct observation is impossible, are able to acquire a wide spectrum of environmental, physiological, and behavioral data. Biomedical telemetry offers wireless, restraint-free, simultaneous, real-time, long-term data gathering of physiological variables in conscious, unrestrained humans. Biomedical telemetry systems consist of various medical and other devices to create a medical sensor network that can be used in various application domains such as: 

Diagnostic Applications: Diagnostic biomedical telemetry systems are used to gather biomedical, physiological or histological, data from the sensors within or around the body in order to identify and diagnose any kind of pathologies (.i.e. eye implants to 8

measure intraocular pressure to diagnose low tension glaucoma, endoscopic wireless camera-pill designed to be swallowed to capture images from the digestive track, …) 

Therapeutic Applications : Therapeutic biotelemetry systems are designed to alleviate certain symptoms and help in the treatment of a disease (i.e. drug delivery systems, glucose transponder to remotely glucose fluctuations, ePatch, ECG holders, …)



Rehabilitative Applications: Rehabilitative biotelemetry systems used to substitute a lost function, such as vision, hearing, or motor activity (i.e. neuromuscular microstimulator to stimulate paralyzed muscle groups in paraplegic and quadriplegic patients, visual prosthetic device designed to stimulate ganglion cells in retina in order to restore vision to people, fall detection sensors, etc).

14.6. Integration of biomedical telemetry with telemedicine

Telemedicine (also referred to as "telehealth" or "e-Health") is defined as the delivery of health care and sharing of medical data over distance using communication technologies. Today’s, telemedicine systems are supported by state of the art technologies like interactive video, high resolution monitors, biomedical telemetry data acquisition systems, powerful computer systems, expert clinical decision support or recommendation systems, electronic patient record systems high speed computer networks and telecommunications systems including fiber optics, wireless networks, satellites and cellular telephony [Meystre 2005, Rashid 2002].

9

Telemedicine services include but are not limited to: i)

Specialist referral health services typically involving a specialist or a group of specialists assisting or consulting remote distant doctor or other medical and paramedical personnel to finalize rendering a medical diagnosis [Traganitis et al. 2001, Chiarugi et al. 2003]. Surveys and research have shown a rapid increase in the number of specialty and subspecialty areas that have successfully used telemedicine [Tsiknakis et al. 2010, Sakkalis et al. 2003].

ii) Patient teleconsultations using telecommunication methods to acquire and transmit medical data, including audio, video, still live images between a patient and a health professional (i.e. using web based communications, wireless or wired computer networks and the Internet) [Spanakis et al. 2005]. iii) Remote patient monitoring using smart medical devices to collect and send data to a remote monitoring station for collection, interpretation and evaluation, usually from patient’s home using special vital sign monitors able to acquire patient’s vital signs (blood pressure, temperature, heartbeat, blood glucose, ECG and many more biomedical indicators for the patient) or even in the case of emergency care and ambulances [Tsiknakis et al. 2010]. iv) Medical education services that provides continuing medical education for health professionals and special medical education for targeted groups in remote locations; and v) Health 2.0 services, referring to the use of a specific set of Web tools (blogs, Podcasts, tagging, search, wikis, etc.) by actors in health care including doctors, 10

patients, and scientists, using principles of open source and generation of content by users, and the power of networks in order to personalize health care, collaborate, and promote health education [Eysenbach et al. 2008, Hughes et al. 2008]. Health 2.0 (as well as the closely related concept of Medicine 2.0) is evolving fast as the technology landscape evolves. However, already there are signs of Health 3.0 emerging, which is defined as delivery of healthcare which leverages the use of elements of Semantic Web such as location awareness, the emerging Internet of Things and embedded sensors.

A survey of the telemedicine applications and biotelemetry systems to be used in eHealth is presented in [Übeyli 2010]. Developing a biotelemetry system and the principal operation of such a system are presented, and its components and the telemetry types are explained. In [Matusitz et al. 2007] the use of distant communication technologies within the context of clinical health care, and the effects it has on health communication are discussed. 14.7. Novel Wireless Communication Protocols and standards

The most common delivery mechanisms for telemedicine are network applications and services designed to interconnect hospitals, emergency units, medical clinics, and other medical facilities and health community centers in rural and urban areas. The communication mechanisms used may include any kind of Internet connections or dedicated high speed communication channels, both wired and wireless. Focusing on 11

wireless technologies, in Figure 14.7.1 we present most prominent wireless technologies depicting the order of magnitude of their transmission data rate versus their connectivity range. It is obvious that for all the spectrum of applications in telemedicine it is necessary to incorporate many technological standards to take advantage of their unique characteristic (Table 1).

Figure 14.7.1: Distribution of various communication protocols (data rate vs. range) Table 14.7.1: Comparison of various wireless technologies Z-Wave

Zig-Bee

Bluetooth

Bluetooth Low Energy

Primary usage/applications

Domestic

Domestic Industrial

Domestic Industrial

Domestic Medical

Topology Interoperability Transmit frequency

Mesh No 900 MHz

Star / mesh / tree No 900/2400 MHz

Star Yes 2400 MHz

Throughput

40 kb/s

40/250 kb/s

Current consumption (Tx) Price # Suppliers Range Frequency hopping, # channels Encryption IEEE standard Max number of nodes in a net Max number of node hops Modulation type

35 mA $4 1 30 m

25 mA $3