Building connectivity of care services to support immersive mHealth in rural America

Despite recent advances in telemedicine and digital healthcare technologies, and new value- based reimbursement models (i.e., Accountable Care Organization), rural America continues to face disparities in the delivery and provision of healthcare services.

This situation is especially amplified by challenges associated with continuity of care. The Centers for Disease Control and Prevention (CDC) and other agencies show a demonstrable statistical significance in chronic disease morbidity and co-morbidity relative to urban America, in effect classifying the estimated 81+ million Americans as a medically-underserved population group. Notable examples include but are not limited to hypertension, diabetes, cancer care and bronchitis. Consider the following statistics:

• Approximately 10 percent of physicians practice in rural America, despite the fact that nearly one-fourth of the nation's population lives in these areas
• Rural Americans are less likely to have employer-offered health care coverage
• 20 percent of rural counties lack mental health services as compared to 5 percent of urban counties
• Medicare payments to rural hospitals are substantially less than those to urban hospitals for equivalent services

There are many factors compounding this unfortunate situation. Namely:

• Challenges in attracting physicians to rural areas, resulting in a lack of specialist/specialist care providers
• Decreasing numbers of acute care facilities (magnified by opportunity cost investments in high-capital digital healthcare technologies at centers that serve larger populations)
• Inherent transportation challenges to rural care facilities due to the large distances involved, which promulgates delays in seeking treatment
• The need to serve a broad spectrum of patient population demographics (ranging from pediatric to geriatric, and privately insured to Medicare)
• Variability in patient flow, impacting retention of clinicians and hence investment in healthcare services
• Complications arising from delayed follow-up due to the distances involved or tangential factors, such as weather

To address some of these challenges, telemedicine companies have greatly improved the delivery and type of healthcare delivery services they offer. Indeed, the vendor landscape has grown dramatically in recent years, reflecting technical innovations in portals, applications and imaging services. Today, there are services focusing on everything from cardiac care to vital sign monitoring, providing primary care physicians with a means of extending service using remote specialists who could be thousands of miles away from the point of care.

Nonetheless, the use of telemedicine is still limited in rural areas due to several reasons: the consumer's digital acumen, on-going reimbursement and regulatory concerns and availability of connectivity services that perform reliably. A 2015 industry study reveals that health equity gaps in rural centers will continue to persist as long as there are inconsistent patient and caregiver interactive experiences. Simply put, without a reliable connectivity framework, patient follow-up becomes sporadic, leading to a lack of awareness of patient outcomes, which negatively impacts adoption of telemedicine systems and results in under-utilization of investments in digital healthcare systems.

Fortunately, an affordable, secure and private connectivity solution is now available to promote an efficient, effective, timely and patient-centered mHealth business model in a rural setting. The proposed connectivity model is based on several assumptions:

• Wearable clinical sensors and wireless peripherals use either 4G-LTE, Wi-Fi or Bluetooth connectivity modalities
• Wireless transport between device peripherals and/or connectivity between the patient's domicile and/or personal body area network to the caregiver's host systems are automatically discovered and configured
• Use of a 4G-LTE macro wireless network for data backhaul under negotiated agreements between the healthcare system and the providing wireless operator
• At all times, best effort data transmission profiles are utilized for real-time data interchange unless there is a loss of connectivity (i.e., air travel), in which case a store and forward mode is engaged until such time as connectivity is re-established
• End-to-end encryption of all data streams for security and privacy
• A rules engine is used to monitor the integrity and authenticity of the data transport to ensure the data is exchanged between the right set of users at the right places and right times, which includes heuristic behavior analysis to detect anomalies against baselined data transmission behaviors
• Funding of the components and negotiated wireless service through a variety of mechanisms including a services solution provider, grants and investors

Technically, the connectivity solution consists of two main components: a home serving gateway and an external macro wireless 4G-LTE network. The former provides several functions. It serves as a virtual private network (VPN) connection point between the patient's local peripherals and the macro 4G wireless network. Additionally, it automatically detects, authenticates and provides local management and control of peripheral devices. The latter delivers the transport to the public internet, through which the data is routed to the digital healthcare operating systems. The key architectural component is the home serving gateway. It is comprised of three elements that are packaged together into a common housing. These are an Enhanced Packet Core (EPC), which acts as a gateway, performing network authentication, registration, routing and rules mediation with the macro wireless network. There is a small cell LTE radio resource controlled by the EPC that also supports Wi-Fi and Bluetooth wireless standards, as well as a firewall appliance.

The fundamental value proposition of this solution is that it achieves consistently high-performing, secure and private wireless connectivity between the patient in their domicile and the healthcare system in a transparent and seamless manner, independent of devices employed. It also eliminates the need for intervention of the patient and the caregiver around specification and management of connectivity services since this is automatically accomplished. Patients are simply provided with a home serving gateway, providing reliable connectivity to subscribing healthcare institutions.

The benefits imparted by this solution directly address many of the afore-mentioned challenges. Particularly as they relate to mitigating poor availability of connectivity, security, privacy, management and control of clinical sensors, data transport manual intervention of (patient) consumers and caregivers and poor user experiences with telemedicine application suites.

Notwithstanding the above, the solution also provides a foundational platform from which healthcare systems can provide new, extensible services beyond simplistic unified communications under a definable level of service. Examples include: augmented reality via remote presence of a caregiver team far beyond simplistic telepresence, location-based biometric services, patient surveillance and on-site real-time disease management and monitoring. Instructively, with the establishment of a high-performing connection and a localized rules engine able to broker localized wireless connectivity services, advanced telemedicine applications are now possible, unfettered by constraints imposed by the limitations of current wireless architectures.

In a hypothetical example, digital glass devices with supporting application feature sets could potentially be used by the patient and caregiver teams to interact virtually, conducting virtual examinations of the patient by directing the patient's own hands while simultaneously collecting vital biometrics from wearable sensors. This allows the patient to focus not on the establishment of connectivity but instead on the clinical encounter, while the caregivers are confident that the connection will consistently support such an important interaction with the patient. The implications are far reaching: meaningful availability of specialists, and provision and treatment services that are effective and timely.

The trifecta of this solution with consumer eHealth applications and digital healthcare systems provides an economically sustainable means to deliver advanced interactive healthcare services between a patient and their caregiver team. By creating a way to automatically manage and consistently control different wearables, tools, clinical communications and telemedicine application services (i.e., video, haptic, and other services), scalable remote patient services can be achieved. This includes caring at home, early intervention, disease management, wellness and fitness, medication adherence, as well as fall and wander detection and management. In accomplishing this, such technology holds the promise of fulfilling the goal of bringing equity in healthcare services to rural America.

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