In Risk Tool Helps Determine Mobile Network’s Capability to Provide Healthcare Services, [i] a table of low-, medium- and high-risk functions and/or products that a mobile network operator could provide was depicted. These functions ranged from those inherent in the mobile telecommunication infrastructure design to complex, integrated services that would need a partnership between a mobile network operator (MNO) and healthcare provider/service. The functions described were fairly general in description. In this article, three MNO executives were interviewed to get a better idea of the types of products they provide as well as what they perceive as the risk inherent in those product offerings.
AT&T
AT&T has worked in the healthcare industry for years, developing one of the first PACS solutions as well as an EMR. Most of their initial work was in the radiology realm, but over the last ten years, they’ve expanded their healthcare work significantly, specifically in developing applications for healthcare while using the underlying telecommunications infrastructure to move the healthcare data to where it needs to be for review and action.
Through their platform-as-a-service perspective, their goal is to capture clinical data where ever it is measured and resides, aggregate it and display it for all of the different healthcare customers. With the platform-as-a-service, all that is needed is a web browser for the customer to access the data they require. Moreover, the platform-as-a-service works in a federated, centralized and/or hybrid data model.
One of the AT&T products using the platform-as-a-service is their Healthcare Community Online (HCO), which is a “cloud-based care collaboration and health information exchange (HIE) platform that integrates patient records and data from multiple sources into a single patient view, providing clinicians with virtually real-time access to patient information and eHealth applications.” [ii] The product offerings are modular in nature and each module represents a step-wise increase in the amount of integration with a healthcare provider for the product functionality. The modular product steps are: e-Connect, which converts paper-based workflows to electronic workflows; Clinical Message Exchange, which automates messaging for point-to-point communication; Portal and Clinical Applications, which provide a longitudinal patient record and clinical value-added applications; and Collaborative Care and HIE, which provides community wide data exchange, analytics and care coordination.
Baylor Health Care System is one of AT&T’s customers using the HCO. According to Diane Turcan, director, healthcare solutions, AT&T, Baylor needed to connect all of their physicians across their enterprise as well as physicians affiliated with Baylor which included physician offices and community hospitals. Together, Baylor and AT&T integrated applications into AT&T’s platform as a service HCO at 60 facilities, which in effect aggregated the data view across many of the applications with a single sign-on. Additionally, by using a service-oriented architecture for the HIE, patient context was maintained between the applications as well as across the different enterprise environments. Moreover, for security the data was encrypted both at rest and in transit, allowing the secure emailing functionality to be effective and meet HIPAA regulatory constraints.
AT&T also built a robust cloud infrastructure for the Indiana Health Information Exchange. AT&T provides all of the mapping and translation between the different clinical applications.
In the mobile realm, AT&T offers a developer and integration platform for mHealth. This approach grew out of AT&T’s experience with their DiabetesManager program for which they partnered with WellDoc. Their initial product offering was only able to work with two Nokia cell phone platforms and one Blackberry platform. Over time, their work with WellDoc allowed spanning across cell phone hardware, operating systems and across mobile network providers such that currently their DiabetesManager product covers 75 percent of all phone set models by installed based by percentage of active cell users in the U.S. Using the mHealth platforms as well as deployment across operating systems and platforms, AT&T has been able to achieve true platform independence for the DiabetesManager application as well as data integration into the enterprise healthcare back-end clinical systems.
According to Eleanor Chye, PhD, assistant VP, AT&T ForHealth, AT&T Business Solutions, the DiabetesManager application currently requires that patients manually key in the glucose readings vs. having the glucometer automatically send the readings to the mobile phone/hub. There are two reasons for this manual input. First, when it comes to using the mobile phone as a hub, having users enter their blood sugars, and then having the phone application provide automatic feedback to the patient keeps them engaged with the application for follow-up steps. Second, and related, AT&T sought to price the solution appropriately for best return on investment to the customer, and a phone-based application is a better value vs. a solution that also requires a connected glucose meter for automated upload of readings.
Moreover, diabetics usually have several differently branded glucometers available to them, which would drive up the cost of solutions which required multiple machine-to-machine (M2M) integrations, in this case multiple vendor glucometers with multiple mobile phone hardware and software platforms. This also more closely matched the traditional direct-to-consumer business model of the mobile network operator. AT&T used themselves as a test case for DiabetesManager as they are self-insured. The goal of the AT&T pilot was to identify best practices in rolling out an end-to-end mHealth solution while making a positive impact on their employees’ well-being. The pilot measured participation and also evaluated how the mHealth solution could change and improve patient behavior.
In a newer product development, AT&T partnered with Ericsson and Intuitive Health to deliver a software-as-a-service solution for remote patient monitoring software loaded on a locked down tablet. The solution has two ‘sides’: patient-facing in which video coaching occurs; and care manager-clinical professional-facing which has a real-time web-browser. The clinician can set up clinical protocols real-time, to be delivered via the software on the tablet. The AT&T solution is meant to be hardware agnostic, use is 4G/LTE as well as other forms of connectivity, and acts as a hub to medical measurement devices using Bluetooth. This is an out-of-the box, vertically packaged solution where AT&T and Ericsson do all of the interfacing.
In terms of risk, Chye says, “AT&T does not create a clinical protocol but we apply the care pathway and standards/guidelines per direction from our healthcare enterprise customers – either the provider or payer. It's medium risk because we are talking about using technology to translate protocols into if-then pathways for the patient for self-management. This is higher risk than straightforward text messaging, but not high risk because AT&T does not provide the algorithm, nor do we prescribe guidelines or clinical decision support. We provide the transparent tool (the pen) but what the healthcare providers do is determine what to ‘write’ with that pen.”
Orange[iii]
Thierry Zylberberg, director of Orange Healthcare, described several of the Orange group’s healthcare offerings and experiences. Orange has partnered with Ideal Life, which manufactures remote monitoring hubs for the home. These hubs are designed to help treat chronic diseases by collecting data from a variety of health-related devices, from blood pressure monitors to glucose, oxygen saturation and heart rate monitors. Once collected, this information is transmitted in real time over the Orange network to physicians who can access it using a variety of devices such as tablets, smartphones and traditional PCs. Orange is providing seamless machine-to-machine (M2M) wireless connectivity for Ideal Life in Canada, Europe and Latin America.
In the European market, Orange has worked with two medical device manufacturers to incorporate mobile telecommunications technology into product lines while tackling security and other regulatory issues. Orange believes that they need a strong partnership with a medical expertise company to provide effective products for the marketplace using mobile telecommunications technology.
In one case, Orange worked with Sorin, a global medical device company, to build their global cardiac remote monitoring solution named SMARTVIEW. SMARTVIEW is a solution that provides advanced diagnostic capabilities and early detection of cardiac disease progression. By using SMARTVIEW, healthcare providers can now access valuable cardiac data and alert messages from Sorin’s implantable defibrillators, while the patient is at home. SMARTVIEW uses a home-hub device situated near the bedside of the patient which captures data from the defibrillator using Sorin’s radio-frequency (RF) protocol. The data is then transmitted from the home monitor using Orange’s global M2M solution to a cloud-based application (which was co-developed by Orange and Sorin) enabling the information to be available to the clinician and/or patient. Although the solution is designed for the home, the use of the Orange M2M service gives the patient the ability to travel more easily while maintaining their normal ability to be monitored appropriately.
In another case, Orange partnered with Sanofi to provide a diabetes management product for both Spain and France (DiabeTIC). For the Spanish implementation, the mobile phone was used a hub for a glucometer developed by Sanofi. The glucometer was physically plugged into an iPhone or Android phone. Upon being plugged into the smartphone, the glucometer readings are automatically uploaded onto the smartphone where a mobile software application analyzes the information and gives an indication of what the patient should do. This information also can be uploaded to a physician desktop application. In this case, Sanofi was responsible for regulatory aspects of the product, the product marketing in the Spanish regions and the development of the physician desktop software. Orange designed and integrated the secure architecture to transfer and host the data from the medical device, and was responsible for the development of the software on the smartphone.
When Orange took this DiabeTIC product to France, they added a partner, Voluntis. Orange followed French regulation for security, which is considered amongst the highest standard for personal health data in the world. Physical security, encryption and auditing is required by law in France and the French government, using a regulatory oversight process similar to that in the U.S. by the FDA, will determine whether or not a product can host medical data. Orange Business Services provided a secure cloud database for hosting the medical data from the glucometer.
Zylberberg discussed risk in several terms when asked if he considered the development of these products to be high risk. He does not believe any of them to be high risk and for him, the “red-line for high risk is critical information.” In the case of Orange’s partnership with Sorin, the “pacemaker implant is entirely autonomous and doesn’t require any network connectivity for a patient’s basic life support function.” From the perspective of an insurer/payer, remote monitoring services provide a lowering of risk. “A patient suffering from diabetes can avoid hypo/hyperglycemia if he or she is being monitored. Similarly, a patient suffering from congestive heart failure can reduce the likelihood of major heart problems through remote monitoring. Whoever is responsible for the risk, solutions using remote monitoring, like those developed by Orange, can help lower the risk.”
Lastly, Zylberberg says he believes there is a critical need for international standards and interoperability for medical devices to communicate effectively. Many consider the EU more standards-based in an evolving approach; with the U.S. more standards-based in a de facto approach, i.e. the first vendor the market sets the standard.
Summary
Both AT&T and Orange believe that a strong partnership with a medically-based device or healthcare services company is required to provide the marketplace with appropriate mHealth solutions. Neither of them consider their products to be high risk as they believe they are using the mobile telecommunications technology they have mastered to enhance clinical protocols or clinical technology already available. They both also understand they have a shared risk for these products. Lastly, they both understand they need to lower the costs of healthcare by either ensuring their products are price sensitive to the end-consumer and/or by decreasing the healthcare delivery costs by lowering the implied clinical risks of particular healthcare problems using remote monitoring, interactive clinical applications combined with mobile telecommunications technology.
The next and last article in this series will highlight some of the newer technologies being developed in the mobile telecommunications industry and how they might help healthcare.
Bridget A. Moorman, CCE, is president of BMoorman Consulting. The author wishes to thank AT&T, Orange and the GSMA for their help in obtaining the interviews and information about mHealth product offerings by mobile network operators.
[i] Moorman, Bridget A, and Kai-Lik Foh, “Risk Tool Helps Determine Network’s Capability to Provide Health Services,” Clinical Innovation and Technology, http://www.clinical-innovation.com/topics/technology-management/risk-tool-helps-determine-mobile-network%E2%80%99s-capability-provide-healthcare-services, accessed 26 Feb 2013
[ii] “AT&T Healthcare Community Online,” http://www.corp.att.com/healthcare/docs/att_hco.pdf, accessed 26 Feb 2013
[iii] Orange Healthcare, http://healthcare.orange.com/eng/Orange-Healthcare, accessed 19 March 2013