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Downloaded from jamia.bmj.com on March 10, 2010 - Published by group.bmj.com Cellular Radio Telecommunication for Health Care: Benefits and Risks Charles A Sneiderman and Michael J Ackerman JAMIA 2004 11: 479-481 doi: 10.1197/jamia.M1532 Updated information and services can be found at: http://jamia.bmj.com/content/11/6/479.full.html These include: References This article cites 25 articles, 8 of which can be accessed free at: http://jamia.bmj.com/content/11/6/479.full.html#ref-list-1 Email alerting Receive free email alerts when new articles cite this article. Sign up in the service box at the top right corner of the online article. Notes To order reprints of this article go to: http://jamia.bmj.com/cgi/reprintform To subscribe to Journal of the American Medical Informatics Association go to: http://jamia.bmj.com/subscriptions Downloaded from jamia.bmj.com on March 10, 2010 - Published by group.bmj.com Journal of the American Medical Informatics Association Volume 11 Number 6 Nov / Dec 2004 479 Brief Review j Cellular Radio Telecommunication for Health Care: Beneﬁts and Risks CHARLES A. SNEIDERMAN, MD, PHD, MICHAEL J. ACKERMAN, PHD A b s t r a c t Cellular radio telecommunication has increased exponentially with many applications to health care reported. The authors attempt to summarize published applications with demonstrated effect on health care, review brieﬂy the rapid evolution of hardware and software standards, explain current limitations and future potential of data quality and security, and discuss issues of safety. j J Am Med Inform Assoc. 2004;11:479–481. DOI 10.1197/jamia.M1532. Radiotelephony has been used in health care since it was ﬁrst ages from 20 cases to a neuroradiologist using a PDA cell introduced commercially in the 1950s,1 but it was not until the phone with 600 x 200 pixel display suggests that this technol- introduction of hand-held transceivers and nation-wide cellu- ogy may provide sufﬁcient information for decision making lar network coverage in the last decade that communication in neurologic and neurosurgical emergencies.8 Digital video using these devices has become ubiquitous in the United States.2 transmission over cellular network from home-bound pa- tients has been judged to be of sufﬁcient quality for clinical Evolution of Applications use by a small sample of home care nurses and physiothera- From the ﬁrst words spoken by telephone in 1876 when pists in Japan.9 Alexander Graham Bell reportedly spilled battery acid and called for assistance, communication technology has been In Warsaw, Poland, 15 pregnant women with insulin-depen- used to facilitate health care. The spoken word is still by far dent diabetes were supplied with blood glucose meters that the major health care application of telephony. Cellular mo- allowed recording of insulin dose and meal data in addition bile has facilitated urgent communication between consum- to self-monitored blood glucose. Those data were uploaded ers, providers, and health care facilities.3 Telephone each night using either cellular or ﬁxed modems in response consultations for health advice in the Kaiser Permanente to automated polling from a central computer. The data were HMO system to specially trained nurses using online man- analyzed by a rule-based program, which was integrated agement protocols have been analyzed recently. Although with an electronic medical record system to determine diabe- the percentage of calls initiated from cellular phones was tes control, trends, and compliance with monitoring and not reported, selected characteristics of more than 4,000 en- treatment recommendations. Endocrinologists telephoned counters studied are germane to considerations of cellular the patients the next day with advice on any needed change voice teleconsultation. Mean call length was 5.9 minutes; in therapy. The overall technical effectiveness of the commu- 42% of calls required some further medical management, nication system was estimated as 91.5% with a standard error but only 18% resulted in urgent disposition; only 3% involved of 6.1%; the authors state that the results obtained were not referral to emergency medical services. Most calls (93%) were statistically different between the subgroups using dial-up to report a symptom, ask medication questions, or seek med- or mobile cellular phones. The patients’ metabolic control ical advice after an ofﬁce visit or procedure.4 was signiﬁcantly improved compared with control in the same patients before the intervention.10 Continuous ambula- Data transmission of limited electrocardiographic (EKG) data tory peritoneal dialysis has been monitored by cellular trans- from a moving ambulance became commonplace after 19705 mission of such data as heart rate, blood pressure, body and now transmission of complete EKG by cell phone before weight, ultraﬁltration volume, and urine volume to an hospital arrival has had a major impact on the management of Internet data server in Japan at a cost estimated at U.S. acute coronary syndrome patients.6 Continuous transmission $3.00 or less per month.11 Remote control of medical devices of multichannel physiologic monitoring data from a passen- (e.g., insulin pump, mechanical ventilator) might require re- ger on a commercial airliner using the cellular telephone in- view by the U.S. Food and Drug Administration of the com- stalled in the seat back was demonstrated as early as 1997.7 munication system as a medical device. To date, we are not A study transmitting cerebral computerized tomography im- aware of any usage of cellular communication to automate a clinical decision. Adjuncts to the conventional telephone system such as inter- Afﬁliation of the authors: Ofﬁce of High Performance Computing active touch-tone response, voice mail, and speech recogni- and Communications, National Library of Medicine, Bethesda, MD. tion are accessible by cellular units and have enhanced the Correspondence and reprints: Charles A. Sneiderman, MD, PhD, 8600 accessibility of health care applications to a mobile popula- Rockville Pike, Bethesda, MD 20894; e-mail: <firstname.lastname@example.org>. tion.12 Features unique to newer cellular phones such as short Received for publication: 01/09/04; accepted for publication: text messaging have been used in health care applications 06/15/04. such as daily medication reminders.13 Downloaded from jamia.bmj.com on March 10, 2010 - Published by group.bmj.com 480 SNEIDERMAN, ACKERMAN, Cellular Radio Telecommunication Spectral analysis of voice mail messages recorded from working having transmission speeds in a gigabit per second asthmatics using global system for mobile communication range with cellular radio systems having speeds in a hundreds (GSM)-compressed digital cellular transmission can reliably of kilobits per second range. 3G systems are expected to have detect those whose peak expiratory ﬂow was reduced by in- the following features: ﬁxed and variable rate bit trafﬁc, band- dependent measure.14 width on demand, asymmetric data rates in the forward and The potential of combining cellular technology with geo- reverse links, multimedia mail store and forward, capability graphic positioning satellite (GPS) transmitters could lead to determine geographic position of mobile units and report to automated notiﬁcation of emergency medical personnel it to both the network and the mobile terminal, and interna- in the event of auto accidents or cardiac arrest.15 tional interoperability and roaming. 3G-compatible radio pro- tocols already in commercial use include general packet radio A novel approach to high bandwidth data, such as video- system (GPRS), cellular digital packet data (CDPD), and over-cellular networks, multiplexed commercially available Bluetooth with several others in testing.18 It is not clear that digital cell phones to transmit images from a moving ambu- any of the candidate 3G radio protocols can support mobile lance for prehospital assessment of stroke.16 units when data rates are high enough that a Doppler shift ef- Evolution of Technology fect of motion on the frequency-modulated carrier signal can The technical advance that made the limited radio spectrum induce errors in reading the pattern of ‘‘on’’ and ‘‘off’’ digits. assigned for telephony available to the millions of current In any communication network, transmission speeds are lim- subscribers is automated frequency reassignment. ited by the bandwidth available divided by trafﬁc demands; Automated switching servers rapidly reassign frequency the available radio spectrum has competing demands from channels across a geographic network of relatively low- applications such as commercial broadcasting, law enforce- power, short-range, static transceivers to very-low-power, ment, air trafﬁc control, military, and devices like garage door short-range, mobile transceivers so that each mobile is sufﬁ- openers and wireless EKG monitors. New frequencies for ciently separated to avoid radio channel interference. Each wireless communication may be allotted if methods for reli- static transceiver uses an array of directional antennae (usu- able service without interference with other vital applications ally mounted on towers) to sense frequency shifts and signal are developed. strength of the mobile units within adjacent geographic cells, so that the system can track and ‘‘hand off’’ a moving call. Risks and Limitations First-generation (1G) cellular systems used analog signal The most clearly delineated risk of using cellular radio tele- transmission for voice; digitized data were transmitted by communication is accidental injury or death associated with modem similarly to wired telephony; however, reliable data the distraction of using the technology while driving a motor speeds did not exceed 10 kilobits per second. The 1G vehicle. This association is apparently independent of networks developed in the United States in the 1980s whether the user is holding a phone or has hands free.19 have largely been replaced by digital second-generation Because mobile radiotelephones transmit as well as receive, systems, which further subdivide and multiplex concurrent their antennae emit electromagnetic radiation (EMR). There transmissions over the limited bandwidths assigned to radio is debate about the human health effects of EMR associated telephony by the Federal Communications Commission. with mobile radiotelephones.20 The Federal Communications The second-generation (2G) cellular systems (used by most Commission (FCC) requires wireless phones used in the United current health care applications) use digital signal processing States to report the speciﬁc absorption of radiation (SAR) to the in which voice and other data are transmitted, usually with head and to comply with a safety limit of 1.6 W/kg of tissue.21 compression, by one of several algorithms including time di- There are reports of increased subjective neurologic and psychi- vision multiple access (TDMA), code division multiple access atric symptoms in cell phone users22,23 with some correlation (CDMA), global system for multiple communications (GSM), with estimated radiation dosage, but these epidemiologic stud- and integrated digital enhanced network (iDEN). Although ies do not control for such factors as occupation, age, stress, or data are encoded in digital packets, these packets are trans- ergonomics. Case reports of scalp nerve conduction abnormal- mitted sequentially over an assigned circuit switched to the ities are also not clearly related to SAR.24 A retrospective asso- individual units for the duration of the connected call. ciation of habitual handheld cell phone use with risk of Because of the multiple 2G algorithms, cellular hardware of- malignant brain tumor on the same side has been reported.25 ten is incompatible unless connected through the landline- SAR to the user’s head is substantially reduced by the use of based public switched telephone network (PSTN). a wired ‘‘hands free’’ earphone-microphone extension.26 Packet switching labels data so that each unit can be routed EMR associated with hand-held transmitters can also inter- over the path of least congestion through a network and reas- fere with electronic medical devices, either by radio frequency sembled at its destination. Current transmission speeds interference (RFI) as with devices like telemetry transmitters27 achieved by 2G cellular systems are not adequate for reliable or by induction of current in devices like pacemakers28 and conversational speech with a packet-switched protocol; so- hearing aids.29 RFI is inversely proportional to the square of called ‘‘2.5G’’ networks divide their assigned spectrum into the distance from the transmitter so that a 2-m buffer is prob- a circuit-switched range for voice and a packet-switched ably safe for any medical devices with any cellular phone.30 range for other data.17 Manufacturers are increasingly ‘‘hardening’’ devices to resist Third-generation (3G) cellular systems blur the distinction be- RFI, but most hospitals still ban the use of cell phones in all tween wireless networks and radiotelephony. 3G systems will patient care areas. use packet-switched transmission for both voice and other With the advent of the Health Insurance Portability and data. A key feature is the integration of wireless local area net- Accountability Act (HIPAA), concern over the privacy of both Downloaded from jamia.bmj.com on March 10, 2010 - Published by group.bmj.com Journal of the American Medical Informatics Association Volume 11 Number 6 Nov / Dec 2004 481 voice calls involving patient data and other wireless data 13. Neville R, Greene A, McLeod J, Tracy A, Surie J. Mobile phone transmission has increased.31 Digital cellular transmission text messaging can help young people manage asthma. BMJ. supports encryption of both voice and packet data. Each dig- 2002;325:600. ital cell phone contains a chip with a unique identiﬁer. 14. Anderson K, Qiu Y, Whittaker AR, Lucas M. Breath sounds, asthma, and the mobile phone. Lancet. 2001;358:1343–4. Assuming that the chip is not stolen and installed in another 15. Pieske O, Lob G, Messner G, Lange W, Haberl J. [ACN (Auto- phone, the origin of a call can be authenticated. 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