Remote Patients Monitoring: Challenges

Assim Sagahyroon
American University of Sharjah
Sharjah, UAE

Abstract - Current advances in communications technologies and comfort a large population of patients with complex chronic
wearable monitoring sensors technology have enabled the conditions including hypertension, chronic obstructive
ubiquitous monitoring of patients in a way that promises to pulmonary disease, congestive heart failure, and diabetes [2].
reshape the future of healthcare services. Remote patients
monitoring (RPM) is increasingly seen as an integral and
essential component of the perceived solutions for the challenging Examples of RPM applications that had positive outcomes
problems facing the healthcare sector in the developing word include the work reported in [3]. Two groups of patients
including the spiraling cost of healthcare delivery. Furthermore, suffering from various levels of blood pressure were
monitoring patients remotely in a patient-centered environment monitored, with one group following the regular office blood
away from the confinement of hospitals leads to a better and pressure measurement routine, and the other is subjected to
improved quality of life for the patients and their families. In this twenty four hours ambulatory blood pressure monitoring. At
paper, we provide an overview of the different challenges facing
the completion of the study, it is found that use of
RPM that prevent us from fully realizing its potential, and
discuss some of the viable solutions that are being explored to telemedicine in monitoring blood pressure has led to better
reduce the effect of these challenges. management of the disease. In a recent study [4] conducted by
National Taiwan University Hospital, two groups of patients
were formed after being discharged form hospital following
I. INTRODUCTION the treatment of COPD. One of the groups was required to use
RPM techniques and physicians had access to data related to
In essence, remote patients monitoring or RPM is the their symptoms and ability to advice in real time After a
ability to monitor remotely the status of a patient. Steady period of approximately two month , it is concluded that time
advances in telecommunication and networking technology, for re-admission was much longer for the monitored group,
miniaturization of medical and wearable sensors, and this highlights the benefits of RPM in reducing readmissions
interoperability software have paved the way for finding
frequency by detecting COPD exacerbation early. From a cost
creative and cost effective solutions for delivering healthcare.
reduction perspective, as well, and in a recent study [5], it was
RPM is at the forefront of these emerging solutions. It
practically extends healthcare delivery to the patient's home, reported that for every 100,000 patient-years of follow-up,
and therefore provide an appealing alternative to the lengthy RPM was associated with 9810 fewer hospitalizations,
and costly confinements of hospitals or clinical settings. 119,000 fewer days in hospital, and $370,270,000 lower
hospital payments. The healthcare industry is actively seeking
RPM allows patients with chronic diseases to be monitored in means to increase efficiency and reduce cost, from this
their homes through the use of devices that collect and
example and few others, RPM is a viable alternative indeed.
transmit data related to their vital signs such as sugar levels,
blood pressure, body temperature, blood oxygen saturation or The focus of this paper is to examine the challenges that face
other signs. The data can be reviewed instantly by remote the deployment and adoption of RPM solutions, and to discuss
caregivers allowing attending physicians to interact from far the viable approaches to mitigate these challenges. In section2,
with their patients, and in real time, providing timely advice and prior to this discussion, we provide the reader with a brief
and recommendations. More and more, these ubiquitous overview of an RPM architecture. To fully appreciate the
monitoring solutions, at nursing or patients’ homes, and
subsequent discussion on opportunities and limitation of RPM,
medical institutions are perceived as a viable option for
disease management, reduction in readmission frequency to an appreciation of the components that form its architecture is
hospitals, reduction in healthcare expenses, and provisioning essential. In section 3 we summarize some of the most
of healthcare services “just in time” as and when needed [1]. pressing issues that are hindering the successful deployment or
RPM solutions, and what might be done to lessen the gravity
Due to various population health initiatives worldwide, of these obstacles.
adoption of RPM solutions is expected to grow in an effort to

978-1-5090-4228-9/17/$31.00 ©2017 IEEE

 II. RPM INFRASTRUCTURE III. RPM: CHALLENGES AND POSSIBLE
SOLUTIONS
An RPM platform provides a complete end to end facility
for remotely monitoring patients and often the case in a closed Despite strong prospects for the continued use of RPM in
loop formation where feedback form the care takers is the health sector, there are still various challenges, and many
instantly provided. The patient is fitted with smart wearable technology-related issues are still a work in progress in an
sensors capable of continuously sensing health-related data effort to successfully meet the requirements of this paradigm
with minimal patient intervention. The sensors collectively shift in healthcare delivery.
form a wireless body area network (WBAN). The short range
ubiquitous communication technologies that facilitate the Below, we summarize the perceived obstacles that preclude us
formation of this network include reliable low power protocols from fully benefiting from RPM, and discuss the viable
such as Bluetooth, ZIGBEE, and Z-Wave. The Continua solutions that might assist in lessening their effect:
Health Alliance [6] has worked extensively on the • Initially, an obvious challenge lies in altering the mind
standardization of the medical devices used in medical set of patients themselves, the elderly specially, and
monitoring, and the protocols that are appropriate for convincing them of the advantages of this game
transmission of medical data sensed by these devices. changer in healthcare delivery. The majority are
A critical element in the successful design of these WBANs is accustomed to physical visitations, and therefore,
the degree of mobility of the patients and reliability of psychologically conditioned to expect physical
transmission of sensed data. Other desirable features include proximity to a physician or a nurse. A report by
minimal weight and low power operation; they must also Deloitte Center for Health Solution [8] argues that it is
incorporate an acceptable level of security that provide privacy often the case the e-health solutions are only viewed
to users. A comprehensive discussion of WBANs is beyond from a technological perspective while the challenges
the scope of this paper. For an in depth discussion of WBANs are societal or cultural in nature, such as ensuring a
readers are referred to [7]. high level of patient’s trust in the use of such
technologies. It further recommends that technologists
Remote Patient Monitoring should work in concert with those in need of these
Medical Services solutions emphasizing co-creation rather than forcing
the technology use on them. Patients’ education, and
X X

their access to information is crucial to the success of

Wireless
X

an RPM scenario. Patients must buy into a partnership

Bio sensors X
between them, technology and healthcare providers to
reap the benefits of RPM, and similar futuristic
X

solutions.
Internet cloud
•
• Another barrier is accentuated by the reluctance of
some heath care professionals and providers to shift to
this mode of care delivery. Professionals might assume
E-Health
Gateway there is a steep learning curve in learning the nuts and
Data Center bolts of this technology, and in keeping with its fast
changing pace. On the other hand, health care providers
Figure 1. RPM Architecture are warry of liability issues and the lack of well-defined
legal and regulatory frameworks that can be followed.
The collected data is transmitted to an aggregator or a smart e- Furthermore, providers need to be educated about the
health gateway that connects to the network. Figure 1 above cost-effectiveness attained by deploying RPM
shows the major components of such a platform. solutions, due to factors such as reduced costs from
The gateway is typically capable of supporting various readmissions and reduced hospital stays, and the ability
wireless protocols and inert-device communication. The to continuously monitor the patients and recommend
gateway communicates with the backend servers at the timely preventive measures. RPM support the extension
healthcare facilities using WAN technologies such as cellular of clinical environments into a patient’s home allowing
or GSM or GPRS, as well as broadband wired technologies for a better quality of life without compromising
(e.g. ADSL, cable). medical attention. We expect, in due time, and because
of the cost effectiveness of RPM, that a majority of
 healthcare providers will eventually deploy RPM-based has limited energy and come with low processing
solutions within their networks. capabilities and hence, it is almost impossible to
implement foul-proof complex security algorithms on
• The need for standardization in the e-health sector in them. It is recommended that in health care applications
general is very clear. Monitoring requires the use of security should be applied at three levels [12]:
different sensors that are most likely supplied by administrative, physical and technical security of the
different manufacturers. The lack of technological hardware used. Nevertheless, new and innovative
standards might hinder the ability of the different solutions are still required to provide an acceptable
devices to communicate effectively, nor for the data to level of security, and security issues will continue to
be stored and managed effectively. Hence, there is a surface requiring intensive research efforts [14].
pressing need for standards that permit device and data
interoperability. On the application side, some of the • Power consumption is considered as one of the critical
used mobile monitoring applications might be viewed factors in WBAN systems deployed in RPM
by regulators on the same level as medical devices applications. Energy is continuously consumed by the
requiring the approval of bodies such as the FDA for its three activities: sensing vital signs, processing and
use in clinical settings. To avoid such delays, the transmission. Batteries with their limited storage
different participants need to come up with guidelines capacity are typically the main source of energy in
that speed up the efficient deployment and use of such WBANs, hence all viable alternatives that lead to
applications. The Continua design guidelines [6] are optimization of power consumption should be explored.
recognized as an international standard for personal The frequent recharging these batteries might burden
health systems to ensure interpretability of devices. At the patients. Even though, the protocols used in WBAN
the network level, the IEEE 802.15 Task Group [9] is such as Bluetooth, and Zigbee are characterized by their
responsible for developing this standard that is low power [15], research focusing on developing new
optimized for low power devices and to serve different protocols and improving existing ones (for example,
applications including telemedicine, consumer addition of the Bluetooth Low Power protocol) for
electronics and few others applications. Also reduced power is an ongoing effort. Work on extending
contributing to the standardization efforts as related to sensor lifetime by utilizing several low power MAC
data interoperability is the HL7 group [10] that provide protocols is an active area of research. For example, in
standards related to the sharing, integration and these protocols, the radio is turned on/off periodically
exchange of electronic health records. to save energy [16]. Specially designed low power
radio chips for WBANs and printed thin film batteries
• The storage, integration, interpretation and managing of have also been developed and used [17]. Currently,
the huge mass of incoming data in a large scale RPM energy-related solutions that are being investigated
deployment can be a daunting task. To realize the full include energy harvesting techniques and the use of
potential provided by the availability of this data, solar cells.
knowledge extraction and data mining techniques have
to be employed. The field of big data analytics in IV. CONCLUSIONS
healthcare is far from maturity but progress continues
Today’s technology has the power to transform and
with the primary goal of having well formed insights
improve the traditional healthcare delivery mechanisms. The
from very large data sets to improve outcomes, while
ability to monitor patients’ conditions from afar is central to
simultaneously reducing cost, for example, by
any future improvements. This paper provides a snapshot of
removing redundant and useless data [11].
the problems that are encountered when seeking the
implementation of remote monitoring platforms. A range of
societal, cultural, and technical issues pertaining to this new
• As depicted in Figure 1, the internet is the primary
paradigm has been discussed and the needed steps to counter
medium for data collection, this in turn raises issues of
them effectively are introduced. We project that RPM use in
privacy and security and the need to address them. The
the medical field will grow in the coming years, and already
attacks that are likely to occur in a healthcare system
major industrial players such as Intel, Philips, and Honeywell
implemented using wireless sensor networks include
have entered this market.
[12,13]: data modification, impersonations attacks,
eavesdropping and replaying. The problem is
exacerbated further by the fact that devices used in
RPM applications are typically low on device-memory,
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