The term infrastructure is derived from the Latin word “structura”, meaning—a fitting together, or to pile/assemble together, and “ infra ” meaning on the underside/beneath; this chapter will focus on understanding the elements that are piled together underneath the telehealth system, so that the practitioner can understand, “what is beneath the hood.” These are not necessarily the brick-and-mortar components, but predominantly the elemental components of the system. The system is not just your office, or your local network, or even your country, it is indeed much larger than that. For example, the components comprising the infrastructure which are in everyday use, include elements which are extraplanetary and reside in outer space.
The infrastructure required in your office may be dictated by a number of factors ranging from regulatory requirements, capital available, right through every link in the network, and may even be influenced by bottlenecks in bandwidth; if your patients are unlikely to have access to high-speed broadband with low contention ratios, then it is tempting to design your infrastructure around this bottleneck. There is little need to have high-definition 4k video equipment if your internet service provider is transmitting information over copper telephone wires, or if your patient is unable to receive such high-definition video. However, it seems evident that we will look back at such statements with the sort of adoring condescension and bewildered incomprehension, that a modern adolescent might have for the significance of the spinning jenny. That is to say, there will be a time, and very soon, where affordable access to high-quality, high-speed internet access, will be ubiquitous. Technology is currently available to load balance and match bandwidth as appropriate, so that users do not experience the infuriating spinning wheel, that symbolizes a buffering video. I would actively encourage all in telemedicine, to come to understand the tools they use to deliver care, much in the same way it is important for a surgeon to understand, not only that electrocautery works, but also how it works, so that they can understand how it can be misused, and how the understanding of its function is necessary, so that harm to patients may be avoided.
The infrastructure requirements were alluded to briefly in the first chapter of this book, and some of these components will be discussed in more detail here. There are many ways in which we can interpret infrastructure in the context of telehealth. For a busy practice, one can and should consider that offering telehealth visits is akin to building an extension to your physical practice. You may find that with considered scheduling, telehealth visits for suitable patients and consultations, do indeed offer the physical space and time for consultation rooms to be used by allied health professionals, and to be prepared properly, while the clinician is occupied with a telehealth visit, and so allow for greater efficiencies within the practice.
One can classify the infrastructure components required in many ways, and using geographic location as a rubric is a useful starting point. Some may read this chapter with more attention to what is local, but again I would stress, that the network is only as strong as the weakest link, only as fast as the slowest interlink, exchange, section of fiber, or roll of copper wire. It is only as robust as the legislation that exists to define its scope and nature, regulation, and protection. I would urge the reader to consider all of the elements. A few of these factors (local and national) will be discussed in more detail, so that the reader can appreciate that while telehealth promises to make access easier, it only does so for those who have access to the devices and services required to conduct a telehealth visit.
Personal and personnel requirements (local factors)
Practitioner demeanor is fundamental to all patient care. Urologists are among the greatest innovators in medical sciences, and have seen and helped lead great change in surgical practice so far this century and last. As a specialty group, many are proud of the nature of the specialty to troubleshoot issues with robots, lasers, endoscopic tools, scopes, and all sorts of digital and analog tools used in practice. The same mentality is required in telehealth. The same openness and cautious evidence-based approach to change is required. Whether that be, adapting new practice procedures and protocols as becomes necessary, evolving to run hybrid clinics, or moving toward sessions which are entirely offered by telehealth. The same dynamism that allows urologists to maintain a diverse skillset from open to minimally invasive surgical skills, from andrology to oncology, fertility to reconstruction, is what is required to adopt telehealth and begin adapting one’s practice to incorporate telementoring, telediagnosis tools, and telemonitoring tools.
In much the same way, it is imperative to have a similar culture across one’s practice. Having coworkers and colleagues willing and able to incorporate something new and sometimes challenging, is equally as important. Being able to welcome new challenges, and using telepresence and digital tools to help improve patient care, is a significant change, and time and training required for staff to gain confidence in their use, will pay dividends and give greater confidence to patients who deserve competent and confident care. Technology can and should make our lives better and safer. But its use often requires careful and considered planning to ensure that everything from the cameras, microphones, digital records, digital patient and practice schedules, and digital payment systems are maintained, secured, and properly used. In many ways, these are reflected by the culture of the healthcare organisation or urology practice, and take time to develop.
Lobbying for better access (national/state-level factors)
While many advocates of telehealth will espouse, the platform allows greater access to better health. However, this is only the case for those who are willing and able to use such portals, and perhaps more critically, for those that can afford and have access to appropriate devices and providers of cellular and internet access. One should not assume that because someone lives in a large metropolitan area or a “developed” nation, that they have access to adequate broadband internet. The average connection speeds in 2020 were ∼42Mbits/s in the United States and 103Mbits/s in the European Union (EU). While these are adequate for videoconferencing and a video consult, remember that gigabit connections were expanding in these regions before 2020, and that these outliers will buoy those average values.
While access to healthcare has long been a priority policy point for healthcare advocates, access to reliable, high-speed internet and suitable devices to conduct telehealth visits, becomes synonymous with access, in a world where telehealth becomes the norm. While some may see this as complicating the issue of access to healthcare, it should be remembered that health access was always complicated, and that with these few infrastructure pieces in place, access to the whole array of health services can become a lot simpler. Consider a patient who needs to see their general practitioner, ophthalmologist, audiologist, podiatrist, occupational therapist, and physiotherapist. On top of the complexity to manage the scheduling, the patient is encumbered with the logistics of getting from one department to the next on time, and from one building to the other, and often these are geographically dispersed practice locations. If one considers that ∼10% of the US population >18 years of age report some mobility difficulty, and according to the CDC, 26% of adults in the United States of America report some type of disability, one now can appreciate that attending medical visits in person can quickly become a near full-time occupation for those who need multidisciplinary medical care ( ). It is therefore important for healthcare workers and practitioners to lobby and promote for better access for patients, and also for easier access for physicians to practice telehealth, to offer alternative routes to access care, and unencumber this significant proportion of the patient population. That is not to say there should be no regulation, and as with most things in the age of the internet, consumers and healthcare providers require protections from those who would seek to exploit such systems. It should also be remembered that while everyone should have access to adequate and sufficient healthcare, that healthcare is not a consumer product. “Productified” health is not healthcare, and many consider it exploitative of patients and physicians and to the detriment of societal well being.
Wireless communication infrastructure
Mobile telecommunications technology continues to evolve, and now even, the term “3G” seems archaic. Research and development of 3G technology started in the 1980s, and by 1999, the International Telecommunication Union (ITU) approved 5 radio interfaces for the standard, with the frequency spectrum ranging from 400 MHz to 3 GHz. 3G is the short form for “third generation” and is used to describe a mobile phone standard. 3G networks enable you to make voice calls and send texts as well as access the internet—giving you the ability to browse the web, check email, and download content at speeds of up to 7.2 Mbps, (although the standard defined by the ITU does not include this). A statement by the ITU did provide some guidance on data transfer speeds, where a minimum data transmission rate of 2 Mbits per second for stationary or walking users, and 348kbits per second in a moving vehicle are required. In practice, 3G download speeds depend on the underlying equipment the providers ultimately installed, where up to 384kbits/s is possible for Universal Mobile Telecommunications System (UMTS); High Speed Packet Access (HSPA), and HSPA+ could potentially provide download speeds of up to 7.2Mbits/s and 21.1Mbits/s, respectively.
Fourth generation (4G) and 4G Long-Term Evolution (LTE) launched circa 2010 and offered not just faster data transfer speeds but also upgraded security. Throughout the evolution of wireless technology, the push to increase bandwidth and transmission speeds has been a catalyst for creating new wireless technology standards. With this we have seen fifth generation (5G) networks become more widespread in the last 3 years (see Table 4.1 ). 4G uses lower frequency bands (with longer wavelengths) below 1 GHz, while 5G uses higher frequencies (and lower wavelengths), and so has greater challenges with signal propagation. Therefore, the distance 5G radio waves can travel is much more limited than 4G, particularly in densely populated areas.
|Year||Generation (G)||Data transmission capability|
|1990s||2G||+SMS text messages|
Both 4G and 5G utilize a public key infrastructure (PKI) system, which is a method of establishing the identity of devices using cryptographic keys. This is an important point, but first one must appreciate how PKI works: public key and private key are created by a certification authority (CA) for each device. The private key should only ever be known to the device that needs an identity, and the public key can be distributed to any part that needs to encrypt messages to the device, for example, the cell phone service provider. The CA that creates these keys is trusted by all devices in the chain that need to check the validity of the certificates. When a device needs to connect, it will present a message signed by its private key to the authorization system. The authorization system will validate the message by decrypting it with the public key that corresponds to the private key of the device. The system will also verify that the public key it used was created by the trusted CA, so it knows the certificates are valid. If all these checks pass, the system will be able to confirm the identity of the device. With 4G devices, the keys for the cryptographic system are placed permanently on the SIM card, (the universal subscriber identity module card). These are permanent keys, and so this complicates security, as if these are disclosed or somehow compromised, keys cannot be reissued without physically changing the SIM card. According to research by Ericsson ( www.ericsson.com/en/reports-and-papers/mobility-report/dataforecasts ), the Swedish networking and telecoms company, that as of June 2022, there are 5.34 billion unique mobile phone users (>2/3rds of the world’s population), and more impressive is the number of connections from Internet of Things (IoT); as of 2022, there were 14.6 billion IoT connections worldwide, and most of these are using 4G or older technologies. This places the significance of a data breach on cryptographic keys in context, and one should consider just how complex, labor intensive, and challenging it would be if even a small percentage of keys required replacing.
5G networks offer a potential security upgrade as its rollout and adoption offers the opportunity for new security protocols. However promising this sounds, this is just one area of vulnerability in such networks, and a number of “security” firms who offer cellular device hacking tools for sale such as NSO (who sell Pegasus spyware) and QuaDream (who sell REIGN) can take control of smartphones and bypass all of these cryptographic protocols entirely. It should be noted that the software products on sale from such firms can take control of the device without the user knowing, and can therefore take control of any connected device that may receive commands from that smartphone. But it also paints a worrying picture where other smart devices, whether insulin pumps or inhalers, can be interfered with.
What urologists should know about spectrum allocation?
While some of this may seem like historical miscellany, it is important to understand the context of spectrum allocation for a number of reasons. First, the bandwidths and frequencies are not unlimited. Many who listened to terrestrial radio are familiar with two radio stations of a similar frequency, interfering with each other, this is known as tropospheric ducting. This is when signals bleed into one another. To avoid this, and because bandwidths are finite, allocation of bandwidth must be respected and may require regulation to avoid interference. In the early part of the 21st century, governments in the EU and United States allocated the finite frequency spectrum, following an auction. In Europe, over 20 years ago, over $100 billion was collectively paid for these frequency spectrum allocations by private industry.
The allocations in the United States are particularly notable, as the entire spectrum was not auctioned. (This is likely the case elsewhere also; however, more information is available on the United States). A significant part of the spectrum was allocated to the US Department of Defense. With growing saturation of commercially available bandwidths, lobbyists have pushed for the Department of Defense to cede or share some of their bandwidths to private industry. Separately there have been discussions about cooperation of the Department of Defense sharing some bandwidth for medical applications, as for a period of time, only they had sufficient bandwidth available, which was reliable enough, secure enough, and with low enough latency to facilitate entirely remote robotic-assisted surgery.
In 2020, the US Department of Defense published an Electromagnetic Spectrum Superiority Strategy. This is a plan to ensure that the United States maintains its military advantages in the electromagnetic spectrum. The strategy has three main goals: to control the electromagnetic spectrum, to deny adversaries the ability to use the electromagnetic spectrum, and to protect the United States from electromagnetic threats. The strategy also includes a number of initiatives to improve the United States’ ability to operate in the electromagnetic spectrum, including developing new technologies and improving training and education. What is similar for defense, as it is for healthcare, is that nearly every form of communication used today in hospitals and by healthcare workers is wireless and leverages the electromagnetic spectrum. The electromagnetic spectrum encompasses all possible frequencies of electromagnetic radiation, from low-frequency radio waves to high-frequency gamma rays. While frequencies above 300 GHz include infrared light, visible light, ultraviolet light, and X-rays, frequencies at 300 GHz and below are used to transmit information for cell phones, television, radio, satellite communications, Global Positioning Systems, Bluetooth communication as well as radio frequency identification chips, commonly used on ID badges, for swipe cards to access buildings and to unlock cars and devices.
For many of the same reasons that the US Department of Defense sees it as a strategic imperative that they have unrestrained, unfettered, and exclusive access to an entire block of the spectrum, one can see the importance for healthcare to have a similar level of access. Commercial advancements proliferating wireless devices and services will continue to erode the capacity for healthcare to utilize the finite resource that is the electromagnetic spectrum. As the airwaves become saturated, how can access be equitably distributed? If healthcare delivery (via telehealth and wearable devices and sensors) will rely upon access to the available electromagnetic spectrum, should the provision of a pacemaker come with a monthly plan? Will those providing connected health have to compete with discretionary consumer spending categories from “connected accessories” from car manufacturers, to cell phone and computer companies, television networks, and retail, social media, and search behemoths, for the limited space available?
The future proliferation of electromagnetic spectrum-dependent systems in health will include almost all elements of healthcare, from diagnosis, monitoring, population health surveillance to treatment and rehabilitation. It is incumbent upon those planning for future health systems, public health officials, healthcare systems, and all stakeholders in healthcare, to advocate and ensure sustained future and equitable access for healthcare systems. And much like the practice of evidence-based medicine, it is also imperative that those in healthcare understand the risks and benefits, the consequences of its use, and any potential adverse effects, arising from the use of such products, devices and services. We will discuss this in a separate section later in this chapter.
What urologists currently use the electromagnetic spectrum for in everyday practice?
Different parts of the spectrum serve different health purposes. X-rays have been in routine use in medical care for over a century, being used 6 months after Roentgen’s discovery to identify bullets in wounded soldiers. Other segments of the spectrum are not as often considered for their utility in medicine, yet those uses are no less essential for healthcare to function. For example, radio waves are still utilized by many health systems using pager systems. They still have advantages over cellphones as they can travel (relatively) long distances and pass through solid objects like buildings and trees, and even receive messages in hospital basements and through lead-lined walls in radiology departments. Microwaves have higher data rates than radio waves and are often used for satellite communications, internet access, and other communications. Microwave energy has also been used in medical treatments for over 40 years, and there are a number of applications in use including tissue ablation, and also in applications such as sterilization. Infrared is of course closely associated with heat sources, and is widely applied in noncontact thermometers, and in screening equipment in waiting rooms and entrances to facilities. Infrared light can be used to help treat conditions such as pain and is widely used as part of rehabilitation therapy, and by others to aid in wound and tissue healing. It has also been adopted in some surgical systems to help visualize blood vessels and tissue perfusion, with the ability to discern relative levels of perfusion and blood flow, and so has applications from disciplines as varied as reconstructive surgery and cancer surgery, to stroke care and vascular surgery. Gamma rays are also familiar to the practicing urologist, as many will have had questions from patients on the “gamma-knife” surgeries performed by radiation oncology colleagues. Gamma rays have the shortest wavelengths and greatest energy on the electromagnetic spectrum, and owing to their properties, are widely used in tissue destruction (or radiation therapy). Gamma rays when administered in sufficient doses are also lethal to prions, viruses, bacteria, and other microorganisms, and so are also used to sterilize medical equipment. Gamma rays are also used in nuclear medical imaging techniques such as positron emission tomography (PET) imaging.
Risks of electromagnetic radiation to patients—long-term exposure to different parts of the spectrum
This section briefly addresses what is known of the health effects of exposure to electromagnetic radiation, as there is ongoing concern among the general public. While the effects of exposure to gamma rays, X-rays, ultraviolet, visible light, and infrared light and their role in disease and medical applications are better understood, those of longer wavelengths are usually the subject of public concern. In response to these concerns, the International EMF Project was launched. It is a research initiative of the World Health Organization (WHO). The project was established in 1996 in response to public concern about possible health effects of exposure to electromagnetic fields (EMFs). The project’s objective is to assess the scientific evidence of possible health effects of EMF in the frequency range from 0 to 300 GHz—in other words, as far along the spectrum as microwaves ( Fig. 4.1 ).