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DE GRUYTER Current Directions in Biomedical Engineering 2020;6(3): 20203003 Jan Gaebel*, Carsten Bockelmann, Robert Wendlandt, Armin Dekorsy, Juliane Neumann, Torsten Musiol, Thomas Neumuth, Max Rockstroh Requirements for 5G Integrated Data Transfer in German Prehospital Emergency Care Abstract: Data from preclinical emergency care is often not medication plan, are usually only available in paper form, available in an integrated, electronic way. Data flow between e.g. at the patient’s home environment. ambulances and trauma centers lacks a communication In Germany, pre-hospital emergency services rely on approach that allows for efficient aggregation, transmission ground-based ambulances and airborne rescue helicopters. and reuse. We present the results of the requirement analysis Both are staffed with paramedics and emergency physicians for 5G-supported emergency care scenarios. With the . Research projects and commercial systems established in illustarted requirements and derived structural consequences, various regions of Germany have been able to support we conclude with a proposal that will allow us to provide emergency services through provisioning of improved mechanisms and technologies to enable integrated emergency communication and documentation. communication for preclinical care using modern Telemedical pre-notification: Paper-based communication technologies. documentation is frequently used in emergency services. From a system for tablet-based documentation, Eder et al. Keywords: Emergency Medical Service, Trauma Team, developed a system, which connects ambulances and clinics Emergency Room, Device Connectedness, Integrated Data . Medical data gathered in the ambulance is transmitted Access, Mobile Data, 5G. alongside with position data and an expected arrival time into the hospital. This data is used to prepare the handover of the https://doi.org/10.1515/cdbme-2020-3003 emergency patient to the hospital as well as to alarm the required medical specialists while the ambulance is still on its way. 1 Introduction Telemedical consultation: To counteract shortcomings of separately dispatched emergency physicians in Germany, Health information technology is being established telemedical consultation for on-site paramedics by stationary increasingly throughout all areas of healthcare. This progress emergency physicians was established by the TeleMedic not only enables a comprehensive documentation along the [Telenotarzt] project initially for the City of Aachen. It is in clinical pathways but also ensures the crucial continuity of use in different regions throughout Germany. Speech, care. However, emergency medical services (EMS) often images, videos and medical data such as a live ECG are lack the integration into hospital IT infrastructure necessary transmitted in real-time via mobile phone networks between to request and send patient data . In general, medical data on-site paramedics and a teleconsultation center. gathered during pre-clinical emergency care cannot be The examples given above for two different use cases of efficiently managed or communicated with other healthcare telemedical services in EMS are based on proprietary providers . Relevant patient data needed to assess the communication protocols and commercial devices. current situation, i.e. patient history, allergy status or Consequently, the systems only gained regional distribution. Nonetheless, they are valuable tools for improving emergency medical services . ______ The MOMENTUM research project, funded by the *Corresponding author: Jan Gaebel: University Leipzig, Faculty Federal Ministry of Education and Research, aims to develop of Medicine, ICCAS, Semmelweisstr. 14, Leipzig, Germany, e-mail: firstname.lastname@example.org a standardized interconnection of medical devices used in Carsten Bockelmann, Armin Dekorsy: University of Bremen, preclinical emergency services as well as a completely Dept. of Communications Engineering, Bremen, Germany integrated communication approach between all medical Robert Wendlandt: University Medical Centre Schleswig- entities involved in preclinical emergency care. In pursuing Holstein, Clinic for Orthopaedic and Trauma Surgery, Laboratory this project, we are trying to overcome the limitations of the for Biomechanics, Lübeck, Germany Torsten Musiol: MECSware GmbH, Ratingen, Germany systems that have been implemented to date, each of which Juliane Neumann, Thomas Neumuth, Max Rockstroh: only realizes parts of in integrated communication from University Leipzig, Faculty of Medicine, ICCAS, Leipzig, Germany Open Access. © 2020 Jan Gaebel et. al., published by De Gruyter. This work is licensed under the Creative Commons Attribution 4.0 License. Jan Gaebel et. al.,Requirements for 5G Integrated Data Transfer in German Prehospital Emergency Care — 2 ambulance via emergency command center into the hospital - Reservation service requirements for medical services and vice versa. In this paper, we illustrate the results of the for guaranteed performance requirement analysis. - Clock synchronization service level requirements related to global clock domain management Summarized performance requirements: 2 Methods - Ambulance setting limited to 4K compressed audio/video, vital signs and a 2K low fps data stream for diagnostic video (CT scan) 2.1 5G specification and medical use - Mobile specialist practice includes very high data rate cases demands with 4K stereo video, fast MRT/CT scan data transmission and multiple additional streams for The term “5G” is an unspecific marketing term that is used diagnostic video with very different meanings and in different contexts. When talking about the mobile communications system 5G, the Current 3GPP use cases detail rather generic requirements on standardization organization 3rd Generation Partnership data rate, latency and availability, but lack detailed analysis Project (3GPP) defines releases that make up the cellular of current medical technologies, their capabilities and communication systems used today (i.e. from GSM to LTE). restrictions. Section 3.1 provides examples of specific With release 15 (Rel. 15) 3GPP introduced the first “5G”- requirements for typical medical data in German ambulances System with New Radio (NR) as its novel air interface (i.e. that are not covered by this view. layers 1 and 2) and the new 5G core (5GC) that handles higher layer functions like authentication, mobility or the gateway to public networks. Within 3GPP 5G standardization 2.2 Technical prerequisites continues with parallel tracks on the finalization of Rel. 16 (expected Q3/20) and ongoing work on Rel. 17 (expected to The German Society of Anesthesiology and Intensive Care finish 09/21). Medicine responded to the technological progress and recent Medical service requirements are discussed in 3GPP growing demands on support with a proposal of minimum since late 2018 initially as part of Release 16 and now as an technical requirements for telemedicine in prehospital ongoing study item in the Systems Architecture (SA) emergency care : working group for Release 17. The current status is - Availability of bidirectional audio transmission, documented in the technical report TR 22.826 , which lists unidirectional video transmission several different medical applications and discusses - Continuous transmission of vital sign/monitoring data, functional as well as performance requirements that are low clinically irrelevant latency relevant for cellular communication systems like 5G. - Secure data transfer, availability in 95% of the Analyzed medical applications range from simple video operation, state of the art data encryption duplication or robot-aided surgery to very challenging remote - Redundancy in communication infrastructure as a surgery. The use cases most relevant for our purposes are: fallback - Mobile specialist practice - Data management compliant to GDPR, medical data - Patient monitoring inside ambulances privacy laws etc. - Cardiac telemetry outside the hospital - Availability of GPS data of ambulance and relevant logistical data, support of operation management and Each use case is characterized by functional requirements, choice of target clinic usually concerning security, privacy and service reliability. - Digital medical documentation for ambulance personnel, The performance requirements are typically detailed on the forensically sound and compliant to minimum application level like video and audio streams for emergency dataset MIND3  communication and diagnostics, DICOM data like MRI/CT This proposal is based on for German EMS available scans, haptic feedback data, telemetry and so forth. In the communication technologies, UMTS, LTE and TETRA radio following we want to highlight and summarize the 3GPP (Terrestrial Trunked Radio). The previously mentioned requirements. systems are using these technologies to provide their subset Interesting functional requirements: of implemented functionalities of . Jan Gaebel et. al.,Requirements for 5G Integrated Data Transfer in German Prehospital Emergency Care — 3 standard emergency care actions present a challenge to 3 Results communication technologies. For example, monitoring of an emergency patient comprises of different parameters, that After observations and investigations in both German when transferred to other a remote party (e.g. leader of the emergency medical services and trauma centers, we propose trauma center in the target clinic), require different to extend the requirements regarding the following use cases: transmission strategies. The following list contains only a - Interconnectedness of medical devices and other few examples of emergency medical procedures and their technical equipment inside the ambulance properties for successful transfer: - Integration/connection to “Telematikinfrastruktur” with - ECG monitoring & oxygen saturation: continuous stream, identification of patient and check for health data low latency, minimal packet loss tolerable - Distributed processing/analysis of collected medical data - Blood pressure: repeated measurement, low latency, inside whole infrastructure lossless transmission - Possibility of the integration of additional - Respiratory monitoring: continuous stream, low latency, devices/technologies (e.g. mobile ultrasound or other minimal packet loss tolerable imaging or sensor technology) - Telemedical adjustment of respiration parameters: - Comprehensive electronic patient record with minimal latency, lossless transmission continuous monitoring documentation and automated data entry (where/when needed) These examples illustrate the heterogenous nature of different - Alerting of the trauma team in the target clinic with medical measurements or activities. Regarding the 3GPP detailed information and individual call-in of medical release, these activities cannot be covered by the given use specialists case descriptions. Further conceptualization is required to integrate the entire medical process with the desired benefits. 3.1 Data & devices in ambulance vehicle 3.2 5G-Scenario architecture German ambulances are equipped according to European standard DIN EN 1789 . Due to German federalism, each German federal state can define the features in detail and may also require additional equipment. Regarding medical devices or technical equipment in general, ambulances contain an ECG monitor with defibrillator, a respirator, syringe driver, suction pumps, TETRA radio and GPS navigation device. Additionally, mobile computers are sometimes available for electronic documentation. To fulfil the aforementioned requirements, we considered additional devices, e.g. mounted or mobile Figure 1: Proposed architecture for emergency services. Top camera systems or medical devices with Service-oriented most involved communication partners are shown. An ambulance connected to a hospital uses a drone to boost its Device Connectivity . To analyze and assess the technical connection to public infrastructure. Middle layer shows the environment needed, we estimated the potential traffic and application view with medical applications and servers and data amount using exemplary data from vendor bottom layer describes the involved 5G system with a small information/websites or scientific publications. cell inside the ambulance to connect medical devices and Our research resulted in very a heterogenous set of (potentially mobile) gateway to public networks. characteristics for different medical applications. Apart from To connect an ambulance (top left) to the hospital (top right) existing technologies, e.g. mobile video transmission, and for reliable two-way communication, we propose an innovative approaches like augmented reality applications, architecture as shown in Figure 1. The ambulance uses a drone (top middle) that can be flexibly placed to enhance connection to public services. This is of special importance in 1 rural areas to enhance signal quality, e.g., in mountain terrain German health care system telematics infrastructure to or within a valley, but can also be useful in urban areas where access a patient’s core data or relevant health data densely placed buildings are blocking radio reception. Jan Gaebel et. al.,Requirements for 5G Integrated Data Transfer in German Prehospital Emergency Care — 4 On the application level (middle layer) the ambulance stakeholders. Technical standards from clinical/surgical will run its own medical network with a variety of medical settings, e.g. IEEE 11073 SDC , enables the connectivity equipment connected to an appropriate server that of medical devices inside the ambulance and even beyond the coordinates data forwarding and local processing. This server boundaries of the ambulance vehicle. This, on the other hand, is the endpoint towards the hospital medical network and allows for an integrated health record of the patient that can applications. be made available to every attending paramedic or physician. The 5G network (bottom layer) is structured to support The MOMENTUM consortium will continue to reliable connections within the ambulance as well as with a conceptualize and implement technologies with integrated public network. Thus, the ambulance provides its own private communication systems for preclinical emergency care. cellular network with a 5G small cell handling traffic of all wireless medical equipment within the ambulance. Note, that Author Statement this requires appropriate bandwidth for a mobile private This work is funded by the German Federal Ministry of network which is not covered in current regulatory rules. Education and Research (BMBF) with grant number Furthermore, the private ambulance small cell must provide 16KIS1030 – MOMENTUM – Mobile Medizintechnik für coverage outside the ambulance to enable mobile use of all die Notfallmedizin. The statements made herein are solely equipment in the vicinity. Access should be available to other the responsibility of the authors. devices/vehicles in a rendezvous system, e.g. by simple NFC- The authors state that they have no conflict of interests. based on-site authentication services. The drone serves as a gateway to the public network and References can be either stowed on the ambulance or in the air with the goal to optimize reception. Currently, to realize the gateway  Martin TJ, Ranney ML, Dorroh J, Asselin N, Sarkar IN. functionality we propose the use of two modems, one Health Information Exchange in Emergency Medical connected to the public network and one to the private small Services. Appl Clin Inform. 2018;9(4):884–91.  Landman AB, Rokos IC, Burns K, Van Gelder CM, Fisher cell network served by the ambulance. In future 5G solutions, RM, Dunford JV, u. a. An open, interoperable, and scalable this might be integrated into a single device. Alternatively, a prehospital information technology network architecture. tether could be used to connect the drone to the ambulance Prehosp Emerg Care. Juni 2011;15(2):149–57. network also solving potential power issues, but constraining  Brokmann JC, Felzen M, Beckers SK, Czaplik M, Hirsch F, Bergrath S, u. a. Telemedizin: Potenziale in der movement. Notfallmedizin. Anästhesiol Intensivmed Notfallmed Schmerzther. Februar 2017;52(2):107–17.  Eder PA, Dormann H, Krämer RM, Lödel SK, Shammas L, Rashid A (2018) Telemedizinische Voranmeldung durch den 4 Discussion & conclusion Rettungsdienst bei Schwerverletzten. Notfall Rettungsmed (2019) 22: 37. In this paper, we present the requirements for an integrated  Eder PA, Reime B, Wurmb T, Kippnich U, Shammas L, communication system and device connectivity in preclinical Rashid A. Prehospital telemedical emergency management of severely injured trauma patients. Methods of information emergency care. in medicine. Georg Thieme Verlag KG; 2018;57(05/06):231– Modern telecommunication technologies enable the development of sophisticated assistance systems. However,  Präsidium der DGAI. Telemedizin in der prähospitalen to ensure the establishment in medical practice and the Notfallmedizin, Strukturempfehlung der DGAI. Anästh Intensivmed 2016; 57: 160–166 acceptance of the potential users, systems must meet the  Messelken M, Schlechtriemen T, Arntz H-R, Bohn A, prevalent requirements. We analyzed existing conditions in Bradschetl G, Brammen D, u. a. Minimaler Notfalldatensatz German preclinical emergency care and related them to MIND3. Notfall Rettungsmed. 1. Dezember 2011;14(8):647– potential solutions. German federalism complicates the  DIN EN 1789:2014-12: Medical vehicles and their definition of generally valid solutions. But progress and equipment - Road ambulances; German version EN modern technologies from other communities, can help 1789:2007+A2:2014; https://dx.doi.org/10.31030/2240534 achieve the goal. With the introduction of Rel. 15, the 3GPP  Kasparick M, Schmitz M, Andersen B, et al. (2018). presents specifications that enable authentication, mobility or OR.NET: a service-oriented architecture for safe and the gateway to public networks. Given the necessary security dynamic medical device interoperability. Biomedical Engineering / Biomedizinische Technik, 63(1), pp. 11-30. measures, this standard may allow preclinical entities to use Retrieved 23 Mar. 2020, from doi:10.1515/bmt-2017-0 mobile communication channels to transfer their data to all
Current Directions in Biomedical Engineering – de Gruyter
Published: Sep 1, 2020
Keywords: Emergency Medical Service; Trauma Team; Emergency Room; Device Connectedness; Integrated Data Access; Mobile Data; 5G
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