ORIGINAL ARTICLE

Telehealth and ubiquitous computing for bandwidth-constrainedrural and remote areas

Robert Steele • Amanda Lo

Received: 10 March 2011 / Accepted: 9 January 2012 / Published online: 21 January 2012

� Springer-Verlag London Limited 2012

Abstract The information and communication technology

infrastructure available in rural and remote areas may often

not have the bandwidth to support all types of telehealth

applications; therefore, for example, some traditionally

envisaged videoconferencing-based telehealth applications

may not be able to be used or not used in their anticipated form

at this time. While the level of broadband services available

may impose limitations on these types of telehealth applica-

tions, in this review article, we identify applications that allow

the maximizing of telehealth benefits in the presence of low-

bandwidth connectivity and have potential benefits well-

matched to rural and remote area healthcare challenges. In

particular, we include consideration of how ubiquitous com-

puting might potentially bring non-traditional approaches to

telehealth that can also come into usage more immediately in

bandwidth-constrained rural and regional areas. In this article,

we review the benefits of ubiquitous computing for rural and

remote telehealth including social media-based preventative,

peer support and public health communication, mobile phone

platforms for the detection and notification of emergencies,

wearable and ambient biosensors, the utilization of personal

health records including in conjunction with mobile and

sensor platforms, chronic condition care and management

information systems, and mobile device–enabled video

consultation.

Keywords Telehealth � Ubiquitous computing � Rural

and remote � Health care � e-health � Broadband �Mobile health � Wireless health

1 Introduction

Telehealth has long been recognized for its capability to

facilitate remote care of patients living in rural and remote

locations [1]. The capabilities of telehealth are perceived to

be highly beneficial for rural communities, especially for

residents who are elderly or critically ill. As defined by

Field et al. [2], telehealth is ‘the use of information and

communication technologies to provide and support health

care when distance separates the participants’. Capabilities

and functionalities of recent telehealth applications have

dramatically improved due in part to improvements in

telecommunication and Internet technologies. In fact, what

began as simple healthcare instructions sent via Morse

Code [3] and later as voice calls over the telephone, can

now include the transmission of data that is more complex

and semantically enriched, which not only can be used to

enhance communication with and to inform stakeholders

involved in an individual’s care, but also has the capability

to carry out remote healthcare actions, and support the

making of clinical decisions, diagnoses and treatments.

Owing to the advent of computers and Internet technolo-

gies, information transmission in the twenty-first century

not only supports textual and audio messages, but also

images and videos and other varied data applications.

Telehealth as it extends to consumer-facing e-health can

also utilize ubiquitous computing technologies and

emerging systems such as social media communication and

mobile device applications.

One of the benefits that telehealth offers is the capability

to improve the quality and continuity of health services

delivered to rural and remote regions, providing better

access to specialized services in remote regions and

increased information availability [4]. It has also been

described that these applications can improve a physician’s

R. Steele (&) � A. Lo

Discipline of Health Informatics, Faculty of Health Sciences,

The University of Sydney, PO Box 170, Lidcombe, NSW 1825,

Australia

e-mail: robert.steele@sydney.edu.au

123

Pers Ubiquit Comput (2013) 17:533–543

DOI 10.1007/s00779-012-0506-5

practice by facilitating continuing medical education,

contact with peers and access to second opinions [4].

Health care consumers can also benefit from telehealth; it

can minimize or eliminate unnecessary travel as well as

increase the range of professional health care services

available to individuals residing in remote regions. While

telehealth applications may promise to be a key enabler in

overcoming the rural–urban disparity in healthcare ser-

vices, there are and there will continue to be challenges to

the realization of telehealth due to the continuing relative

deficiency of information and communication technology

(ICT) infrastructure in rural and remote areas.

Existing studies investigating the enablers of successful

implementations of telehealth applications usually focus on

factors such as users’ perception and concerns, policy and

operational issues as well as degree of usability and fit with

current work processes within the healthcare sector [5, 6].

As the magnitude of the benefits provided by a telehealth

application is also dependent on its technology character-

istics and functionalities [7], any impediments preventing

those functionalities are likely to affect the application’s

effectiveness.

This review article highlights the dependency between

ICT infrastructure and potential health care services

deliverable via telehealth-enabled health systems in rela-

tion to availability and capacity of infrastructure and also

highlights the benefits ubiquitous computing and low-to-

medium bandwidth telehealth may bring. As the quality of

infrastructures available to a rural or remote community

cannot be controlled by health care providers or system

designers, it is important to understand how telehealth

potential for a rural or remote community can be maxi-

mized despite limitations posed by the available ICT

infrastructure.

2 Background

The Internet over the last decade has significantly trans-

formed the way information is transmitted [8]. It has

strongly affected the modes of communication, changing

and enhancing the way work can be carried out. Within

health care, the emergence of the Internet has transformed

the term telehealth. Telehealth no longer merely refers to a

simple phone conversation between two health care pro-

fessionals; it can also be used to describe a range of ICT

applications such as the use of videoconferencing between

health care providers located at different sites, instant

transmission of records, images and other health-related

data, the provision of home care via robots [9], the control-

ling of surgical devices from a remote location, which is also

known as telesurgery [10], or the use of consumer-facing

ubiquitous computing technologies such as smartphones,

sensors or social media for health applications [11]. Without

Internet access and its attendant support for data transmis-

sion, it would not be possible to carry out any of the above-

mentioned applications.

There are numerous telehealth applications developed to

remotely deliver various types of health care [3, 12–15]

with many of them supporting the use of telehealth in rural

or remote areas [3, 12, 15]. Numerous studies have dis-

cussed the potential of telehealth for improving the quality

of health care delivery in rural and remote areas [7, 16, 17];

however, the lack of ICT infrastructure is likely to restrict

the type of telehealth applications that can be made

available to a rural community particularly in the near

term. For example, the ViCCU developed by CSIRO

Australia for telepresence support in the emergency, high

dependency and obstetric departments between two distant

Australian hospitals requires a 100-Mbps connection at

each site [13]. A telesurgical system developed in Korea

also requires a 100-Mbps connection to facilitate data

transport between sites [18]. A study from Canada has

determined that bandwidth below 4 Mbps is unsuitable for

telesurgery; it is recommended that a speed of 6 Mbps is

the minimal bandwidth requirement for telesurgical appli-

cations [19].

While not all rural and remote communities require the

use of such bandwidth-intensive telehealth services, a lack

in ICT infrastructure can render it impossible to deploy

these specialized telehealth services in a remote or rural

area until the required infrastructure has been put in place.

For instance, areas where only a wireless or satellite con-

nection is available are likely to face more restrictions

during the deployment of such telehealth systems as these

types of connections are likely to have a narrower band-

width, as well as being more intermittent when compared

to a wired fibre-to-building connection.

2.1 ICT in rural and remote areas

ICT technologies have gained wide acceptance in urban

areas, are increasingly seen as key enablers of a national

communications infrastructure, and are to cover most rural

and remote areas. Although analogue communication

technologies such as traditional telephone line are univer-

sally available, differences in ICT infrastructure exist in

rural and urban areas [8]. While accessing the Internet or

the deployment of a telehealth system does not necessarily

require broadband access, inability to access such infra-

structure will affect the capacity and speed of data trans-

mission. Currently, there are two main forms of ICT

broadband infrastructure available to rural and remote

communities—wire- and wireless-based broadband.

Wire-based broadband has the capacity to support

bandwidth of more than 100 Mbps and can be delivered via

534 Pers Ubiquit Comput (2013) 17:533–543

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coaxial or fibre-optic cables taking in the form of tech-

nologies such as fibre optics, cable Internet or a digital

subscriber line (DSL). Although wired broadband is

increasingly available in many urban areas, it is still rela-

tively unavailable for the majority of rural and remote

communities. This inaccessibility is largely due to the fact

that the installation of data cables in rural areas is some-

what cost-ineffective due to factors such as low population

density, distance from urban areas, as well as challenges

posed by the terrain, which may prevent the successful

installation of data cables. A significant national project

such as the $AU 36 billion Australian National Broadband

Network [20] is deploying high-speed wired broadband

infrastructure to 90% of homes in Australia and so will

overcome such bandwidth constraints for many over time;

however, this network’s completion time is envisaged as

taking until the end of 2020 [21], so there is still an

important need to consider how to most rapidly advance

telehealth capabilities in the interim and for all regions that

will not have such connectivity for far longer periods into

the future.

Those who are unable to obtain wire-based broadband

may opt to utilize wireless-based technologies, which can

support an average speed of up to approximately 12

Mbps. These technologies, such as WiMAX [22], Uni-

versal Mobile Telecommunication Systems (UMTS) [9]

and Mobile Broadband Wireless Access (MBWA) [23],

provide a relatively cost-effective solution for broadband

access. However, this technology utilizes atmosphere-born

electromagnetic waves for data transmission; therefore,

the quality and reliability of the connection may be

affected by factors such as poor weather conditions and

other atmospheric factors and distance from the nearest

tower.

Due to the challenges in establishing broadband infra-

structure in rural and remote areas, it is not surprising that

ICT services available in rural regions typically fail to

match their urban counterparts in regards to price, speed

and download limits [24]. According to the ABS 2006

census, the digital divide between urban and rural Australia

is significant. For example, in 2006, 46% of dwellings

within the Australian major cities have a broadband con-

nection versus 28% in remote Australia [25]. The per-

centage is lower in very remote Australia, with only 24%

of dwellings having a broadband connection [25].

Although more than half of regional Australia has access to

the Internet, it has been found that more than half of

regional and remote Australia relies heavily on dial-up

Internet access [25]. This problem is not unique to Aus-

tralia, with other developed countries such as Canada

reporting a similar gap between urban and rural areas due

to the lack of high-speed ICT infrastructures in rural and

regional Canada [26].

2.2 Ubiquitous computing and telehealth

In general, the provision of ubiquitous computing tech-

nologies to support telehealth has the potential to provide

several benefits to both patient and providers. The rapidly

emerging adoption of smartphones and to some extent

social media provide a significant step towards realizing

some previously envisaged ubiquitous computing capabil-

ities [11, 27–29]. Fundamentally, ubiquitous computing

technologies allow health-related communication and

processing to occur wherever an individual is in their day-

to-day lives. As such, ubiquitous computing technologies

may have particular relevance to the care and management

of chronic conditions much of which ultimately occurs in

the home or community environment, and chronic condi-

tion management often requires lifestyle change interven-

tions. Ubiquitous technologies have the potential to offer

improvements in an individual’s quality of life, especially

for older people, and also allow them to retain their inde-

pendence by having sensors assist with checking their

health status whilst at home [27]. These sensors can be

used to monitor various conditions such as cardiac symp-

toms [28] and enable transmission of other health data and

health information to the provider [27]. The use of ubiq-

uitous technologies yields several advantages for the health

system overall, as individuals can monitor their health

progress at home, as opposed to travelling to a healthcare

site and the attendant greater expenditure, particularly for

rural and remote residents, that this involves [30]. This

could assist in taking the strain off health facilities, and

with the increasingly ageing population, such technologies

could prove to be of significant benefit. Indeed, such

ubiquitous technologies are particularly advantageous for

those in rural areas, given the longer travelling distances

for health consumers to attend even local medical and

health consultations.

3 Telehealth functionalities and bandwidth

requirements

‘Store-and-forward’ or asynchronous telehealth applica-

tions [31] are those that are not required to send captured

data immediately but can send it at a later time. Real-time

or synchronous telehealth applications involve immediate

communication. A store-and-forward application is likely

to have less bandwidth requirement as compared to a real-

time system as its data are mainly stored as images or text

and data transmission can occur over a longer period of

time. However, a lower bandwidth is likely to increase the

time it takes for information to be transmitted and hence

decreasing the system’s performance. This also implies

that the transmission of high-quality images and other

Pers Ubiquit Comput (2013) 17:533–543 535

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multimedia-based data could take potentially hours or days.

Real-time or synchronous systems [31], on the other hand,

are likely to have a higher requirement on bandwidth as

functionalities like videoconferencing require a relatively

stable and fast connection to support smooth video

streaming. Although there is evidence demonstrating the

possibilities and benefits of utilizing low-quality video-

conferencing systems over narrow bandwidths [32], these

systems are only beneficial for some consultation purposes

and may not be used to support critical healthcare decision-

making. For instance, both dial-up- and ISDN-based vid-

eoconferencing systems described in Malagodi et al.’s [33]

study failed to portray a tremor in a patient’s hands. Hybrid

systems [31] make use of both store-and-forward and real-

time communication.

The Telehealth Technology Taxonomy developed by

the Center for Information Technology Leadership

(CITL) [31] has provided a reference to the minimum

bandwidth requirement of various functionalities imple-

mentable in a telehealth application. The transmission of

textual information requires the least bandwidth; a con-

nection of less than 10 kbps can effectively facilitate the

transmission of pure textual data [31]. Real-time as well

as hybrid telehealth applications are likely to have higher

bandwidth requirements as these applications usually

involve the use of at least one form of synchronous

technology such as video- or voice conferencing. It has

been estimated that a connection of at least 364 kbps is

recommended for transmitting high-resolution video,

while a minimum of 128 kbps is recommended for the

transmission of high-resolution images or low-resolution

videos [31]. With increasing demand to deliver a wider

range of specialized healthcare services through telehealth

as well as the need to provide a stronger sense of pres-

ence in telehealth platforms, it is believed that emerging

and future telehealth systems are likely to be more

bandwidth-intensive than current telehealth applications.

Based on the bandwidth requirements provided by CITL,

the following table outlines the kinds of ICT technology

recommended to support the efficient transmission of

various types of data found within a telehealth application

(Table 1).

Clearly, the amount of bandwidth demanded by a tele-

health application depends on the type and quality of

information being transmitted. In addition, an application’s

communication complexity, which is dependent on the type

and number of functionalities it offers, can also affect the

system’s bandwidth requirement. As illustrated in Fig. 1,

Store-and-forward applications, in general, are likely to

have a lower communication complexity level compared

with real-time or patient-monitoring-based systems as

these applications do not require constant uploading and

downloading of data when compared with real-time or

patient-monitoring applications, hence requiring less

communications between sites. Such applications as patient

referral systems require high-quality large data such as

medical imaging to be sent, leading to a relatively high

bandwidth requirement.

Table 1 Minimum

recommended connection type

for different types of healthcare

data

The speeds provided are only

theoretical downlink speeds.

Due to load or users being

further away from the exchange

(cell towers in the case of

wireless connections), they are

unlikely to experience these

speed. Uplink speeds are usually

lower

536 Pers Ubiquit Comput (2013) 17:533–543

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4 Telehealth and ubiquitous computing for bandwidth-

constrained rural and remote areas

Various specific challenges for rural health care have been

well documented in the literature, and these include bar-

riers due to geographical distance, a higher disease burden,

high-risk work, a shortage of local physicians and other

health professionals, an ageing population, lack of pre-

ventative care and wellness resources, and challenges for

effective health emergency response [34, 35].

Below, we identify a range of discrete areas of remote

and rural health care that are amenable to the application

of low-to-medium bandwidth telehealth and ubiquitous

computing technologies. It is also noted that the most

significant recent platform development in relation to the

emerging application of ubiquitous computing to rural and

remote areas is the rapid and continuing uptake of

smartphones during the last few years. There are, how-

ever, also other significant emerging developments with

a potential bearing on emerging telehealth applications

for rural and remote areas, including the increasing use

of social media, the continuing progress in sensor

technologies and improvements in video-over-Internet

technologies.

4.1 Social media for preventative health care, peer

support and public health intervention

Social media generally has very low-bandwidth require-

ments due to the typically textual nature of such commu-

nication, although audio and video resources can often be

referred to in social media communications. As such, its

application to support health care and public health in

bandwidth-constrained rural and remote areas has relative

advantages. It is applicable both in terms of bandwidth

required and also a match to some of the challenges of rural

health care mentioned below. It should also be noted that

social media usage is increasingly a ubiquitous computing

phenomenon with, for example, 40% of tweets being sent

from mobile devices by mid-2011 [36] and 40% of Face-

book use or 300 million monthly active users accessing

Facebook from a mobile device as of end of 2011 [37].

One increasingly anticipated and utilized use of social

media is to provide peer support for those with a particular

condition via online condition-specific social networks [11,

38, 39]. Such services as patientslikeme.com [40], tudia-

betes.org, inspire.com and curetogether.com already can

provide such services as physician Q&A, peer support [11]

and sharing of condition-specific news [41]. The use of

Fig. 1 Various telehealth applications and their approximate bandwidth requirement

Pers Ubiquit Comput (2013) 17:533–543 537

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social media for public health interventions and health

education is also increasingly being explored [11, 42].

Such applications have a particularly good fit for rural and

remote community health care as they can occur at a dis-

tance (no physical interaction required), can increase health

awareness amongst residents and can provide consumer

health education and health information [43].

In addition to supporting patients, social network sites

can also be used to support physician-to-physician inter-

action via sites, for example, such as Sermo (http://www.

sermo.com). Once again, this can provide particular benefits

for physicians or other health professionals in rural and

remote areas where professional isolation is recognized as a

particular challenge [17].

The use of social media from mobile devices has also

raised its potential for usage in public health interventions

[11]. It has also been considered how the use of social

media can support more personalized public health inter-

vention [42]. The area of persuasive technology [44] also is

envisaged to likely be enabled via mobile, and as such, this

represents a potential tool for public health improvement.

The use of social media from mobile devices, given the

relatively low bandwidth requirements, may match rural

and remote area circumstances in relation to public health

messages specifically relevant to such regions such as rural

work safety information.

4.2 Emergency detection and notification

Emergency detection and notification also does not require

significant bandwidth, but could have significant and life-

saving benefits. For example, 30% of those who suffer

heart attacks die before reaching the hospital [45]. A

common aspect of life in a rural and remote community is

individuals working alone or being in areas without many

people nearby. Furthermore, often work in rural and remote

areas can be unusually hazardous [34]. These characteris-

tics increase the risk of a health emergency and pose a

particularly dangerous situation and potential longer delays

reaching a hospital for those who do experience such a

health emergency.

There has been extensive work on the use of sensors to

carry out remote measurement and capture of physiological

data [46–50]. The emergence of the smartphone also rep-

resents a profound community-wide change in this field

that appears the lead candidate platform to support and

enhance such sensor-based emergency detection and

response, both via smartphone internal sensors and con-

nected external sensors [51, 52].

The immediate detection and notification of an emer-

gency situation can offer a life-saving capability. The

ability to flag a health emergency immediately upon its

occurrence and provide the location of the individual is

already technologically achievable via smartphones or

other phones for that matter. However, smartphones can

provide superior capabilities in such scenarios, particularly

in relation to situations where the emergency makes man-

ually operating the phone impossible. In an emergency

health situation, an individual could (1) be able to operate

their phone or alternatively (2) be unconscious or unable to

activate their phone or smartphone for some other reason.

• In the case where an individual or observer of an

individual is able to use their phone or smartphone,

traditional approaches can be used such as contacting

the emergency phone number, or activating an appli-

cation on their smartphone to alert the occurrence of an

emergency to emergency responder personnel, and at

the same time, automatically providing the user’s

location information via the GPS or other location

service provided by the smartphone.

• In the case where an individual is unconscious or

unable to use their smartphone, a range of sensor-based

approaches can provide critical capabilities. It is likely

that in most anticipated configurations, such sensors,

regardless of their type, will communicate via short-

range wireless with the individual’s smartphone that

can then communicate to the remotely located emer-

gency responders. Such potential sensor approaches

could include accelerometers as have been proposed for

fall detection [53], car-based sensors to detect car

accident–related emergencies [54], or ECG, EEG or

other vital sign sensors worn by or implanted for the

individual [55, 56]. A pulse oximeter sensor, which is

able to measure heart rate, is a sensor that could be a

candidate sensor for detecting life-threatening emer-

gencies, as it has relatively advanced commercial

availability including in a convenient form [56].

Further, any sensor-based approach will detect the

occurrence of an emergency with greater or lesser

accuracy. Once such an emergency is automatically

notified, an approach to verify via text to the phone

could be enabled, allowing the overcoming of false

positives from the sensors. Multiple sensors can also

assist in detection of potential emergency situations or

of false positives. A false positive is preferable to the

failure to detect an individual’s genuine health

emergency.

While wearing some form of vital sign sensor continu-

ously may appear impractical or overly privacy–invasive,

this is not necessarily the case. Initial studies have shown

relative acceptance of the use of sensors by some at-risk

groups [47], and there are privacy-ensuring configurations.

For example, the output of the vital signs sensor need not

be transmitted by the smartphone or other gateway device.

When a potential emergency is detected due to a loss of

538 Pers Ubiquit Comput (2013) 17:533–543

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vital sign signal, the user could be prompted via their

smartphone to confirm if this is a false alarm. Only if the

user does not ‘dismiss’, this potential alarm would the

emergency notification be then sent to the emergency

responders.

4.3 Measurement and storage or transmission

of physiological data

Once again the smartphone is the most important emerging

platform for this application of ubiquitous computing, but

is optionally combined with a Personal Health Record

(PHR) [57, 58] for such an application area.

Sensor usage for capturing physiological information is

not just of use for emergency situations but also to build up

a picture of the ongoing health of a rural and remote res-

ident. Such systems can support capture of health data

whilst in the home [59] and also whilst outside the home

environment [46, 51]. Particular sensors might be worn

only once an individual is diagnosed with a related health

problem or identified to be at-risk. For example, if an

individual is identified to have diabetes or pre-diabetes,

they might utilize a continuous blood glucose (CGM)

monitoring sensor to monitor their glucose levels

throughout the day, or if they have been identified to be at

high risk of heart attack, they might wear an ECG sensor to

monitor changes in heart beat activity and regularity. Other

examples include car-based sensors capable of capturing of

health information and vital signs information [60]. Sys-

tems to support the security and authority to access data

both at the level of access to sensor data and by practi-

tioners for access to PHR data are available [61, 62].

Further developments in relation to sensor usage for

health and physiological measurement include the Quan-

tified Self movement (quantifiedself.com), whose focus is

the usage of sensors to capture a more complete and con-

tinuous knowledge of oneself through the use of biosen-

sors. The group’s motto is ‘self knowledge through

numbers’. Other contemporary developments in relation to

mainstream use of sensors include the sharing of sensor

data that capture such physical activity as jogging or riding,

and posting such physical activity to social networks [11,

63]. Current applications of this nature include Nike? and

RunKeeper.

Such sensors can have particular applicability to rural

and remote residents as (1) it is harder for individuals to

travel to have tests done in face-to-face clinical settings, (2)

the greater potential lethality of medical emergencies is not

pre-emptively detected, managed and prevented, given the

distances to emergency treatment, and (3) the bandwidth

required for such data services is small and can be

accommodated by even low-bandwidth connectivity cov-

erage. This information can also be integrated to a PHR

allowing a capacity in theory for physician remote moni-

toring of their patient. Such an approach can allow greater

capture of health data into health records than hitherto

possible [64]. It should be noted that the transmission of

textual data, even when semantically rich and involving the

highest throughput applications, can operate with medium

bandwidths [65]. While many of the physician workflow

aspects are yet to be fully determined for such PHR-inte-

grated applications, the technical capability is rapidly being

made available and the relative benefit of their adoption for

rural and remote communities is higher than for urban

communities for the reasons given above.

Another consideration that system designers should take

into account is whether the available connection is ‘always

on’ or it requires users to ‘dial in’. Clearly, connections that

are ‘always on’ are more suitable for real-time systems

such as telemonitoring; however, with changes to the sys-

tem design, those with only a dial-up connection can still

be ‘monitored’. For example, data collected can first be

compressed then stored on the patient’s computer and can

be ‘pushed’ to the healthcare professional when the patient

is connected to the Internet.

4.4 Chronic condition care

Chronic disease accounts for over 70% of health cost and

80% of deaths in the US [66], and one quarter of those with

a chronic illness suffer significant limitations to daily

activities [67]. As such, it is the most significant category

of health problems. Chronic disease is nevertheless best

combated through lifestyle change, and this must occur

within an individual’s daily living and work environments

and not in a clinical setting.

Personal health records have the potential to assist in the

physician-guided management of chronic condition. Purely

textual PHRs can be utilized over even dial-up connections,

and low-to-medium bandwidths can also accommodate

image and audio content, although noting that the files

from some forms of medical imaging can pose large delays

for lower-bandwidth connections.

The capability of smartphones to reach individuals in

their daily lives and support m-health [68] may also

potentially assist in lifestyle change adherence and support

chronic condition management. Current studies have

shown some initial promise in relation to mobile-based

interventions for chronic condition care [69, 70]. Previ-

ously, SMS-based phone interventions [71, 72] have also

shown initial promise. Similarly, applications for smart-

phones have also been created that allow patients to better

manage their own health or follow care plans, with pre-

ventative applications also assisting patients in reducing

their chance of illness. Applications have been created that

allow patients to self-manage rehabilitation and disease, so

Pers Ubiquit Comput (2013) 17:533–543 539

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instead of being reliant on daily visits to a health profes-

sional, patients can use the application to manage the

condition that is in turn monitored by a health professional

[52]. Instead of travelling large distances to be monitored

by a health professional, transmission of information

through smartphones enables patient’s information to be

transferred quickly and easily and supports community-

based or home-based care.

4.5 Mobile and desktop videoconferencing

For urban residents, travel to their local health care pro-

vider or specialist is typically far less burdensome than

such travel for rural and remote residents. As such, one of

the most significant benefits that can be achieved is

reducing the need for rural residents to travel to physical

meetings. At the same time, achieving this with lower-

bandwidth-requiring techniques is needed for its applica-

tion to bandwidth-constrained rural and remote areas.

Emerging technologies such as Apple FaceTime, an

iPhone video-phone capability released in 2010, have the

potential to provide real-time, mobile phone-based video-

conferencing, with potential benefits resulting from its

simplicity of call set-up and use [73]. The bandwidth

requirements of the FaceTime application are, however,

relatively high [74], approaching 400 Kbps. Another

advantage of such mobile device–based videoconferencing

is its greater support for video-based conversation with

emergency responders in emergencies inside or outside of

the home environment.

5 Discussion of real-world deployment: progress

and issues

The characteristics of the above-described emerging tele-

health applications are those of reaching the patient or

health consumer in their everyday lives. This is inherently

a characteristic of ubiquitous computing and also has par-

ticular advantages in relation to rural and remote health,

given the typically larger travel distances required to travel

to even local health facilities.

5.1 What about high-bandwidth telehealth

applications?

High-bandwidth telehealth applications such as telesurgery

[19] and telepresence [75] also have particular benefits for

rural and remote health care. However, the current lower

levels of bandwidth available in these areas will delay their

application. This article concentrates on a wave of lower-

bandwidth telehealth applications involving the utilization

of ubiquitous computing technologies that have seen

substantial recent technological uptake assisting their

deployment readiness.

In addition, another form of high-bandwidth telehealth

application involves the transfer of large medical imaging

files. It should be noted that there will typically not be a

need to transfer these from home environments, and it will

not tend to provide the benefit of less travel, as the

sophisticated imaging equipment to capture such images at

this time only exist at medical facilities to where patients

will still need to travel to have the imaging carried out. Of

course, high bandwidth to rural and remote health facilities

can realize significant efficiencies via remote assessment of

large medical images or teleradiology [76].

5.2 Potential and outlook for increasing real-world

deployment

The ubiquitous technologies discussed in Sect. 4 are all

currently commercially available, can work at low-to-

medium bandwidths, and are relatively inexpensive. This

form of telehealth has the capabilities and potential as

described, but for its further real-world deployment, it must

be integrated into practice within the healthcare system.

Two directions are needed to enable further real-world use

of these technologies: (1) government enablement through

regulatory and reimbursement changes and (2) greater

consumer awareness and demand.

5.3 Government regulatory and reimbursement

enablement

As described in this article, non-traditional telehealth

achieved through ubiquitous computing technologies has

significant potential to benefit health care in rural and

remote areas. While consumer uptake plays an important

role in the feasibility of such systems, the potential inte-

gration of these systems into clinician and health system

practices would also require further regulatory and funding

initiatives.

Recent times have seen significant legislative steps to

open the way for the utilization of these technologies in

health care particularly to support their home-based usage.

The Fostering Independence Through Technology (FITT)

Act currently before the US Senate [77] is a bill to establish

pilot projects and provide incentives for the use of such

home-based telehealth technologies. Also in the United

States, in late 2011, the US Department of Agriculture has

awarded $US 30 million of grants to support over 100

remote telehealth projects [78].

Telehealth videoconferencing [79] is currently begin-

ning in Australia following the federal government

announcement in 2010 that telehealth consultations would

be recognized for medicare reimbursement [80]. These

540 Pers Ubiquit Comput (2013) 17:533–543

123

medicare reimbursements are targeted to support older

adults and those in remote areas, but are for consultations

that take place at physician’s office or aged care facilities.

Such funding and policy support has rapidly enabled this

form of telehealth.

For the further integration of ubiquitous and home-based

technologies into healthcare practice and into the health

system, further such regulatory, reimbursement or incen-

tive changes would need to be introduced.

5.4 Consumer awareness and demand

Uptake by consumers of smartphones, social media and in

some cases the usage of sensors is very high as described.

These directions offer significant potential for engagement

of consumers in health communication and their health.

The rapid consumer engagement with these technologies

and media for many information and communications

activities has the potential to be leveraged for further

engagement of consumers in their health care and health

communication. Whether such developments as the quan-

tified self movement or the social sharing of fitness data

[61] continue to see adoption will be seen over time.

6 Conclusion

In this article, we have reviewed the literature to demon-

strate the capability and benefits of applying emerging

provider-to-consumer telehealth technologies including the

utilization of ubiquitous computing technologies for rural

and remote areas with low-to-medium bandwidth com-

munication available. This demonstrates how large near-

term benefits could be potentially realized for telehelath for

these areas. We have considered the use of new forms of

health consumer and public health communication via

health social networks, the use of advanced and automated

health emergency notification systems including smart-

phone-based systems, the use of smartphone-enabled sen-

sor technologies for home-based capturing of physiological

data for at-risk patients, the use of personal health records

by chronically ill and emerging mobile device–based vid-

eoconferencing capabilities. We have also reviewed current

regulatory and uptake issues associated with further real-

world deployment.

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