Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

U.S. Healthcare: Too Much Money/Too Little Results Our spending is out of control vs. rest of developed world: 17.4% of GDP spent on healthcare (next highest is Netherlands at 12.0%), UK is 9.8%, Canada is 11.4% U.S. Per capita spending of $7,960 – next highest is Norway ($5,352); Canada ($4,363) and UK ($3,487), and Japan ($2,878) - World Bank/Organization for Economic Cooperation & Development Our performance pales by objective metrics: 47 th in world ranking for infant mortality (we are second lowest in developed world and even rank below Cuba!) 25 th in world for life expectancy (we are below Chile & Greece – Japan leads) We do NOT have the best healthcare system in the world – at least not in cost/benefit terms - World Health Organization/CIA World Fact Book

Wireless Telehealth – Vital for our Country The problem in numbers: 60% (over 100 million) of American adults have at least one chronic condition (disease that is long-lasting or recurrent) 77% over 65 have two or more chronic conditions 90% of all health care spending is towards treating chronic conditions. - US Dept of Health & Human Services Undeniable evidence of the benefits of Remote Patient Monitoring: 89% of agencies reported an increase in quality outcomes 76.6% cited reduction in unplanned hospitalizations 77.2% cited reduction in ER visits 76% reported patients improving self care by proactive disease management - Philips Healthcare

Chaz 56 years old, married, Harvard MBA Recently received 2 nd Pacemaker Implant Completely dependent on device now for cardiac rhythm management Still runs marathons and works out regularly Wants to work closely to monitor own condition Technophile/early adopter of consumer gadgets Wants to maintain active lifestyle despite risks Judith 87 years old, twice-widowed Generally good health; received replacement heart valve 7 years ago Lived in same home for 56 years; wants to stay as long as possible Biggest concern is staying in home Doctor appointments are a major effort; Late adopter of computers/ Active in local Ageing in Place organization Wireless Telehealth - Real Impact for Individuals

Wireless Telehealth: Great Opportunity Wireless Medical Devices Herald a New Revolution in Healthcare. Gerson Lehrman Group / Huge Complexity Wireless Telehealth Solutions Face Many Challenges, including... Complexity... Acceptance... Costs... Reimbursement Forrester Research

Telehealth has a language of its own 510k alliance analog ansi ata Asynchronous Transfer Mode (ATM) Audio-teleconferencing Backbone Bandwidth Basic Rate Interface (BRI) Bit bis cardiac care ccd cdc cesl chf chin chronic care continuaa copd CMS Defense Data Network (DDN) dax devices diabetes doj Dedicated Line Demarc Dip (Dual In-line Package) Switch Distribution Amplifier Duplex Audio ehr emr fcc fda forward ftc hcaho hcii hie himss hitsp Home Tele-Health (HTH) Hard Wired Half Duplex hl7 hme hmo hpsa icd9 implantable cardiac devices initiative interoperability ip matmo mcot meaningful use medix mhealth iniative monitoring Monitored Medication Dispensing Systems (MMDS) Monitoring Center/Station MBPS (Megabits per Second) mua nchsr nhsc ohih phr point of care post-acute care pots Patient Tele-Monitoring Systems (PTMS) Pendant Peripherals Programmable ppo ppp pprc protocol reimbursement remote sonet ss7 store & forward t1 t3 tcp telematics telemedicine tia-50

Adding Wireless Increases Complexity of Telehealth Even More 1800mhz 1900mhz 1xrtt 2g 3g 4g adl agps nalog-to-wireless ansi apis bearers bluetooth bridged bsc bus cdma certifications command converter counter csd ctia debug dialserv dna dns dota edge ether ethernet etsi ev-do evdo event fast fcc fcm flash fota gateway ggps ggsn gpio gprs gps gsm hlr hsdpa hspa http iccid imei imsi incoming indication infrastructure input integrated ip iso iwf leo lte management memory mesh messages mobile model module modem msc mt 100a2w-g-eu mt100a2w-g-gb mt100a2w-g-nam mt100a2w-nam object plugins power-up ppo protocols pstn ptcrb receipt registration rf rj-11 rs-232 secure serial service sgsn shell sim sms standards tcp tftp timer trace translator udp udpapi unsent usb vlr voip wap wifi wimax wireless zigbee

Successful Wireless Telehealth Initiatives Must Solve Many Issues Whats the best way to configure & activate devices? Should I use a module or embedded modem? How can we optimize the payload to make it affordable? Whats the right wireless network(s) to use? How do I pick a wireless module? Can I automate orders and requests for equipment? How do I manage support when patients call in? What is the right rate plan? How do I protect my data so I am compliant with all regulations ? How will we ship hardware so it is plug and play? What about international coverage? How will I handle billing to insure reimbursement? What if something isnt working – how will we handle returns? Can I integrate into our legacy systems? How do I manage my devices over the air?

Distilling the complexity into D-N-A helps simplify things Whats the best way to configure & activate devices? Whats the best way to configure & activate devices? Whats the right wireless network to use? Should I use a module or embedded modem? How can we optimize the payload to make it affordable? How can we optimize the payload to make it affordable? How do I pick a wireless module? Can I automate orders and requests for equipment? How do I manage support when patients call in? What is the right rate plan? How do I protect my data so I am compliant with all regulations ? How will we ship hardware so it is plug and play? What about international coverage? How will I handle billing to insure reimbursement? What if something isnt working – how can will we handle returns? Can I integrate into our legacy systems? How do I manage my devices over the air?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well Analog to Wireless Conversion as a First Step? Smart Phone vs. Hubs vs. Stand-Alone Devices? Embedded Module vs. Modem vs. Hybrid? Challenges of Designing Solutions for WIreless? Regulatory / Network Certifications Needed?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well When to use GSM vs. CDMA vs. Satellite? How Much to Pay for Data? Single Console Management of Multiple Networks? Complete Network Visibility? Domestic Footprint – Especially in Rural Areas? What about Global Coverage? Network Security, Privacy & Patient Rights? From 2G to 3G to 4G and beyond?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well Device & Network Agnostic Platform? Administrative Console w/ Device Management (FOTA, etc.)? Hosted or Self-Managed Data Center? Application Monitoring Tools? Easy Integration to Legacy Systems?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well Financing? Electronic Order Management? Device & Network Out of the Box Experience? Drop Shipping & Fulfillment Services?

DNA is the key to Wireless Telehealth – but Product Lifecycle Management services are vital as well Recurring Monthly Billing? First and Second Tier Customer Support? RMAs and Return Management?

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

To Cut Development Time & Costs – follow a proven process Follow a proven, three phase process to design, develop, and deploy successful wireless telehealth solutions. Design Phase 1 - Solution Definition Working sessions & requirements for device, network, application – as well as data integration into existing legacy systems. Deliverables include Phase 2 Statement of Work. Phase 1 - Solution Definition Working sessions & requirements for device, network, application – as well as data integration into existing legacy systems. Deliverables include Phase 2 Statement of Work. Develop Phase 2 - Proof-of-Concept Build a small number of working prototypes of the complete end-to-end solution. Also develop a detailed ROI model that quantifies the benefits and justifies moving to Phase 3. Phase 2 - Proof-of-Concept Build a small number of working prototypes of the complete end-to-end solution. Also develop a detailed ROI model that quantifies the benefits and justifies moving to Phase 3. Deploy Phase 3 – Initial Commercialization Implement a carefully constructed early stage deployment which validates the ROI model in real market conditions. This includes sufficient scale for valid results, but limits out-of-pocket. Phase 3 – Initial Commercialization Implement a carefully constructed early stage deployment which validates the ROI model in real market conditions. This includes sufficient scale for valid results, but limits out-of-pocket.

Minimal transaction count Minimal transaction size Asynchronous communications Stateless applications Minimal implementation of transport layer functions Wireless Application Architecture Is Different

Polling Verbose messages (Ascii text) Sending static/duplicate data Sending unchanged/unimportant dynamic data Over-reporting Confirming transactions/excessive handshaking Synchronizing state between client and server Synchronizing time between client and server Using session-based, confirmed delivery transport Common Wireline Application Issues

Wireline applications must usually be rearchitected Assumptions underlying wireline application architecture are invalid Fundamental system design usually has to change Tuning or optimization can improve performance – a little Otherwise, high usage-based charges on every device forever Good news! – Its almost always software Converting Wireline Applications to Wireless

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Consider a Two-Step Process to Wireless Conversion

Examples of Wireless Converter Devices

Conversion Device Solutions using PPP Pass-through Require Little or No Change

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Smart Phone/Tablet Glucometer data downloaded to Patients Smart Phone or Tablet + leverages patients existing hardware & network rate plan - Patient must own a Smart Phone or tablet w/ data plan/app & download data - Lack of standardization of devices Glucometer data downloaded to Patients Smart Phone or Tablet + leverages patients existing hardware & network rate plan - Patient must own a Smart Phone or tablet w/ data plan/app & download data - Lack of standardization of devices Hub Device Smart Hub Device aggregates data from multiple sources + Combines multiple medical devices in one location - Opens possibility of managing multiple diseases & symptoms - Typically fairly expensive and complex to implement Smart Hub Device aggregates data from multiple sources + Combines multiple medical devices in one location - Opens possibility of managing multiple diseases & symptoms - Typically fairly expensive and complex to implement Stand Alone Device All-in-One Device (Glucometer PLUS wide area wireless communications) + Simplest implementation – allows total control of process -Lowest cost -Longest time to market All-in-One Device (Glucometer PLUS wide area wireless communications) + Simplest implementation – allows total control of process -Lowest cost -Longest time to market Three Alternative Device Approaches (Diabetes Examples)

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Embedded Module vs. Pre-Certified Modem Consider using a modem/module with enhanced capability a la Java (to do heavy lifting apart from PCB) to limit exposure on FDA approvals

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Wired ConnectionsWireless WAN Connections Free connectivityUsage-based charges Always connectedConnect on usage Low latencyVery high latency IP and MAC addressesAlso MSISDN and IMSI identifiers Static/known IP client addressDynamic/unknown IP client address Monolithic InternetHome carrier and roaming Wireless Is VERY Different from Landline or Ethernet Connectivity

Minimize transaction count Exception-based reporting Batched reporting Custom transport layer protocol functions Custom application and presentation layer protocols Minimize transaction size Employing UDP Custom application and presentation layer protocols Client application designed for configurability Client application designed for modular updating Other techniques Data model modification Time-base management and calibration Best Practices for Wireless Telehealth Applications

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Standard Regulatory / Network Certification Flow

Typical Regulatory / Network Certification Timetable

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Combine coverage footprint of Tier I (blue) and Tier II/III (orange) carriers to deliver maximum coverage in U.S. Consider Coverage in Rural Areas

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

International GSM cellular coverage: 185 countries (All EU, SingaporeCanada, United States and Spain have country-wide GSM service). Global Coverage Exists for Wireless Telehealth

World SIM For Devices & Patients Moving Around the Globe OR Where opening new countries w/ low density of connections Single SIM, Simplified Rates One SIM works everywhere. Simplified rates for >185 countries Dual IMSI Technology Domestic & international profiles on a single SIM card allows for Single console management of all Connections Local SIM For Devices Permanently Installed in a Fixed Location AND Where in-country density of connections exists (>10,000) Locally Sourced SIM With enough in-country density local SIMs provide the most competitive rates Requires Local Contract With enough in-country density local SIMs provide the most competitive rates Consider Two International Approaches – based on density

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

ISO/IEC 27001: 2005 certified (ISO 27001) 11 Security Domains 33 Control Objectives 133 Security Controls ISO facilitates compliance with HIPAA requirements FERC/ NERC Security Mandates Other security laws/regulations Sarbanes-Oxley Compliance Data Security, Patient Privacy – What to Look For

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

2G/2.5G Most Existing M2M Applications still use this technology or GPRS Will eventually be sun- setted by carriers – lots of consternation Lowest cost modules in this category Many different flavors of 3G (HSPA, EVDO, etc) – most useful for data intensive apps (web sites, etc.) Modules must be backward compatible for non-3G coverage and are larger/more costly Modules becoming more affordable 4G & beyond Stands for Long-Term Evolution No agreement yet (Sprint vs. AT&T/Verizon) on convergence High speeds not required for Telehealth apps Modules typically much more expensive (for now) Wireless Network Evolution 1xRT T

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Each Network Type Has Its Plusses & Minuses

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

How Much Data is Needed – What Should it Cost? Smart Vehicles Taking Readings Every Second Accumulating GPS AND engine performance data Usually sending data 1x per minute (when moving) <500 KB to 1 Meg/month Smart Electric Meter Taking Readings Every 15 minutes Aggregating usage and unit performance data Usually sending data 1x per day + exceptions Point-to-Point Data <50 KB/month Smart Telehealth Not as data intensive as vehicles but... Most companies claim to need more data Probably points to improper architecture/optimization for Wireless

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

49 Console Management Of Multiple Cell Networks

50 View and Manage all SIMs & Rate Plans from one screen

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Deep Network Visibility at the summary level

Deep Network Visibility at the SIM level

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Best Practice Wireless DNA Architecture

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Extensive Device Management Tools

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Representative Virtual Architecture - Hardware

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Data Center Must Allow for Deep Application Monitoring

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation

Easy Integration to Legacy Applications & Interoperability?

Wireless Technologies: The Challenges and Opportunities Facing Telehealth Henry Rosen Vice President, M2M Business Solutions Numerex Corporation