President Trump talks up the TeleHealth opportunity at White House Department of Veterans Affairs Event

mHealth Insights

Visually this is all just ridiculous: Wearing white coats while video calling (CHECK), carrying a stethoscope (CHECK), reading from technology from ancient Egypt (CHECK), windows 95 user interface (CHECK), claims that it is affordable to deploy at scale the precise telehealth kit used onboard the Presidents $400Million modified Jumbo Jet (CHECK), etc.

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President Trump: “Today, I’m pleased to announce another historic breakthrough that will expand VA services to many more patients and veterans. We will do this through telehealth services. It’s what it’s called — telehealth services. We’re expanding the ability of veterans to connect with their VA healthcare team from anywhere using mobile application on the veteran’s own phone or the veteran’s own computer”

I think we should be mindful about the terms that are being used to describe how we are modernising the 2000 year old model of healthcare. TeleHealth means “remote health” (‘tele’ is a Greek derived word-forming element meaning “far/far off/at a distance”) and surely we can all easily see that this isn’t what veteran’s are going to be getting here.

Being ‘far away’ or ‘distant’ is the last thing a Patient will feel when informed healthcare advice that they can trust is for the first time accessible 24×7 by just reaching into their pocket and Facetime video calling their Nurse or Doctor.

With your access to the internet and my medical degree can you imagine what we could achieve

President Trump: “This will significantly expand access to care for our veterans, especially for those who need help in the area of mental health, which is a bigger and bigger request – and also in suicide prevention. It will make a tremendous difference for the veterans in rural locations in particular”

President Trump: “We’re launching the mobile app that will allow VA patients to schedule and change their appointments at VA facilities using their smartphones. So, this is something they were never able to do. Technology has given us this advantage, but, unfortunately, we have not taken advantage of that until now. We’re working tirelessly to keep our promises to our great veterans. Very important”

I think it’s time to be a lot more ambitious and to use our imagination. In 2017 Veterans shouldn’t have to need to download an app to a smartphone to do something as simple as booking an appointment. Surely it’s obvious that making an appointment for an office visit is not really taking advantage of the connected super computers that we all now carry in our pockets eg. in 2013 I reported here about how a 92 year old in the UK was frustrated that her Practice Nurse didn’t use Facetime.

Tim OReilly Quote

Secretary Shulkin: “What we’re announcing today is a big deal for veterans. It’s really going to expand access for veterans in a way we haven’t done before. And, as you may know, VA already has the largest telehealth program in the country. Last year we had 700,000 veterans who got telehealth services through the VA, and we actually can do this for 50 different specialties”

I think the VA shouldn’t be so ready to clap themselves on the back as 700,000 may seem like a large number but it’s still means that less than 4% of veterans are using the VA’s telehealth services (there are 18.3Million Veterans in the USA).

Secretary Shulkin: “what we’re announcing today dramatically expands our current capabilities. Mr. President, by working with the Office of American Innovation and the Department of Justice, we’re going to be issuing a regulation that allows our VA providers to provide telehealth services from anywhere in the country to veterans anywhere in the country, whether it’s in their homes or any location. We call it “anywhere to anywhere” VA healthcare. That’s a big deal”

It surprises me that this is only now happening as Doctors I’ve talked to who work for the US army have told me they’ve been doing this for years eg. the USArmy’s Consultant Ophthalmologists who produced video tutorials to train GPs how to record and share good quality eye exams with their smartphones.

Secretary Shulkin: “…you talked about mental health and suicide prevention; this is one of those areas that we can really use that expertise. And today’s announcement is going to allow us to do that. What we’re going to be rolling out nationally with a rollout across the country is what’s called VA Video Connect. VA Video Connect allows VA providers to use mobile devices to connect with veterans on their mobile devices or their home computers. That’s a big deal”

I don’t think this initiative will achieve the desired outcomes. Enabling video call access to professionals won’t start to properly dent the suicide statistics because Veterans find it challenging enough to share information in face to face office encounters. The VA urgently needs to understand that quick convenient video chats don’t substitute for a Doctor Consultation because the “The biggest “disruption” in healthcare is honest, direct, accessible communication” (2012) and we know that we’re more honest with our phones than our Doctors.

Secretary Shulkin: “And there’s one more thing, Mr. President. We’re going to be announcing a new technology called the Veterans Appointment Request. And what that is, is it’s allowing the veteran, on their smartphone, to be able to schedule their appointments directly with VA providers, or to change their appointments, or cancel their appointments with VA providers. Now, today, this is available in all 18 of our regions across the country. And we’ve already booked more than 4,000 appointments from veterans directly from their smartphones so that they can schedule their own appointments. But now we’re announcing the national rollout of this”

I’m stunned at this. I know small GP clinics in the UK and Ireland that have been doing this for 7+ years and have provided more mobile appointment bookings than the entire VA. Talk about the future being here already but just not evenly distributed!

Secretary Shulkin: “Now, let me show you how this works, Mr. President. If we come over here — we use technology in a way that’s pretty incredible. In fact, Mr. President, I’m one of those doctors. I practice right here in Washington to my clinic in Grants Pass, Oregon. And I want to say hello to our veteran today. Mr. Amescua, how are you? Mr. Amescua is a veteran. He served in the Coast Guard for 26 years. He was a helicopter rescue swimmer and served the country. And here we are in Oregon. And this is our great team — Peggy and Denise and Terry. And, Peggy, would you mind — I understand there might be some area of concern on Mr. Amescua’s skin. Can we take a look at that, please? Team Member: Yes, sir. Dr. Shulkin, this is the area that is of concern. Secretary Shulkin: Okay. So, as we focus in on that, you can see, Mr. President, I can take a look at that area and if I have any concern about it we can send this to a specialist or we can take a look at it”

What an incredibly inefficient process. The VA should cut the waste and consult the Born Mobile Generation to redesign this Patient Care Experience.

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Secretary Shulkin: “Mr. President, if you walk over here, this is actually the new doctor’s bag – the doctor’s bag of the future. And you may actually recognize this because this is the doctor’s bag that travels with you when you go on Air Force One. And so we have Dr. Ronny Jackson, your doctor here that usually takes care of you, Dr. Jackson. And we now are able to bring this doctor’s bag into the home of our veterans. Our nurse practitioners, our technicians are able to use this type of technology now – the same technology available to the President of the United States. And that’s the way it should be, because our veterans deserve that type of technology”

The first thing I’m thinking is that this aluminium encased laptop must cost a bomb but seriously how many nurse practitioners are going to put out their backs in the next year if they are having to lug that in and out of their trunk and into every Patients home?

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Couldn’t they achieve the same with an iPhone/iPad and some smartphone medical accessories?

Secretary Shulkin: “Now, I’m going to show you just one or two other things. Dr. Neil Evans over here, one of our doctors, is going to show you VA Video Connect that I talked about. So here we are in Grants Pass, Oregon. Hi, Mr. Amescua, how are you? Can you raise your hand? Good. So, here we are in Grants Pass, Oregon on our mobile device, and this is how we can use VA Video Connect. But watch this, Mr. President. If we need to bring in a specialist from anywhere
in the country into Grants Pass, Oregon, we can”

I can’t see why the President of the United States is supposed to be impressed by a video conference call? He’s probably been using it at least once a week for the last 10 years (eg. when being interviewed on the TV news channels).

Secretary Shulkin: “Dr. Watts is a specialist – an internal medicine specialist in Cleveland, Oregon, and she is now connected in with Mr. Amescua in Grants Pass, Oregon. So, we can get the expertise from anywhere in the country immediately. The VA is able to do this right now. So, thank you very much. And so, Mr. President, this is how we’re expanding access. This is how we’re bringing the very best technology available in the country. And really thanks to your help in cutting through the regulation, the Office of American Innovation, we’re able to expand that success dramatically today and to roll this out”

I think it’s clear that the terrible design of this synchronous system will have no chance of expanding access to expertise. By utilising staff and Patients so efficiently it will waste resources and ultimately limit access to expertise.

Look how many staff members are being used here to bounce around what is a straightforward bit of dermatological history and a picture that Mr Amescua could probably have taken on his own using nothing more than his mobile during the month that he probably waited to get that video consultation in the clinic:

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International Congress on Mobile Health Devices & Seizure Detection in Epilepsy, Copenhagen, 7-9 July 2017

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Starting Friday (7-8 July 2017) in Copenhagen Denmark the “1st International Congress on Mobile Health Devices and Seizure Detection in Epilepsy” looks set to be a fascinating meeting and I only wish the program had been posted earlier as I would’ve made plans to attend.

Very unlikely there will be a livestream (as the event organisers aren’t even using Twitter etc) but I’ll add the links to the speakers etc in the below (refresh post later to see these) as it will make for some good research and background reading (especially as the meeting is being conducted in English).

Key Topics/Speakers include:

Seizure detection using intracranial EEG for closed loop system
Martha Morrell, Department of Neurology and Neurological Sciences, Stanford University (USA)

Seizure detection using scalp EEG
Christoph Baumgartner, Karl Landsteiner Institute for Clinical Epilepsy Research and Cognitive Neurology; Sigmund Freud University, Austria

Seizure detection using movement sensors
Johan Arends, Epilepsie Centrum Kempenhaeghe (The Netherlands)

Seizure detection using surface electromyography
Sándor Beniczky, Danish Epilepsy Centre and Aarhus University (Denmark)

Non-EEG based seizure detection: necessity, availability, possibilities, requirements and challenges
Anouk Van de Vel, University Hospital of Antwerp (Belgium)

EpSMon – Safety in your pocket: Patient self-empowerment saves lives
Brendan Mclean, The Royal Cornwall Hospitals NHS Trust (UK)

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Seizure detection with integrated sensor garments
Kristina Malmgren, Sahlgrenska Academy and University Hospital (Sweden)

User based evaluation of applicability and usefulness of a wireless wrist accelerometer in registering tonic-clonic seizures
Pirgit Meritam, Danish Epilepsy Center (Denmark)

Integrating technology and advanced analytics to improve outcomes of people living with epilepsy
Erik Janssen, VP Global New Patient Solutions Neurology, UCB Biopharma SPRL (Belgium)

RADAR-CNS: remote monitoring of epilepsy using wearable sensors
Prof Mark Richardson, King’s College London, Institute of Psychiatry (UK)

Data compression strategy for long term home monitoring
Nikolaos Voros, Technological Educational Institute of Western Greece (Greece)

Continuous multimodal recording using EpiWatch
Gregory Krauss, Professor of Neurology, Johns Hopkins University, Baltimore MD, (USA)

 

Automated video-based detection of convulsive seizures in a residential care setting
Evelien Geertsema, Stichting Epilepsie Instellingen Nederland (Netherlands)

Ear-EEG for mobile long-term EEG monitoring of interictal and ictal events
Ivan Zibrandtsen, Neurological Department, Zealand University Hospital (Denmark)

Automated R-peak detection algorithm for patients with epilepsy using a portable electrocardiogram recorder: first step towards portable seizure detector
Jesper Jeppesen, Dep. of Neurophysiology, Aarhus University Hospital, Denmark

Tonic seizure detection based on multimodal detection methods using the EpiSense sensor
Joyce van Sluis, Kempenhaeghe Epilepsy Centre (The Netherlands)

QNeuro – cloud-based medical assistance and decision support system for effective treatment and assistance of epilepsy patients
Piotr Zwolinski and Mariusz Chmielewski, EnQuant (Poland)

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Obstacles in the implementation of wearable seizure detection techniques in a residential care facility
Nicole Rommens, Stichting Epilepsie Instellingen Nederland (SEIN) (The Netherlands)

Feasibility of home video telemetry polysomnography for assessing sleep related neurological disorders
Peter Muthinji, Specialised Clinical Physiologist, King’s College Hospital (UK)

An automatic multimodal seizure detection algorithm for evaluation of ambulatory EEG recordings
Franz Fürbass, AIT Austrian Institute of Technology GmbH (Austria)

Seizure detection using multimodal signals
Frans Leijten, University Medical Centre Utrecht (The Netherlands)

Seizure prediction
Andreas Schulze-Bonhage, Epilepsy Centre, Medical Center, University of Freiburg (Germany)

Wearable devices in SUDEP prevention
Philippe Ryvlin, Department of Clinical Neurosciences, CHUV, Lausanne, Switzerland and Epilepsy Institute IDEE, Lyon, France

Implementation of wearable devices in praxis: the point of view of the healthcare providers
Hasse Petersen, Head of Secretariat, Welfare Innovation Zealand (Denmark)

Wearable sensors and low-power integrated circuits in health care applications
Prof Esther Rodriguez-Villegas, Department of Electrical and Electronic Engineering, Imperial College London (UK)

Transformational Power of an Integrated HVT Service Model. An Impact Analysis.
Franz Brunnhuber, Lead consultant for Clinical Neurophysiology, King’s College Hospital (UK)

Clinical evaluation of the Brain Sentinel® GTC Seizure Detection and Warning System
Josè Cavazos, co-Founder, Brain Sentinel (USA)

Ultra-long-term recordings of brain and heart
Troels W Kjær, Zealand University Hospital, Roskilde (Denmark)

Register

Delegate tickets cost from 3700 DKK (about €498).

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“We live in a time when we have to spend a lot of our time undoing misinformation”

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“What Used to Be Fraud Is Now Alternative Medicine…    …Sometimes a very, very common story that I hear is, “Yeah, I saw two or three physicians. I think I have Lyme disease, and my physicians say I don’t have Lyme disease because my tests are negative and I don’t meet the criteria,” whatever. “But I looked up the symptoms on Google and I have all the symptoms. So then I went to a naturopath and he did a lot of tests on me, and he says I do have Lyme disease, and he gave me this homeopathic remedy for it. This is unfortunately a common occurrence. Obviously, we have to form a therapeutic relationship with our patients and you can’t be judgmental towards them, so it’s a very challenging framework in which to confront these issues. But I think a few things. One, if a patient is in my office, they’re there to get my professional advice and they are already acknowledging by their very presence that they have some respect for science-based medicine, for evidence-based medicine. I do think that they expect that I’m going to give them my honest opinion, and so I give it. I say, “Listen, I looked at the research on this, and in fact, I do not think that this is a valid treatment. I don’t think that this is going to be effective,” or “I don’t think that you have Lyme disease for these reasons.” They generally appreciate the fact that I took the time to actually look at the literature even though it may be more of a fringe treatment and not something that physicians are giving, and they appreciate that I take the time to explain to them why I feel the way that I do. I don’t pull my punches, but I say just very non-judgmentally, “These are the facts. This is my interpretation of the evidence,” or “Here’s the standard recommendation of the relevant professional society. This is why we think…” You also have to gauge what’s the patient really thinking? You can’t just lecture them. You have to sort of interact with them. Sometimes they have misconceptions that are pretty easy to fix. So, it takes … you have to invest the time to understand the narrative, understand what the patient is thinking, understand what they want, address the information that they’re being given. So, yeah, we live in a time where we have to spend a lot of our time, I think, undoing a lot of misinformation that’s being fed to our patients, but it’s absolutely worth it and the effect could be definitely worth the time that you’re investing. Because if you think about it, you could have the best plan for your patient that’s all science-based and has class I, double-blind, placebo-controlled clinical trials, but if they don’t believe it because they were told something else by their naturopath or whatever, it doesn’t matter. You have to get them to buy into how to approach the therapeutic strategy that you’re going to be taking. Patients do share with us. We all want to use what works, right? We want to know what works and what is safe. We all have that same goal and you should have a pretty sophisticated understanding, I think, as a practitioner of how we know what works and how we decide what is above the waterline in terms of using it. You should get the patient to understand that at least … they’re going to buy into your treatment recommendations…”

Some invaluable points made in this interview with Steven Novella MD, Neurologist and host of the “The Skeptics’ Guide to the Universe podcast.

While it’s very disappointing that in the USA the healthcare system is so broken that the only viable corporation providing a direct Doctor video consult service is just filling prescriptions for cannabis I think this interview with Dr Novella brilliantly explains why we need to move beyond offering the “visit a stranger in their office” model of care and urgent need to train medics to use the internet with their Patients because in 2017 while every Patient/Carer is Googling their symptoms/diagnosis we still have young Doctors coming out of some of the best UK medical schools not realising that Patients judge them by how they use the tools of our time and 50% of US Medical Students believe that using a mobile in front of colleagues/patients would make them appear less competent.

Related post: Malcolm Gladwell: In the cause of efficiency we’ve disrupted the very thing the Patient really wants

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mHealth impact in Oncology is now “exploding”

“so we’re excited this year that ASCO has continued to emphasize the importance of mHealth or Mobile Health to its membership, this is an exciting area that’s now exploding”

Adam Dicker, MD, PhD, of the Sidney Kimmel Cancer Centre, Philadelphia, talking at the American Society of Oncology (ASCO) 2017 Annual Meeting that was held in Chicago on the 1-5 June 2017.

While I can’t find a recording of the actual conference session (get in touch if you’d like to help us produce/record and distribute a ‘mHealth for Oncologists’ course) I think this is very positive because the major Cancer Charities are proving a big let down in this area (eg. they’re proving they’re experts in the abuse of personal data rather than in ways that advance science and help Patients/Carers) and it’ll get us a step closer to getting widespread support for mobile first designed clinical trials which will be a lot more productive than “wearing a pink ribbon or dropping a dollar in a bucket“…

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Should London look to tech to temporarily make dangerously clad tower blocks safer?

Last week I was in London attending London Tech Week (check out the comprehensive mHealth guide here) and was going to post a few notes on my experience but couldn’t bring myself to publish them as the event for me was overshadowed by how a complete lack of tech adoption in London has led to a 24 story Grenfell tower block being clad in flammable and toxic fume producing cladding/insulation and residents being given instructions to stay in their apartments within a building that had no sprinkler system (the authors presumably had no idea about the dangerous cladding materials?).

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In reaction similarly clad social housing towers across the UK are being evacuated and  4000 residents in London have already been made to sleep in temporary shelters within council properties like leisure centres until the cladding on their blocks is removed.

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How did anyone think it would be a good idea to have the Council authorities (who paid for and expensively installed these dangerous materials) to be in charge of handling how to react to it now being clad all over their buildings?

Has no one done a risk assessment and realised that the families here are probably at more risk of coming to harm from being relocated to live with one another within buildings that weren’t designed for high density habitation and don’t have the facilities.

I see no point talking about being the Capital for Technology when you don’t try and use tech to temporarily fix these issues, for example:

> Instead of issuing advice to remain in burning buildings update the advice given to residents and have them register their mobile numbers to enable personalised updates to be made as well as contact in emergencies.

> Work with the Fire Services to let citizens Facetime/3G Video Call the emergency services (it well help collect information and enable emergency services to more speedily make more appropriate responses to calls).

> Position fire fighting equipment on the landings so that residents can manage small incidents themselves and provide a training session for residents on it’s use.

> Fit mobile embedded smoke alarms in all council buildings and program them so that Fire Services respond to them knowing their precise location and building details.

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> Fit Kidde Remote Lync devices in the council buildings so that residents also get early notification of nearby smoke/co monitors being activated:

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> Put some military helicopters on standby until you have the cladding taken down with buckets filled with fire fighting fluids:

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I don’t like to be so negative so here’s a bit of balance: the tragic fire led to an outpouring of generosity and community spirit amongst Londoners. Of the many things I saw one was this guy anonymously (I covered up his face as he might not want to be recognised) gifting lunch to the heroes in his local firestation:

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Share: The surefire way to ensure a Sickcare Society won’t invite you back

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How the American Diabetes Society Unleashed The Streisand Effect by Marie Ennis-O’Connor explains how outdated social media practices are at last back firing on the large sickcare conference organisers/societies that use them to try and maintain their commercial interests.

A couple of years ago I made the mistake of recording and sharing (freely on YouTube) the talk and slides that I was paid/invited to give at the biannual World Diabetes Congress in Vancouver (the world’s biggest diabetes industry conference). It remains the only talk from the entire event that you  can find online (and there were over 300+ hours of presentations given by experts who travelled from every corner of the world).

By taking this step we’ve built a little more trust with Patients, Carers and Clinicians but guess who won’t be invited to ever again present at an International Diabetes Federation Congress?

Related Post: What are you doing today in your business that makes people around you think you’ve completely lost your mind?

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Mobile industry is hopeful that mHealth may be the most exciting use case for 5G

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A very interesting GSMA Mobile World Live article by Chris Donkin in light of the talk I’m giving next Thursday on “Better Networks for Better Healthcare” at the 5G World conference (part of London Tech Week – check out the comprehensive mHealth guide here if you’re going).

mHealth Insights

“Connected health is one of the most exciting use cases for 5G with an impressive list of potential benefits for operators, vendors and society. However, with the regulatory complications of dealing with the healthcare industry and the grave implications should something go wrong, can it ever truly meet its potential?”

It’s interesting how this view is just being accepted by analysts. Something is going wrong:

The vast majority of Patients can’t even view their health records, yet I work with a Consultant Paediatrician (Prof Sam Lingam) who gave all his NHS Patients access to their records 30 years ago!.

Going to the Doctor for young people by and large means a 5 min chat with a stranger.

Chronic disease management is by and large a process of intensivising treatment yet no one’s asking what the Patients actually need.

“5G is a great prospect for healthcare, opening the potential for wearables to take glucose readings and remotely monitor patients, virtual appointments, and even remote surgery, but experts – and, vitally, the public – still need convincing”

Where’s the evidence that wearable devices even have the battery power to be communicating vast data volumes with mobile networks? I think it should be obvious now that we need to be thinking extreme low power (as per the wearables guru Philippe Kahn).

“At an event on 31 May at King’s College London set up by Ericsson to discuss the issue, a surgeon performed a short demonstration of an operation performed using a mocked-up 5G network, a connected glove and a robotic arm. Impressive stuff. Indeed, Prokar Dasgupta, professor of Robotic Surgery and Urological Innovation at King’s, said 5G will address reliability, security and connectivity concerns to make such remote surgery a reality, though he conceded there remains much work to be done in terms of developing the robotics themselves. However, it is a use case laden with risk. While a stalling 4G network may result in buffering of the TV programme you are trying to stream, a 5G network going down halfway through a robot performing open heart surgery is a very different story”

I think Ericsson have fallen into a trap of thinking the opportunity is in the network – just like everything  seems like it’s a nail when all you’ve got is a hammer.

I think it should be obvious that robots will be doing surgery long BEFORE 5G networks will enable surgeons to connect remotely to control a robot to do the surgery.

Speaking to Mobile World Live at the King’s event, Hanna Maurer Sibley, head of Network Products, west and central Europe at Ericsson, said the use of 5G for deep healthcare applications will require a great deal of cross-industry collaboration and was unlikely until at least 2030″

The way things are going (eg. with Google Fi, Apples software SIM offering embedded connectivity, etc) citizens won’t even have a relationship with mobile network operators in 2030.

“If the liability issues and technical bugs are ironed out, maybe by 2033 we’ll all be under the virtual knife”

The mobile industry needs to stop propelling dangerous myths like this and start helping the medical device industry realise everything is converging to the smartphone. The solution to liability and technical bugs lies in embedded connectivity. 

Related:

Join us at the 5G World Futurist Summit, 13-15 June at ExCel London

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