5G 2021 PDF

REVIEW ARTICLE
5G Use in Healthcare: The Future is Present

Konstantinos E. Georgiou, MD, MSc, PhD, Evangelos Georgiou, MD, PhD,
Richard M. Satava, MD, MS
ABSTRACT applications, education and research in medicine and

surgery, in addition to the administrative infrastructure
Background: Most healthcare providers are unaware
are addressed. Additionally, we explore the nontech-
of the extraordinary opportunities for implementation
nical challenges, that either support or oppose this
in healthcare which can be enabled by 5G wireless
new healthcare renovation. Based upon proven
networks. 5G created enormous opportunities for a
advantages of these innovative technologies, current
myriad of new technologies, resulting in an integrated
scientific evidence is analyzed for future trends for the
through 5G ‘ecosystem’. Although the new opportuni-
transformation of healthcare. By providing awareness
ties in healthcare are immense, medicine is slow to
of these opportunities and their advantages for
change, as manifest by the paucity of new, innovative
patients, it will be possible to decrease the prolonged
applications based upon this ecosystem. Thus,
timeframe for acceptance and implementation for
emerges the need to “avoid technology surprise” -
patients.
both laparoscopic and robotic assisted minimally inva-
sive surgery were delayed for years because the surgi- Key Words: 5G, Telecommunications, Healthcare, Artificial
cal community was either unaware or unaccepting of a intelligence, Internet of Things.
new technology.
Database: PubMed (Medline) and Scopus (Elsevier)
databases were searched and all published studies
regarding clinical applications of 5G were retrieved.
INTRODUCTION
From a total of 40 articles, 13 were finally included in
our review. Today, the explosion of several information and com-
munications technologies radically changes and creates
Discussion: The important transformational properties
an extraordinary ecosystem for new opportunities in an
of 5G communications and other innovative technolo-
unprecedented rate. Every sector and industry, includ-
gies are described and compared to healthcare needs,
ing healthcare, has been impacted by digital transforma-
looking for opportunities, limitations, and challenges
tion. Digital innovations including the further expansion
to implementation of 5G and the ecosystem it has
of telehealth, the development of fifth generation wire-
spawned. Furthermore, the needs in the clinical
less networks (5G), artificial intelligence (AI)
approaches such as machine learning and deep learn-
Department of Propaedeutic Surgery, Hippokration General Hospital of Athens, ing, Big Data (BD) and supercomputing, and the
Athens Medical School, National and Kapodistrian University of Athens, Athens, Internet of Things (IoT), as well as digital security capa-
Greece (Dr K. E. Georgiou).
bilities such as blockchain, have created an extraordi-
Medical Physics Laboratory Simulation Center (MPLSC), Athens Medical nary opportunity to create an integrated ecosystem
School, National and Kapodistrian University of Athens, Athens, Greece (Dr E.
Georgiou). for new opportunities in healthcare and other indus-
Professor Emeritus of Surgery, University of Washington, Seattle, WA (Dr Satava).
tries.1 These developments could potentially address
Disclosure: none.
some of the most urgent challenges facing health service
providers and policy makers, including universal, equi-
Funding sources: none.
table, sustainable healthcare service.
Conflict of interests: none.
Address correspondence to: Dr. Konstantinos E. Georgiou, Department of Together, these integrated technologies can fundamentally
Propaedeutic Surgery, Hippokration General Hospital of Athens, Athens Medical change screening, diagnosis and monitoring of diseases,
School, National and Kapodistrian University of Athens, Athens, Greece,
Telephone: 130 6942066216, Fax: 1302107462369, E-mail: kongeorgiou@med.
enable more accurate profiling of disease progression
uoa.gr. and further refine and/or personalize treatments. Nascent
DOI: 10.4293/JSLS.2021.00064 technologies for therapy, such as next generation com-
© 2021 by SLS, Society of Laparoscopic & Robotic Surgeons. Published by the munications, AI, IoT, telesurgery, to name a few, will be
Society of Laparoscopic & Robotic Surgeons. addressed.
October–December 2021 Volume 25 Issue 4 e2021.00064 1 JSLS www.SLS.org

5G Use in Healthcare: The Future is Present, Georgiou KE et al.
The fifth generation wireless networks (5G) have an forecasting capabilities.5 Due to all of the above, 5G has
extremely low latency (less than one millisecond (ms) of been already adopted by a few centers across the
delay compared to about 70 milliseconds on the 4G net- world.1,6–8
work), together with higher data transmission speed
Although, telemedicine has been widely applied under
(about 100-fold from the current 10 megabit per second
different circumstances and applications, it faced several
on 4G) by using higher frequency millimeter waves com-
difficulties stemming from the limited latency and speed,
pared to existing networks.2,3 All this increase in func-
especially in telesurgery applications which are reviewed
tion occurs while it simultaneously reduces energy
below.
consumption by all the connected devices4 by having
low power requirements. However, because 5G trans- Therefore, this report is limited to reviewing the literature
mits at higher frequencies, signal degradation becomes a of healthcare application of the 5G which already exists
greater challenge, and “base stations” need to be densely and, after presenting the communication basic principles,
populated (approximately every 250 m).5 Yet, such to discuss future applications in the context of the other
deployment provides unique opportunity to bring all critical supporting infrastructures and biologic principles.
those technologies locally to the point of care – and in
real time.
METHODS
However, a word of caution is needed. There are critical
biological and physiologic factors of basic science that
Search Strategy and Article Selection
must be taken into consideration in developing and
applying the new opportunities which the 5G ecosystem All published studies regarding clinical applications of 5G
provides, especially for telemedicine – not all the capa- were retrieved. The present study was conducted in accord-
bilities of 5G can be leveraged at this moment, especially ance with the protocol agreed on by all authors was the
the huge number of healthcare related instruments and Preferred Reporting Items for Systematic Reviews and Meta-
devices which are available on the IoT. Likewise, there Analyses.9,10 PubMed (Medline), and Scopus (Elsevier) data-
are unique requirements within the domain of human bases (last search: December 3, 2020) were searched using
interface technology (HIT) that must be investigated in the following medical subject heading (MeSH) terms and
order to optimize human use of the new communication text words based on the following search strategy:
capabilities; in addition, there are limitations and chal-
lenges in exploiting the communications spectrum. • Group A terms: “5G” OR “high bandwidth telecommu-
Finally, there are other technologies in addition to the nications”
Internet, such as AI, BD repositories, computational ana- • Group B terms: “telemedicine” OR “telepresence”
lytics (CA), supercomputers (including soon to be com- • Group C terms: “telesurgery” OR “teleradiology” OR
mercialized quantum computers) and factors involved in “telepathology” OR “teleophthalmology” OR “teleder-
accessing and storage in ‘the cloud’ which dramatically
matology”
impact the opportunities to exploit the new communica-
tions systems.
Group’s A, B, C and D terms were combined. Therefore,
An existing and special use case is telemedicine, which is our search algorithm was as follows: (((((((5G)) OR (())))
now well established and can be advantageous as it can AND ((((((((((((5G)) AND (telemedicine))) OR ((telemedi-
provide more efficient and equitable distribution of cine))) OR ((telepresence))) OR ((telesurgery))) OR ((tele-
healthcare when limited resources are available and radiology))) OR ((telepathology))) OR ((teleophtha-
patients’ transportation challenges might exist, all of lmology))) OR ((teledermatology)))))).
which reduces unnecessary visits and exposure risks.
Evidence of the effectiveness of this ecosystem will be
presented in the review of the COVID-19 pandemic Inclusion- Exclusion Criteria
(below). Of the articles retrieved through the above-described
search strategy only those that met the following criteria
Finally, the sheer capacity of 5G combined with AI, and
were included to this systematic review:
the capability to transfer data in order to accumulate and
analyze BD, can be valuable in understanding the devel- 1. Original papers were only included. Review papers
opment of disease progression and improving that met the inclusion criteria were not included;

However, their reference lists were used to retrieve A full text review of the selected relevant articles was made
any relevant study of any publishing date. in order to detect the studies included in this systematic
2. All articles should report at least one clinical example review. Moreover, relevant full text review and/or system-
of 5G. atic review manuscripts were used to retrieve articles of any
3. Articles conducted in the last 5 years. publishing date from their reference list and include them to
4. Articles written in English language. this systematic review.
Additional limits were applied to restrict manuscripts to The PRISMA flow diagram of the search strategy is pre-
those related to human subjects. sented in the Figure. Note: Many other articles that sup-
ported the discussion and remainder portion of the
manuscript were included.
Article Selection
Articles were retrieved when their abstract were judged to
possibly meet the inclusion criteria by two independent
RESULTS
reviewers (EG, RS). If either author suggested retention,
the study was included. The process was repeated for
Data Extraction
abstract review and, again, if either reviewer suggested
retention, the study was included. All the retrieved article A total of 40 articles were retrieved and screened (title/
titles and abstracts were screened for relevant manuscripts. abstract) and two more were retrieved from other sources
Records idenfied through Addional records idenfied

Identification
databases searching through other sources

(n = 40) (n = 2)
Records aer duplicates removed

(n = 42)
Screening
Records screened Records excluded

(n =42) (n = 24)
Full-text arcles assessed Full-text arcles excluded,

Eligibility
for eligibility with reasons

(n = 18) (n = 5)
Included
Studies included in
qualitave synthesis
(n = 13)
Figure 1. Preferred reporting items for systematic reviews and meta-analyses flow diagram.

and their abstracts were assessed for eligibility. Twenty- beams at a time, thus increasing the throughput and spec-
four of those were unanimously considered as nonrele- trum effectiveness in both uplink and downlink.13
vant and were excluded from further analysis. From a
Additionally, 5G requires up to 10 times less energy than
total of 18 full text articles which were evaluated, five
the previous 4G/LTE mobile communications standard.12
were excluded with other reasons and therefore 13
It is expected that the 5G network will have a 1,000-fold
articles are included in this systematic review. The limited
rise in traffic in the coming decade, although the energy
number of relevant publications emphasizes the lack of
usage of the whole infrastructure will be just half of
knowledge of and attention to these revolutionary tech-
today’s system’s consumption. Therefore, this is a crucial
nologies, and the opportunities for future implementation
factor for reducing the total cost of ownership, including
in healthcare.
the environmental impact of the networks.13
The following data were extracted from each study:
The above mentioned qualifications meet the require-
Author, publication year, Country, Type of study, Primary
ments imposed by many new digital applications like the
specialty, Participants, Results/Conclusion, and Remarks
interconnection between physical and virtual objects, the
(Table 1). As can be seen in Table 1, the geographical
IoT, autonomous driving,14 machine-to machine connec-
location of the studies was mainly from China (8/13). Ten
tion in industrial production,15 as well as different medical
of the studies were clinical applications or at least had a
applications that were previously technically impossible
clinical component using 5G technology.
to implement.16 The latter systems conform to the
Ultrareliable low-latency communication protocol where
a sub-millisecond latency with a response rate smaller
DISCUSSION than 1 packet loss in 105 packets is required for patient
safety.17
1. Communication Basic Principles To achieve their goals, the industry reached a consensus
to use emerging major technologies like network function
5G technical Parameters virtualization (NFV) and software-defined networking
Currently, mobile data transmission is mainly based on (SDN). The most remarkable technology to simplify a
4G/LTE or on Wi-Fi. The 4G/Long-Term Evolution (LTE) healthcare network management is SDN, which takes
offers a minimum signal delay of 20 ms mainly designed apart the network control from the data forwarding plane.
for internet (e.g., browsing and video streaming) which is Thus, the control plane oversees the entire network
well below that required for real-time integration of sen- below as well as the network resources by using a pro-
sor data. Furthermore, Wi-Fi solutions are an alternative, grammable Application Programming Interface (API) .17
but they can be interrupted by other users at any time due
to unprotected radio bands.11 As 5G is expected to greatly influence our lives, its secu-
rity is even more important than before. Two types of 5G
The new 5G telecommunication standard offers high network security are implemented:
bandwidths as compared to the current mobile transmis-
sion standard 4G/LTE: 5G is a 100 times higher data trans- a. Security using software such as firewall applications
mission rate (up to 10GB/s), and, at the same time, an installed in the perimeter of any network, based on
extremely low latency time (<1ms), and 1000 times need.
higher capacity (bandwidth) with a high quality of service b. AI-based security as it can sensibly identify the termi-
which is almost equal to the zero data response time in nal actions and requirements on time to avoid service
the real world.12 Millimeter wave telecommunication is interruptions.
such an advantageous technology for 5G networks
In order to further enhance the security one can also use
because it allows extremely high data transfer speeds
security automation and Blockchain security assessment
(several gigabits per second). However, a large number of
techniques.17
small cells with limited radius deployment must be used
to achieve seamless and efficient coverage and form a 5G The 5G network requires more complex antenna design
ultradense cellular network. The cells may be of different and distribution in the space needed to be covered in
size, and they are classified as Femtocells, Picocells or order to achieve faster speeds and low latency. Therefore,
Microcells. The massive multi-input, multioutput is an specific antennas are proposed for the 5G network, also
evolving technology capable to transmit multiple data known as active antennas (in contrast to passive antennas

Table 1.
Summary of Studies of 5G Medical Applications and Their Variables of Interest
Primary Specialty
Clinical/Research/
Study Year Country Type of Study* Both No. of Participants Results/Conclusion Remarks
Diagnostic applications
Naruse et al.38 2020 Japan Cardiotocogra- Ob/GynClinical - Successful transmission

ph Lab testing via 5G
Angelucci et al.22 2020 Italy Observational Pneumonology 18 volunteers Better than traditional Home monitor chronic
Both telemedicine systems obstructive pulmonary
disease via smartphone
5G application
Ye et al.33 2019 China Tele-ultrasound Radiology/ 23 patients 5G robot-assisted Larger studies and resolv-
in COVID-19 Internal medicine remote ultrasound ing technical obstacles
Clinical effectively allows car- are required before
diopulmonary assess- widespread
ment of COVID-19
patients
Zhou et al.55 2020 China Observational Cabin hospital for Engineering Prospect of 5G soft- 1 – 2 days to setup.
COVID-19. Research only ware wireless network Software designed
Engineer common better than wired network
healthcare profile conventionally
Surgical applications
Zheng et al.48 2020 China Preclinical Robotic 4 swine nephrec- Ultraremote distance Remaining obstacles for
Research lab la- Laparoscopy sur- tomy part hepatic 300 km, latency 164 ms clinical use are discussed
tency time by gery Clinical cholecystectomy round trip 114 ms
distance packet loss 1.2%
Tian et al.52 2020 China Clinical Orthopedics 12 patients. 62 5G telerobotic spinal Newer systems for bone
Clinical only pedicle screw surgery is safe, effica- grinding nerve decom-
implanted cious, and feasible pression required.
Jell et al.40 2019 Germany Telesurgery & General Surgery & N = 5 pigs 5G data 95 – 106 MB/ 2 patients – 1– 6 km dis-
Surgery engineers Both Surgeons and sec, 75% data in 30 ms. tance Need more
Education clinical and basic engineers Latency 146 – 202 ms research, especially
research allows telesurgery clinical
Lacy et al.41 2019 Spain Clinical Surgery Clinical 2 patients under- 5G-assisted telemen- It would be an optimal
only went lap operation tored surgery is safe, resource for underdevel-
and feasible oped areas and/or scar-
city of experienced
surgeons
Imaging applications
Wu et al.31 2020 China Tele-ultrasound Radiology & 4 patients Teleultrasound proto- For early imaging assess-
COVID-19 Internal medicine col allows early diag- ment of COVID-19
Clinical nosis and reassessment
available in the isola-
tion ward
Madder et al.35 2020 USA Preclinical Transcontinental Telestenting. 2 Transcontinental Easy to perform percuta-
Interventional percutaneous cor- robotic percutaneous neous coronary interven-
Cardiology Both onary intervention coronary intervention tion lesion with 5G
ex vivo models (36 is feasible in ex-vivo
lesions) models @ 3500 mi
latency = 162 ms

Table 1. Continued
Primary Specialty
Clinical/Research/
Study Year Country Type of Study* Both No. of Participants Results/Conclusion Remarks
Ye et al.60 2020 China Research Engineers COVID-19. Health China’s shows health Health information tech-
Engineer stats Community information tech- info tech has pivotal nology has much more
research nology community role in COVID-19 work facing the global
and decision pandemic pandemic of COVID-19
makers
Hong et al.54 2020 China COVID-19 Various healthcare 152 remote com- The COVID-19 teleme- Additionally, 1094
Observational. professionals puted tomography dicine system increases patients received tele-
5G multimodal Engineers scans. Focus on diagnostic accuracy of phone consultations or
telemedicine Community resource manage- difficult cases and interventions from 137
network func- research ment for improves treatment of clinicians
tionality telemedicine severe/critical case
research
Yu et al.32 2020 China Tele-ultrasound Radiology/ 2 patients ultra- Tele-ultrasound for 5G robotic ultrasound is
COVID-19 Internal medicine sound clinical trial early diagnosis 700 km easy to perform at bed-
Clinical only teleradiology diagnosis side remotely
used in 4G) which differentiate 5G network in terms of in the area of network security/privacy and maintaining
speed, latency, and security. Healthcare Insurance Portability and Accountability Act
(HIPAA)5 compliance.
Recently, big international telecommunication companies
With the current full life cycle development of a technol-
have taken the lead in the competition for the upcoming 5G
cellular technology, as it is thought to be their most impor- ogy product from concept to commercialization at 10–
tant future source of revenue. It is expected that the 5G net- 15 years, it is likely that the 6G may be available within
that time period, or perhaps slightly sooner. With integra-
work will be broadly introduced as a simple framework for
hyperconnected mobile devices and will ultimately evolve tion of other advanced technologies, such as smart
into a modern 5G platform. It should be noted, however, devices, composed of micro-electro-mechanical-systems
(MEMS) sensors, AI and computational analytics on a single
that there is currently no uniform 5G standard. For a detailed
technical review of the architecture and security of 5G chip, automatic diagnosis can be immediately generated at
Technology, the reader can refer to reference.17 the point of care (edge computing) and transmitted to a
waiting consulting physician or directly to the electronic
Looking beyond 5G, the future generation of telecommuni- medical record. Another emerging area of 6G, will support
cations (6G), is already in the late research and develop- virtual reality (VR), where a simulated presence is generated
ment (R&D) phases (Technology Readiness Levels - TRL by computer graphics and allows users to interact with the
3–5), with an exponential increase in bandwidth and capa- simulated elements in a seemingly real way. Augmented
bilities that will allow implementation of applications that reality (AR), where computer-aided information is generated
even 5G cannot fulfil (Table 2). This is especially important and graphically augmented (overlayed) to the display real-
Table 2.
Parameters of Current and Next Generations of Telecommunications*
Generation Bandwidth Speed Latency
Current 4G 5–200 MHz 10–50 megabits per second 50–60 ms
2020–2030 5G 1 –23 GHz 10–200 gigabits per second 1–10 ms
2030–2040 6G 1–7 THz 1–7 terabits per second 1–10 ms
*Due to multiple companies and each company’s versions, these are estimates of the averages of generations.

time, can also have broad implications for healthcare. is rapidly becoming a new standard of care adopted by
Counselling patients and preoperative consent can likely be multiple centers across the world, as it enables triaging
enhanced with augmented reality, and nonclinical functions prior to patients’ arrival into hospital to avoid unneces-
in hospitals such as navigation, in particular for visually sary visits and exposure risks.1, 6–8
impaired patients.5 Both humans and machines will use 6G 3. Finally, the collection, storage and transmission of
which will allow for truly immersive extended reality (XR) data offer the potential of combining telemedicine
and high-fidelity mobile hologram which could have enor- with AI and many other innovative technologies.
mous implications for healthcare; but although the 6G net- When used prospectively with longitudinal data, vast
working will provide ample potential for VR/AR or even XR, swathes of new knowledge such as disease progres-
the immersive experience of these alternative realities has sion and real world, real-time incidence calculation
yet to find a practical application within the clinical health- could be harnessed. Moreover, this could grow into a
care field. consistent source of longitudinal data which would
be valuable in the development of disease progres-
Telemedicine sion forecasting capabilities by training and incorpo-
The most use of 5G networks in healthcare is currently rating AI.
Telemedicine, and when the world emerges from global
COVID-19 pandemic, healthcare will become a hybrid 2. Other Critical Supporting Infrastructures
medical practice of live’ face-to-face’ clinical care and tele-
medicine-based care. Even as the Internet has been exponentially growing,
and the communication systems (cabled and wireless)
The World Health Organization (WHO) has announced have likewise logarithmically increased, there are other
COVID-19 was a “pandemic” (World Health Organi- parallel information-based technologies that have rap-
zation,2020). With the nonlinear rapid disease expansion, idly grown as well. In most cases, these technologies
COVID-19 has caused widespread healthcare, socio-polit- have developed in their own silo, usually due to inad-
ical and economic impact.18–20 Countries and healthcare equate communication systems to unite them. The
systems around the world have been forced to rapidly emerging 5G wireless networks are finally providing the
adapt to telehealth and digital innovations to mitigate the bandwidth, speed, and low-latency to act as a force to
impact of the risk of virus transmission to what is widely begin integrating these parallel technologies into an ‘in-
regarded as the “new normal”. The clinical adoption of formation ecosystem’. What enables this huge increase is
telemedicine has been much slower (usually only the change of the networking from connections by phys-
used for special-use opportunities), however with this ical ‘wires’ (cables), to wirelessly distributing the net-
COVID-19 pandemic, there has been a surge in all dig- work using software (software designed networks –
ital communications. SDN) and “network slicing”: an analogy of instead of
Healthcare applications, especially telemedicine, has ‘laying another wire or cable’, the software instead ‘sli-
finally rapidly expanded, mainly because it enables physi- ces’ the wireless network into different frequencies
cians to remotely evaluate their patients. This can be ad- when a new connection is needed. This allows the inte-
vantageous for several reasons: gration of ‘other’ technologies, and most importantly the
IoT which also supports robotics and sensor technology,
1. Telemedicine can assist to more efficient and reasonable BD acquisition, data repositories, AI, computational ana-
distribution of constrained healthcare assets, by deliver-
lytics, and supercomputing (Appendix 1).
ing support with innovative service design that already
exists, to distant areas where there is a shortage of physi- The new telecommunications networks are not only con-
cians and other healthcare professionals, by reducing necting human to humans but also connecting ‘smart
travel transport challenges and the associated carbon devices’ (especially the 8 billion smart phones) of the IoT
footprint. Furthermore, in acute cases patients could total of 14.2 billion devices now, with projections of 25
receive immediate specialist input even if one is not billion by 2025 and 60 billion by 2030. In addition, there is
available locally and access to care for both chronic and massive data acquisition continuously monitoring by
acute disease patients could be reduced while maximiz- microsensors from machines (devices, equipment, sys-
ing the quality of the telemedicine consultation. tems) or living systems including humans, most of which
2. During the COVID-19 pandemic, telemedicine is no is machine to machine communication for maintenance
more focused on only targeting remote regions, but it and/or autonomous control – and all linked together

using Global Positioning System (GPS) for precise for safely performance of remote surgery (telesurgery).
geolocation. Conversely, there are human ‘systems’ which are ex-
traordinarily complex such as the human neurosensory
Careful attention must be paid to the interface between
system (with 23 different types of nerve endings for
the HIT that provides the final connection of the commu-
sensing, at a density of 1000 nerve endings per cubic
nication system with a person, be it the current video
millimeter, in an average hand surface area of 4000 mm,
technologies, or any of the forms of VR, or possible future
each sending stimuluses at 1000 times/second), such
interfaces such as wearable contact lens displays, or the
that even recent exponential advances in microtechnolo-
ultimate brain-machine interface. After all, this informa-
gies and computation power are woefully insufficient to
tion ecosystem is a ‘system-of-systems’, with each link in
currently create high-fidelity haptics to provide the sense
the chain dependent upon the success of all others, that
of touch for a safe robotic system for surgery. Examples
decisively results in success.
of many other mismatches between human (especially
the 5 major senses and the neuromuscular responses)
3. Fundamental Biologic Principles and ‘machine’ are in Appendix 2, thus emphasizing the
When integrating any two systems, there are points of need for greater attention (and research) in human inter-
‘connection’ (interface). With systems that are alike (for face technologies.
example machine or electronic connections), their interfa-
ces are similar (physical systems) and the solution is rela-
4. Clinical Applications Using 5-G Wireless
tively straight forward since both systems obey physical
Networking
laws. However, when integrating two dissimilar sys-
tems (machine and human), the connection (interface) The current capacity of 5G telecommunications provide
becomes much more intricate, since both the laws of the perfect ecosystem to reassess care delivery and to
physics and biology (which are radically different) adopt the synergistic and complementary digital technolo-
must be accommodated. This integration is defined as gies discussed above, incorporating AI utilization, and
HIT: a means or place of interaction between two sys- facilitated by 5G networks, IoT and BD and computa-
tems; especially, the interface between people (users) tional analysis. Below are some clinical applications of
and computers or devices.21 using 5G:
The new advanced technologies, such as telecommuni- The following examples illustrate the large breadth of
cations, computers, imaging, etc., work at microsecond healthcare clinical services that can now be provided
speeds; humans perceive and react milliseconds, so an because of the emerging 5G networks.
interface must be built such that the human systems can
be accommodated and enhanced (see Table 3) for the
Pulmonology
effect of how telecommunication latency can affect
Up to now, there is conflicting evidence that telemedicine
human performance). For example, the recent develop-
solutions help address chronic respiratory diseases.22
ments of 5G telecommunications that results in huge
increase in bandwidth and speed with extraordinary low However, a recent paper (see Table 1), profiting from the
latency (; 1 ms) has the potential to extend the distance capacity to parallel several IoT applications due to the
Table 3.
Human Performance (Laparoscopic Knot Tying) Compensation Under Conditions of Latency
Latency (ms) Errors Perception of Delay Compensation
0 ms 0 None None
50 ms 0 None perceived Automatically subconsciously
100 ms 0–1 Aware of a ‘difference’, Unclear of cause Automatically and deliberately
150 ms 0–1 Aware of delay Consciously takes action – e.g., move-and-wait
200 ms >2 Very aware of delay Attempts various methods, mostly successful
> 300 ms critical Very concerned of delay Frustrated, often unsuccessful

coexistence of multiple streams by 5G connectivity, pre- dynamic telepathology has recently been introduced,
sented a home telemonitoring system designed for where the transmission of microscopic slide images to the
chronic respiratory patients. recipient is done in real time via live telecommunication.
Furthermore, through the implementation of remote
All data were streamed to an iPad which was connected
robotic control of the microscope, the consulting patholo-
via Wi-Fi to a 5G router and thereafter to the 5G infra-
gist can also control the magnification, a feature extremely
structure. The authors could access the data by means of
useful for interoperative pathological analysis.29 The intro-
a dedicated dashboard. The whole system was tested on
duction of advanced, micro-miniaturized imagers, such as
18 healthy volunteers during nonsupervised recordings
optical coherence tomography (OCT) and near infrared
lasting at least 48 hours. Due to the 5G bandwidth, the
spectroscopy, are being introduced through gastrointesti-
results showed that the system provided more complete
nal endoscopes, providing immediate ultrahigh-resolution
and clinically relevant and real-time information than
images of intra-cellular structural pathology for the endo-
other previously studied telemedicine systems.22
scopist,30 which can be streamed live to the consulting pa-
thologist and/or archived for future reference.
Medical Imaging and 5G
As a massive number of images accumulates and manual
Remote Ultrasonography
segmentation requires a lot of time, it becomes a big chal-
Much interest has been shown in robotic-assisted teleultra-
lenge for analyzing and diagnosing and furthermore, it
sound and expert remote consultation. During this proce-
may not meet the demand of analyzing big images data.23
dure, the operator manipulates a simulated robotic hand to
This problem is attacked by using automatic methods for
remotely control the robotic arm at the patient end. An ultra-
sectioning medical images (SMI) to obtain any viewing
sound probe is fixed on the robotic arm to scan the patient.
angle via multiplanar reconstruction (MPR) by using a
Up to 2GB of ultrasonic image data from a lung ultrasound
plethora of various technologies, for example, region-
scan lasting a few minutes is produced and transmitted at
based methods, clustering methods, threshold algorithms,
high speed with low latency. The robotic arm is movable
machine learning, and deep learning.24
and easy to use, allowing clinicians to collect lung images
However, since each MPR’s interaction requires the recon- directly and monitor patients remotely.
struction of the raw data, thus hundreds of megabytes of
From a technical point of view, the network download
SMI data must be transferred, resulting in a higher require-
rate is 930 Mbps and the upload rate of 132 Mbps, main-
ment for network transmission via Internet without a bot-
taining a stable level with latency being at 23–30 ms and
tleneck creation as well as a higher security risk of data
the network jitter at 1–2 ms, thus allowing a smooth scan-
leakage.25 This is an example of the advantages and op-
ning by the robotic arm and an undetected time delay. No
portunity for 5G communication with Software Designed
package loss was detected during all the procedures and
Networks (SDN) and ‘network slicing’ to more flexibly,
thus the images quality transmitted to the attending physi-
efficiently and cost effectively provide enhance Intranet
cian had no visual reduction compared with those
and Internet capability and security.
obtained by traditional on-site examination. Therefore, it
Of course, this is not the case for less demanding imaging is concluded that by breaking the temporal and spatial
such as echocardiography or dermatology images trans- limitations due to the high bandwidth network, robotic-
fer, where effective transmission of high-quality images assisted teleultrasound succeeds in bridging the gaps
can be accomplished either through low-cost transmission between specialists and patients from remote cities.31 This
systems or with images/video from publicly available real-time image acquisition of robotic ultrasound across
apps.26,27 The same applies to otolaryngologic exams, long distances has the following advantages:
especially regarding remote of video-otoscopy images, as
1. Examiners can be protected from cross infection by
a recent review suggests that they can deliver adequate in-
remotely monitoring patients without any personal
formation suitable for diagnosis in most cases and results
contact thus diminishing the number of those who
in high levels of user satisfaction.28
come into contact with the patients.
Diagnostic pathology is mainly depending upon image 2. Experts by using this technology can remotely perform
quality. The conventional cytological glass slide examina- real-time ultrasound scan on patients in distant loca-
tion is time consuming as only one person can view it at a tions, thus alleviating the pressure of shortages of med-
time. Beyond the use of the static images in telepathology, ical resources.

3. The robotic ultrasound can be performed anywhere, at and ease of use. Compared with ordinary ultrasound, 5G
the patient’s bedside or even in the patient’s home.32 remote robotic ultrasound has the added advantages of
protecting operators, alleviating the pressure of medical
As can be seen from Table 1, there are three relevant equipment shortages, and considerable portability. The
articles using robotic teleultrasound lung scanning for sus- authors conclude that 5G remote robotic ultrasound may
pected and/or declared COVID-19 patients, all originating become a suitable choice for diagnosis and monitoring
from China: patients with COVID-19 infection.32
The first article evaluated robot-assisted teleultrasound
and expert remote consultation for early cardiopulmonary Ophthalmology
evaluation by performing lung ultrasound, brief echocar- An excellent review summarizes the digital technologies
diography, and blood volume assessment in four patients applied across different countries which are expected to
hospitalized in isolation wards and the examination increase the clinical workflow of ophthalmologists.5 It is
results were immediately delivered to the attending physi- exactly because the data-rich image requirements needed
cians. Furthermore, the authors report the use of this in Ophthalmology that 5G, IoT and AI are introduced for
robot-assisted teleultrasound examination as a routine for OCT and fundus cameras and algorithms which are
evaluating acute abdominal diseases such as cholecystitis, changing ophthalmological service delivery. These tech-
appendicitis, pancreatitis, and urolithiasis. In addition, tel- nologies are expected to enhance the quality and continu-
eultrasound has been applied in focused assessment with ity of eye care to all patients.
sonograph for trauma (FAST) and extended FAST, muscu-
loskeletal injuries, thyroid gland diseases, and subcutane- Recently, a 5G connected smartphone attached to a porta-
ous soft tissue lesions.31 ble slit lamp provided a live streaming in real time of high
enough quality to be used clinically, thus opening up
The second article used a robotic ultrasound system, inte- even more potential for telemedicine and teleophthalmol-
grating remote robotic control, audio-visual communica- ogy in the future.34
tion and ultrasound examination, and assessed its
The implementation of these technologies remains chal-
feasibility in 23 COVID-19 cases. Furthermore, they estab-
lenging, including the validation, patient acceptance, and
lished a standard examination and evaluation protocol as
education and the training of ophthalmologists on these
follows: A cardiopulmonary assessment completed suc- technologies. It is imperative that they must collaborate
cessfully for all patients lasting on average 10 to 20 min. with technology experts and data scientists to achieve uni-
An ultrasound image contained information regarding dis- versal quality and sustainable ophthalmic services and
tribution characteristics, morphology of the lungs and sur- continue to adapt to the changing models of healthcare
rounding tissue lesions, left ventricular ejection fraction, delivery.5
right/left ventricular end diastolic area, pericardial and/or
pleural effusion, and lung ultrasound score. Although Interventional Cardiology
they had excellent results in COVID-19 detection, they Robotic telestenting, in which percutaneous coronary
admit that the 5G robotic-assisted remote ultrasound sys- intervention (PCI) is performed on a remotely located
tem is still in its infancy, has several limitations (i.e. restric- patient, availability of 5G could improve patient access to
tions of the examination position of critically ill patients, PCI, but has not been attempted over long distances likely
limited operating angle of the robotic arm, use of only required to reach many underserved regions.
one ultrasound probe) and requires further improvements
as well as multicenter trials to establish its feasibility as a In a recent study cited in Table 1, telestenting perform-
valuable tool for remote lung pathology detection.33 ance was compared in regional (206 miles) and transcon-
tinental (3,085 miles) distances from the interventional
The third article of two cases discusses the advantages of cardiologist. Ex vivo models of telestenting were used,
using US versus chest CT for detection of lung abnormal- and robotic PCI on endovascular simulators was
ities due to COVID-19, stating that limitations of CT are: a) attempted over both wired and 5G wireless networks and
difficult to perform on patients in critical condition who audio and video communications between the cardiolo-
cannot be moved. b) CT is not available everywhere, and gist and the simulation laboratory personnel were estab-
c) the enclosed environment of CT may contribute to the lished over the network. A total of 20 consecutive target
spread of the coronavirus. On the other hand, ultrasound lesions in the regional model and of 16 consecutive target
has the advantages of repeatability, absence of radiation, lesions in the transcontinental model were successfully

performed. Outcome measures included procedural suc- recent publication, where the authors simulated the feasi-
cess, procedural time, and perceived latency. Procedural bility to concomitantly transmit not only CTG but also real
success was achieved in all lesions in both models. time fetus US videos as well with excellent results. Thus,
Latency was imperceptible in all cases in both models except CTG, the images during ultrasound examinations
and the greater distance of the transcontinental model were high-quality videos on patient actors, which were
had not significantly different procedural times compared transmitted without problems.38 Thus, home monitoring
to the regional model for cases performed over wired of a fetus with the 5G system is a particularly useful appli-
or 5G-wireless networks.35 This is the first study which cation, which could create a new future for obstetric care.
demonstrates that remote robotic manipulation of
coronary devices is now possible using wireless network
Surgery
connectivity.
While the practice of a surgeon is very much like the
practice of general medical practitioner, the distinguish-
Emergency Medicine ing feature is the amount of time committed to perform-
The emergency department (ED) is a good example for the ing surgical procedures upon their patients. Surgeons do
widespread introduction of virtual triage via telemedicine, have the same clinical, educational, research and admin-
rather than coming directly to the ED in person. The patients istrative requirements as all physicians, including the
benefit as they are not obliged to attend in person and can basics of history, physical, lab/imaging studies, outpa-
be treated with remotely delivered prescriptions. If they do tient and in-hospital care, discharge and follow-up.
need to attend, an appointment time can be scheduled Likewise, in response to the COVID-19 pandemic, this
more efficiently, being seen directly by the specialists rather includes the increased use of teleconsultation, telecon-
than spending long hours in the ED waiting room. ferences, etc., which is anticipated to be continued upon
Additionally, with the maturation of chatbots, much of the resolution of the pandemic. However, like all healthcare
patients counselling can be performed flawlessly through specialties, there are additional unique requirements
video consultation. Additionally, the healthcare providers and opportunities, which is the focus of the following
benefit from the absence of physical attendance, the costs surgical areas:
associated with additional time and space utilization, as well
as the use of personal protective equipment. The healthcare 1. Pre-operative preparation
personnel who can work from home can contribute to the 2. Intraoperative procedure, and
efficient use of human resources at a time where sustainabil- 3. Postoperative follow-up (both in hospital and outpa-
ity must also be considered. Reduced in person ED visits tient care).
also decrease the general workforce risk of COVID- 19,
avoiding the highly undesirable scenario of transmission 1. Pre-operative Preparation
between clinicians and patients.36 The safety and efficiency The surgeon meets the patient in the pre-anesthesia area
of remote triaging and automated counselling need to be and needs access to all the medical information from the
evaluated, and until then, clinicians need to oversee each medical record for review – which includes both medical
consultation as is standard process prior to the pandemic. data and medical images. If it is a complex procedure,
many surgeons will not only have review of a full 3-D
Obstetrics reconstruction of imaging studies (computed tomography
So far, in an attempt to make accurate diagnoses in emer- [CT], magnetic resonance imaging [MRI], etc.), but may
gencies, smartphones are used to take videos transmitted have also actually previously rehearsed the procedure
in real time to consultants located at a central hospital using simulation, all of which requires real-time access to
who then can assess the situation.37 One such emergency massive amounts of imaging data.
is to estimate in real time the status of a fetus in utero
through a cardiotocogram (CTG). However, it is used in 2. Intraoperative Procedure
medical care clinics only, and there are few reports More and more operations are being performed by mini-
attempting to send CTG data via a mobile network from mally invasive surgery (MIS). Often, the video image is
home or from an ambulance to a medical institution. being captured, with the potential for sharing real-time
Several problems could occur and only one successful with other surgeons or archiving. When used for educa-
case has been published so far.38 With the deployment of tional purposes, high - bandwidth is needed for the trans-
5G this solution could be implemented as described in a mission of the video image, along with audio for the

surgeon to communicate with the learners in the ‘audi- Clinical Telesurgery

ence’. The archived video of the procedure can be used Telesurgery (or remote surgery) aims to break the obstacle
for many educational and administrative or legal pur- of geographical boundaries in providing high quality health-
poses, including credentialling, privileging, or remedia- care in the most complex medical interventions and sur-
tion. In addition, during surgery, the surgeon often will geries. High-qualified medical expertise will be transferred
need to take a biopsy which is sent to a pathologist to from the major hospitals to the decentralized ones with the
be examined and reported back to the surgeon waiting use of remote-surgery, remote diagnostics and telemedicine
for the results to complete the operation. New instru- resulting in significant cost reduction, and improved effi-
ments now are able to capture the image of the pathol- ciency in health care services. Telesurgery, where parts of
ogy in real time and transmit the image directly to the the procedure are controlled by a surgeon from a central
pathologist for diagnosis, saving significant operative site to a remote location, is the most demanding application
time. Telepathology can be in the same hospital, or liter- among the remote healthcare services and thus by success-
ally anywhere around the world for consultation in diffi- fully validating this application, the validation of technology
cult diagnostic cases. Another technology, data fusion, for the entire range of less demanding remote healthcare
permits overlaying the live video image with additional applications can be implied.39
images (CT, MRI, fluorescence markers, etc.) to guide
The domain of applications of remote surgery, apart from
surgeons with ‘X-ray vision’ to see structures and pa-
decentralizing health care, are remote surgical operations
thology within organs or lymph nodes (for cancer).
under extreme conditions, such as at the battlefield and
remote operations in extreme environments like in space
3. Postoperative Care (Including Outpatients) missions. Telesurgery entails the use of a master-slave
The immediate postoperative care of a surgical patient robotic surgical system. Currently, the only Robot-assisted
has previously been done within an in-hospital stay, Minimally Invasive Surgery (RAMIS) system with FDA ap-
however the newer MIS procedures have allowed many proval is the da Vinci surgical system, which has offered
patients with simple, uncomplicated surgical procedures to surgeons’ a greater visualization, enhanced dexterity,
to go home the same day. Teleconsultation to the greater precision and greater comfort; to the patients it
patient’s home, especially during the COVID-19 pan- has offered shorter hospitalization times, reduced pain
demic, has exponentially increased. Not only is there and discomfort and faster recovery time.
the opportunity to speak to the patient by using a cell
As can be seen from Table 1 there are very few clinical
phone, but it is now possible to actually see the patient
reports using 5G for telesurgery. For example Remote
and use the phone (or any one of the many new ‘in-
RAMIS (telesurgery) has already had investigational test-
home’ medical devices to examine the site of the sur-
ing in various scenarios and conditions.40,41 The first true
gery, saving patients the need to come to the hospital
telesurgery on a patient was performed in 2001 between
for follow up. This capability for a visual examination is
New York, USA and Strasbourg, France (;6200 km apart);
also in very high demand for many chronic nonsurgi-
the so-called “Lindbergh Operation”.42 The authors used a
cal diseases, especially for wound care and dressing
dedicated trans-Atlantic fiber-optic cable. The average
changes.
round-trip delay was 155 ms including delays in image
Trauma and accident injury is a special needs surgical transmission, which made delay of movements executed
application because minutes to surgical care can be criti- by the surgeon in NY, apparent but easily managed within
cal. Innovation in instruments, devices, procedures, and the 155 ms. Telesurgery has since been performed by
training, including the Advanced Trauma and Life Support other researchers. Anvari and colleagues43 have reported
(ATLS), has dramatically increased the lives saved. The the largest patient series with more than 30 remote opera-
new capabilities of communicating with an ATLS trained tions between the central site located in Hamilton,
responder, especially in a telemedicine-enabled ambu- Canada and the remote site in North Bay, Canada
lance, can bring a sophisticated trauma surgeon’s consul- (;400Km apart), over a virtual private network (VPN) on
tation directly to a first responder anywhere. Because of a nondedicated fiber-optic line. Reported average latency
the military’s need for (and research in) battlefield was 140 ms which was noticeable by the surgeon, who
trauma care, it is anticipated that a significant increase in automatically compensated for the delay. It has been sug-
remote, telemedical care (including the possibility of gested that the ideal latency time for telesurgery should
remote telesurgical care) will be enabled by the scope of be less than 100 ms and that problems such as inaccurate
5G communications. manipulation could appear if the latency time is longer

than 300 ms.44 All aforementioned research outcomes do nephrectomies in 4 swine, estimating the latency time due
not include haptic feedback, which severely increases la- to long (300 Km) distance,48 and another one operating in 5
tency. It has yet to be tested whether future telesurgery pigs in a shorter distance (1–6 Km) 40 Rayman et al. per-
systems will be able to integrate haptic feedback that is formed robotic telesurgery to perform a left internal mam-
accurate and precise enough to increase the surgeon’s mary artery dissection in pigs through a satellite network
performance without increasing latency. with a maximum bandwidth of 10 Mb/s.49
In order to implement remote surgery, we should address Regarding remote telesurgeries, in USA, a surgeon from
the critical technical challenges of robotic telesurgery, which Texas, 1200 miles away from a Florida Hospital, remotely
are the minimization of latency between master-slave and manipulated the da Vinci robot, performing operations on
the maximization of reliability, availability and security of simulated patients through the Internet. In China, Hainan
the communication channel. The desired specifications are: Hospital of Chinese PLA General Hospital and Beijing
Jishuitan Hospital performed remote positioning for brain
1. Latency (end-to-end round trips) of ⱕ 100ms depend-
pacemaker implantation surgery and screw fixation sur-
ing on the application.
gery, respectively, through a 5G network. However, these
2. Ultrareliable communications (“seven nines”).
surgeries do not require high demands on network la-
The term ultrareliable can be quantified in terms of fixed- tency and bandwidth of the 5G network as compared to
line carrier-grade reliability of seven nines i.e., an outage the continuous manipulation and 3D video transmission
probability of 10 7, which translates to microseconds of in laparoscopic surgery.48,50
outage per day. These specifications cannot be provided
While the future for telesurgery looks bright, there are a
today by existing 3G and 4G networks.
number of challenges that need to be addressed. The fol-
The hypothesis is that 5G infrastructure offers the desired lowing are suggestions for research studies:
reliability and latency and therefore is an enabler for safety-
1. Both the surgeon console and the patient side cart
critical applications such that remote surgery, from a central
need to be more compact or portable. Ultimately, the
major surgical hospital medical center can be matched to a
surgeon console could be as portable as a laptop com-
specific patient’s medical needs in a remote hospital loca-
puter and the patient side cart should be compact so
tion. In the more distant future, when haptic technologies
that it can be placed in an ambulance or a mobile ward
develop to a safe level of precision and accuracy, these
(En-route ‘damage-control’ surgery).
technologies can be applied to RAMIS telesurgery systems.
2. Surgical robots need to be combined with AI, capable
It should be noted that the same infrastructure of haptics for
to alert of dangerous actions during the operation
telesurgery could be applied to other remote healthcare
(error prediction and hazard avoidance).
applications such as telediagnostic tools, which could be
3. Protocols and responsibilities need to be clearly
available anywhere, anytime, allowing remote physical ex-
defined to define whether causation of errors is from
amination which could include palpation.45
device (robotic and/or telecommunication system) or
As with all newly implemented emerging technologies surgeon control.
like telesurgery, facilitation by the 5G network is a game 4. Communication corporations need to take measures to
changer. Highly delicate procedures like spinal surgery assign and guarantee enough bandwidth and high pri-
could benefit from high capacity, low latency. This also ority for telesurgery.
applies to other surgeries in other specialties like cardiac 5. With network security is still one of the major challenges
surgery, urology, and colorectal surgery. In short, the to telesurgery, a security guard system for the 5G network
entire domain of surgical procedures could be enhanced has to be designed and implemented (anti-hacking).
with 5G enabled telesurgery.
Telerobotic Spinal Surgery
Before 5G, only a few telesurgeries were reported which
It is well known that robot-assisted spinal surgery has been
were carried out through a 4G network while mostly inter-
a popular and reliable surgical procedure. Furthermore, a
net and satellite networks were previously used for telesur-
recent meta-analysis showed that the accuracy of robot-
gery.46 Thus, Wirz et al.. performed robotic telesurgery to
assisted pedicle screw placement was significantly higher
complete a pituitary tumor resection on a simulated model
than the freehand method.51
over the Internet with a bandwidth of 1 Gb/s in 2015.47
Regarding surgical applications our review revealed two A recent study (Table 1) in which 6 hospitals participated
preclinical studies: One article reporting 5G mediated from 6 different cities in China, 5G telerobotic spinal

surgeries for 12 patients were performed and a total of 62 computational analytic software. The data is frequently
pedicle screws were successfully implanted using the 5G being fed autonomously from the billions of devices,
telerobotic surgery system.52 The operation time was equipment and instruments connected to the IoT.
142.5 6 46.7 minutes, and the mean guide wire insertion
Basic science research, especially at the cellular, molecu-
time was 41.3 6 9.8 minutes without any intraoperative
lar, genetic and “-omics” levels, produce vast amounts of
adverse events. They concluded that telerobotic spinal
raw data which previously was too large to share among
surgery based on the 5G network is accurate, safe, and
institutions and researchers, let alone be processed by AI,
reliable. The application of the 5G network in the clinical
computational analytics, and super computers. For clinical
area has great potential and value in the future.
researchers, acquiring enough patients for large enough
The authors also explored the new pattern of “one-to- clinical trials to prove validity can now be accomplished
many” remote surgery. Under this mode of remote sur- through collaboration in near real-time because of avail-
gery, one expert surgeon can simultaneously provide sur- able bandwidth inherent in the 5G telecommunications.
gical care to more than one remotely located hospitals,
something which previously was significantly restricted
6. 5G and the COVID-19 Pandemic
by the limit of network bandwidth. A “one-to-three” tele-
robotic surgery was successfully performed during this When the COVID –19 pandemic broke out in Wuhan, China,
study, and it is believed that even more multicenter the city’s healthcare system was rapidly overwhelmed. A dis-
remote surgery is simultaneously possible, due to the vast aster response was quickly established, including the new 5-
potential of the 5G network.52 G telecommunications networking.54 In the first 29 hours, 3
‘shelter’ (fangcang) hospitals of 4000 beds were created in
5. Medical Education and Healthcare Research empty stadiums and auditoriums, including a complete
intra-net within the hospital and internet connecting hospi-
Attention must be paid to the unique needs of both medi-
tals globally, especially giving access to the internet of the
cal education and biomedical research, especially in this
existing 5-G high bandwidth wireless networks throughout
era of ‘evidence-based medicine’. Obviously, the equiva-
all the city’s hospitals.52 The intranet connected all the com-
lents are evidence-based education (a complete paradigm
puters, smart devices (for example, Real-time Remote
shift for education) and evidence-based research (an op-
Computed Tomography (CT) Scanning on 152 patients with
portunity to improve speed and quality of research).
COVID-19), in addition to critical information systems (X
5.1. Medical Education rays, laboratory tests, Electronic Medical Record, mainte-
In the surgical specialties, technical training has changed nance, administration and wireless mobile phone) services
from subjective mentored ‘see one, do one, teach one’ in the immediately, without the need to spend weeks running
operating room, to objective assessment of performance cables throughout the hospitals.54 Over the remainder of the
with proficiency-based progression (PBP) training53 in the week, an additional 13,000 beds were created using ‘cabin
simulation center. Assessment is enhanced by AI software, hospitals’, essentially standard ‘shipping containers’ that had
analysis of performance through computational analytics on previously been outfitted as individual departments of the
the massive data acquired in the simulators and use for im- hospital for beds and services. Simply connecting the various
mediate, formative feedback. During the beginning weeks containers (cabins) together and instituting 5G networking,
of the COVID-19 pandemic in Wuhan, China, there were each department was assigned their own VPN using a soft-
over 800,000 accesses to the COVID-19 training database. ware technique called “network slicing”.25 The result of the
After the pandemic, it is postulated that there will be huge 5G bandwidth was creating an additional 17,000 beds,
increased emphasis on a new ‘hybrid model’ of medical all immediately connected (essentially no latency) through-
education, with many of the advantages of just in time and out the city for standard telecommunications, teleconsulta-
remote learning enriching traditional educational models. tion for medical experts throughout the country, telereferrals
for critical patients (a total of 425 emergency teleconsulta-
5.2. Healthcare Research tions), and other healthcare services. In addition, AI was
The new 5G information ecosystem greatly increases the implemented in intelligent diagnosis of medical imaging and
productivity on both basic science and clinical research. temperature measurement technology based on computer
First, the technologies greatly facilitate collaborative, vision and infrared technology; while AI together with BD
multi-institutional studies and secondly through the were used for epidemic situational analysis; tagging, contact
access to massive data (BD), repositories, AI and tracing and monitoring of personnel movement as well as of

positive cases; just-in-time logistics, inventory control, asset technologies, such as, 5G communications, AI, telemedi-
tracking and material allocation. In short, the availability of cine (and telesurgery), automatic image interpretations,
huge bandwidth significantly reduced the chaos of the disas- genetics, proteomics58,59 and others are radically (and rap-
ter by providing real-time access and ‘visibility’ to all aspects idly) changing the practice of medicine. Two areas need to
of healthcare delivery.55 An abridged version of the Wuhan be addressed: The core technologies in 5G communication,
response is contained in Appendix 3. that are supporting most every industry and the healthcare
specific technologies for medical needs.
7. Pitfalls of the Use of 5G in Healthcare The assumption is that the 5G and subsequent genera-
tions of wireless communication technologies will pro-
The technology of 5G communications bring great prom- vide service now and in the future with exponentially
ise to significantly improve healthcare – from the technol- increasing bandwidth (for data/information flow), dec-
ogy standpoint. However, Medicine is as much an Art as it reasing latency (for real-time, near-real-time or just-in-
is a Science, and therefore what appears to be a very sim- time requirements) and with reliability/availability (the
ple elegant technological opportunity, which healthcare “seven nines” 99.99999% reliability), usability (simple
providers really want and which will greatly benefit human/machine interface), accuracy (received/delivered
patients, there are often challenges from business, politi- to the correct person/location), and especially security/
cal, behavioral and other sources which can impede or privacy. The second assumption is that while the transmit-
thwart even the best of technologies. ting and receiving of information must obey physical
Transforming an innovative idea to a commercial product is a laws, the interfaces (devices) for humans must obey both
long and arduous process, with about 10% of the ‘great new physical laws and biologic limitations [Note: machine-to-
ideas’ being successful. During the 15–20 years (or longer) machine interfaces only obey physical laws].
process there are numerous challenges and pitfalls. This is Finally, attention must also be paid to the type of ‘support-
especially true in the high-risk, risk-averse conservative pro- ing technology’ requirements, such as AI to enhance
fession of healthcare, where resistance to change is uncom- human intellectual performance in solving problems,
promising. Unfortunately, any innovation will usually be supercomputers and BD repositories, sensors/actuators
overhyped, and unable to meet expectations which is espe- and MEMS on the IoT for data acquisition, etc., which are
cially deleterious in the healthcare profession. Another critical driving the need for better communication networks.
pitfall along the way is, should the technology be completely
successful, approval for reimbursement for using a device will Surgery is in its fourth generation (Open surgery, endolu-
be very difficult to establish, or will be established at an exorbi- minal surgery, laparoscopic surgery, and now robotic sur-
tant cost.56 Other reasons for lack of success are that inability gery) with the emerging fifth generation of surgery being
to raise enough funding to complete the prototype to a com- directed energy. The trend is for less invasive procedures
mercial product, a poor fit of the device for clinical application, (endoluminal) through natural body openings (mouth,
inadequate return on investment (ROI) and many other finan- nose, rectum, ears, etc.) to perform surgical procedures.
cial considerations.5 Solutions to the technology transfer have This has been followed by and today the newest genera-
been implemented at many academic and hospital institutions tion is robotic assisted minimally invasive surgery
with establishment of “centers for Innovation” where dedi- (RAMIS). Postoperative follow-up visits are being per-
cated Director, administrative staff, resources and funding, formed with teleconsultation. Until now, only a few
multidisciplinary teams with clinicians, engineers and other “remote surgeries” (telesurgeries) have been performed
nonmedical fields work synergistically to complete the full life because of the connecting cable between the surgeon
cycle develop of a new device or product.57 console and robot arms. It is anticipated that the wireless
5G networks, with huge bandwidth and low latency, will
lead to more implementation of telesurgery.
Future Directions
A reflection on the enormous number of advanced technol-
CONCLUSIONS
ogies rapidly occurring in this new ‘Information Age’
emboldens the authors to make certain ‘extrapolations of The newly emerging advanced healthcare ecosystem
known advancements in science’ to suggest ‘forward-look- which is being totally integrated through the high band-
ing statements’ about likely technology outcomes for the width of 5G communications is truly disruptive. In spite of
future. However, It is apparent that some of the emerging the limited deployment of 5G at this time, new clinical

application examples clearly illustrate the opportunities (or semiautonomous), and BD repositories (the Cloud) with
across all healthcare specialties, including the administra- supercomputing (eventually quantum computing) running
tive and nonclinical applications solutions for cost savings sophisticated algorithms with computational analytics, that
created the need to innovate even more to keep up with the
and improved efficiency. The larger the bandwidth and
ever-increasing demand for more capable communication
the lower the latency, the greater the number and size of infrastructure.
the enabling technologies; in turn, this increases the It is the interdependence of this escalating upward spiral of
demand for more telecommunication capabilities, thus innovation that continues to stimulate and challenge communi-
creating an ever escalating upward spiral of growth. cation networks, and hence the need to interact with other tech-
nologies to sustain growth. But do not forget the interface
This ecosystem of innovations has also created a milieu ripe between the human and the technology that provides the final
for telemedicine to thrive and expand, as evidenced by the connection of the communication system with a person, be it
response to the COVID-19 pandemic, which has hastened any of the forms of VR, wearable contact lens displays, or the
the rapid increase of telemedicine and awareness of the im- ultimate brain-machine interface. After all, it is a ‘system-of-sys-
portance of these digital technologies. Evidence from the tems’, with each link in the chain dependent upon the success
of all others, that decisively results in success. Below is a sam-
pandemic has revealed the utility of telemedicine. Physicians pling of many (but not all) of such systems.
must continue to adapt to the ever-changing models of care
delivery and collaborate with broader teams involving tech- THE INTERNET OF THINGS
nology experts and data scientists to achieve universal quality
and sustainable healthcare services. The internet of things (IoT) is composed of an estimated of
number of 14.2 billion connected devices (of which 5.2 billion are
Two of the great innovations of 5G are software designed unique cell phone users), with more than 21 billion connected
networks (SDN) and bandwidth “slicing”, especially for devices by 2025, compared to the 8.2 billion global population as
in-hospital networking. However, some of the technology of Jan 2021.3 In addition, there an unknown number of machine-
limitations and challenges to be faced include mismatch to-machine connections, many of which are used for autonomous
between new communication capabilities with human machine/device maintenance. There are more devices and
machines talking to each other than people communicating,
limitations (solution: attention to human interface technol-
machines that are sharing information and automatically adjusting
ogies), and the nontechnical limitations of behavior, poli- themselves. Although many machines used by humans are used
tics, equity, cost, access and availability. Finally, two for human-to-human communication over the internet (e.g., com-
common technologies which are not ready (without revo- puters, cell phones), the machines/devices with their sensors, and
lutionary discoveries) are haptics and virtual reality, both receivers/actuators, and data storage, are going about their ‘busi-
of which are truly still in their infancy. nesses” without human intervention. There is certainly oversight
of these machine activities, however the overwhelming mass of
The good news is that this is still just the beginning of a data (BD) is beyond human comprehension and sophisticated
great new revolution in digital healthcare with unlimited software of computational analytics is needed to for humans to
opportunities for growth. have all that data to be converted into information relative to a
person’s needs. As people begin using more and more wearable
or embedded microdevices for health monitoring, there will be a
APPENDIX 1. Other Critical Supporting logarithmic increase in generated data which will eventually con-
Infrastructures nect every aspect of an individual’s life. In addition, possessions
such as automobiles, appliances (stove, refrigerator, etc.) and
Although the 5G communications infrastructure is a major driver other aspects of the ‘smart home’ that are currently attaching to
for healthcare innovation, it is the interaction among multiple the IoT will be seamlessly integrated into IoT. The new 5G net-
other technologies that empower each other, well beyond the sin- work can accommodate this initial increase data flow, with the
gle contribution of each technology. It is the IoT - devices that expectation that 6 generation (6G) and later networks will also
are mobile, or location based, consisting of microchips of exponentially increase communication to accommodates needs.
sensors, actuators, transmitters and/or receivers, other For example, the IoT is estimated to increase to about 500 billion
MEMS and (soon) nanotechnologies that provide the input new “things” by 2030 (about 60 times greater than the global
or output at either end of the communication network. population), which is about the same time that 6G network is
Recall the beginning of modern remote communication expected to be commercialized.61
systems (radio, telegraph, and telephone systems), that it was The integration of human and machine generated data
only when there was ubiquity of the transmitting and receiv- will radically change healthcare services. In order to accom-
ing devices that the telecommunication infrastructure flour- modate these healthcare needs, an entire communication
ished. So too, with 5G (and the follow-on generations of infrastructure integrating the IoT, BD repositories, AI, super-
communication systems) that only with addition of IoT for the computing, innovative computational algorithms, edge com-
input/output, AI to make processes ‘smart’ and ‘autonomous’ puting (microsensors which include processing at point of

data acquisition data, etc.) will be needed to form a ‘telecom- VIRTUAL REALITY (VR), AUGMENTED REALITY (AR),
munication ecosystem’, which not only be able to archive, MIXED REALITY AND EXTENDED REALITY (XR)
monitor and optimize current activities, but also be used lon-
gitudinally to estimate future trends in personalized medi- The original mobile phone-based AR/VR game applications
cine, as well as overall healthcare services. The opportunities (like Pokémon) were among the first types of practical apps on
in telemedicine and telesurgery are reviewed in their sec- 4G. Now 5G networks, and in time 6G, will be able to support
tions. Additionally, the 5G networking will allow for reduced fully immersive VR. Rather than a graphic overlay of a real image
latency, and less dependence on network bandwidth and of AR, the entire display (mobile phone, computer, etc.,) are
availability, and potentially enhanced security.5 replaced by an entirely simulated computer-generated graphics
At the moment there are research projects62 investigating which provides the sense of “presence” in an imaginary “world”.
such potential systems. In the distant future, there is the possi- Through a variety of ‘interfaces” (input devices) users are able to
bility that the bathroom will also become extensively populated interact within the simulated world in a somewhat natural way.
with all types of sensors for automatic daily monitoring health In AR, a graphic image, which is then fused in real-time to the
status, providing a complete physical examination every day to display, especially to provide useful healthcare information, such
update health status on a daily basis, while the person is simply as blood pressure, oxygen levels, positions of tissues and organs
performing the normal daily bathroom activities. during surgery, etc. As a generalization, full VR is implemented
in simulation and training, whereas AR is most advantageous for
ARTIFICIAL INTELLIGENCE, MACHINE LEARNING, clinical care. Important tasks, such as counselling patients and
AND DEEP LEARNING preoperative consent can likely be facilitated with AR, and non-
clinical functions in hospitals such as navigation aids for visually
As a practical definition for this manuscript, AI is: “tech- impaired patients.9
nology which mimics human behavior”.63 Two areas (sub- These ‘realities’ still remain in their infancy and have only
fields) of AI have drawn attention in healthcare: few applications in healthcare (principally in education and
training, using online information or in training labs with simu-
1. Machine Learning: Algorithms which can automatically
lations/simulators). [Note: There are currently over 100 certified
learn rather than be programmed, and is the principle ‘simulation centers’, in major hospitals and medical schools].
source for predictive analytics, especially for clinical However, once their implementation of virtual worlds, simula-
practice and speech translation;64 tions and applications become practical, reliable and of high
2. Deep Learning: The discovery of underlying ‘features’ visual quality, there will be significant demand for high band-
and ‘meaning’ (such as cause and effect) in data from width with minimal latency for remote learning and training.
multiple processing layers using neural networks,
mimicking the process used by the human brain.65
APPENDIX 2: Fundamental Biologic Principles
In healthcare, DL is the best infrastructure for speech recog-
nition66 as well as in image recognition i.e. automatic presump- One of the most overlooked issues in healthcare (and most
tive diagnoses of known diseases from various imaging other industries) is the capability of humans to adjust to a
technologies, such as X-Rays, CT, MRI, OCT, etc.67,68 At this new technology – physically. While everyone is personally
time, AI has not reached a point of being able to independently aware of ‘information overload’, there is scarce attention
perform diagnose and manage patients without human input. paid to the principal characteristics of the ‘biologic systems’
Currently, human review of all AI image interpretations requires which humans use with technologies: Nervous and musculo-
clinician review, which provides a clear difference between au- skeletal system (brain/muscles), vision (eyes/imaging), hear-
tonomous and assistive AI. ing (ears/acoustics) and touch (hands/haptics); the senses of
taste and smell play a relatively small/focused role, especially
BIG DATA, QUANTUM COMPUTING, AND in interacting with technology.
COMPUTATIONAL ANALYTICS The science of HIT is defined as “a means or place of inter-
action between two systems a means or place of interaction
The original process for the internet was: INPUT (Raw data between two systems; especially, the interface between peo-
typed in from a computer); TRANSMIT (communication over ple (users) and computers or devices.21 In order to address im-
dedicated land lines via local area network (LAN)/distant portant new technologies (such as rapidly expanding
wide area network (WAN); OUTPUT to a receiving computer communication technologies), consideration to the capabil-
(for storage and processing). The present status is MULTIPLE ities and limitations of the ‘human’ systems’ is important in
TYPES of INPUTS of data acquisition (see IoT), TRANSMIT order to optimize the devices to enhance human capabilities.
(massive data over lines and wireless communication) for Table 2 gives an example of typical human capabilities in
MULTIPLE TYPES of OUTPUT (massive “Big Data, to storage, regard to human performance related to perception and adap-
streaming, computing with sophisticated algorithms for AI, tation to latency in communication systems (earlier unpub-
etc.). The result of the Input and Output sides is an explosion lished data by the author [RMS] but consistent with the average
of data that requires very wide bandwidth with decreased la- robotic knot tying in ‘box trainer under varying amounts of la-
tency, accuracy, reliability, privacy and security. tency) and within the same range as the data stated by Anvari

69
under conditions of real time patient surgery. Recent long the remote and underserved, but it can routinely serve the
distance telesurgery case reports using 5G have stated latency wider population as it has been shown to be safe, efficient, and
much less than 200 milliseconds (ms), indicating that safe tele- inclusive, provided that measures to ensure security, robustness
surgery is likely to increase with the use of 5G networking; and capacity, particularly in densely populated regions with
however, larger validation studies are required. Another dif- massive competing demands for bandwidth.54
ferent example of human capability limitation is, although While the COVID-19 disease, initially discovered in Wuhan,
most persons claim to multitask at many different cognitive China in Dec 2019 is well known, what is of specific interest is
tasks simultaneously,70 the literature indicates that the frontal that the pandemic is one of the earliest examples of emergency
lobe (the attention center) can only perform 3–4 tasks at use of 5G technology for many of the important applications for
once.71 The explanation of the difference is that some authors healthcare, not only as a communication tool, but also as a fun-
considered automated functions which are controlled by the damental infrastructure to provide the necessary systems inte-
cerebellum and system of reflexes (such as when riding a gration among the multiple informatics technologies.
bicycle, a person does not focus their attention on each leg Telemedicine had been available for decades, however
and pedal when riding) or situational awareness, as part of only used in a small number of specific medical applica-
multitasking. In addition, performing more than 2 cognitive tions, in part due to limited capabilities of the communica-
tasks simultaneously results in increase error and decrease ef- tion networks – everything changed with the Covid-19
ficiency. Thus, when a person multitasks, there will be a HIT pandemic. Lockdowns were initially instituted within China
mismatch of massive data input overwhelming focused cogni- with such a resounding success in Wuhan, that as the pan-
tive ability of the brain to process it, thereby decreasing per- demic spread globally, lockdown followed. Without 5G, the
formance and safety. existing 4G networks were insufficient because businesses,
For the vision systems, will more new devices be devel- education, research, healthcare and personal (especially
oped using nanochip technologies, such as the ‘smart contact family) communications all battled for a share of the limited
lens’,72 that can receive massive data to extend human vision bandwidth.5
beyond the visible spectrum; and if so, what will be conse- The criticality of using multiple information-based technol-
quences of such capabilities? ogies is documented by Ye, Zhou and Wu 60 in their report of
Or perhaps the reverse is an important issue for the sense of the informatics technologies used and the experience gath-
touch: on a fingertip there are 23 different sensors, at a density ered in responding to the COVID-19 epidemic in China
of 1000 nerve endings per cubic millimeter, in an average hand through the perspective of health informatics. Due to the pan-
surface area of 4000 mm, each sending stimuluses at 1000 hertz/ demic, the so called “5G1 Health” has moved from the experi-
second. Even with 5G or 6G (see Table 3), will there be enough mental to the clinical phase. A plethora of technologies,
bandwidth to transmit in real time that massive amount of data including cloud computing, BD, the IoT, mobile internet, AI,
per second (in addition to all the other massive data flow from and 5G mobile network, were used for epidemic prevention
all the other systems in the milieu for surgery) and their inter- and control in China. Taking full advantage of mobile internet
face to the input device (hand controller) for a robotic surgeon and 5G technologies active internet health care services pro-
to precisely perform a complex surgical procedure? vided by clinical experts from all over the country has been
Such examples beg the issue of defining accurate human per- realized, both within the hospital as well to many essential
formance measures to enable new technologies to accurately be supporting services outside of the hospital. More specific
designed and developed that match human needs. Such mis- examples include the fact that citizens were able to access
matches can result in too much data overload, or insufficient sen- real-time epidemic situation dynamics and prevention knowl-
sory input which results in loss of accuracy and precision and edge through the mobile internet. BD were used for epidemic
errors. The biologic complexity of human performance is well situational analysis; tagging, contact tracing and monitoring of
beyond the complexity of man-made systems, and therefore the personnel movement as well as of positive cases; just-in-time
regulation of data flow, even as large as the 5G systems, needs to logistics, inventory control and material allocation. AI has
be modulated to match the capabilities of the human. Therefore, been implemented in intelligent diagnosis of medical imaging
HIT is an area of research that requires much more attention in and temperature measurement technology based on computer
order to optimize both the mechanical devices and the communi- vision and infrared technology. By increasing bandwidth and
cation system. reducing latency, telemedicine based on 5G technology has
also played an important role in the consultations and treat-
ment of patients with severe COVID-19 and in facilitating
international cooperation.
APPENDIX 3. Use of 5G IN Wuhan China during The above-mentioned clinical information systems deployed
COVID 19 have the following 3 advantages as described by Chen S. et al. 36
in the description of the physical and functional attributes of an
As the restriction lockdown emerged globally due to Covid-19 entire emergency hospital network:
pandemic, a sudden strain occurred on existing cellular net-
works: Healthcare, education, work, and most other human
interactions were suddenly pushed onto the virtual arena. It has • “A rapid deployment: The first three shelter-hospitals
therefore been shown that telemedicine is not reserved only for (called fangcang hospitals) in Wuhan with 4000 beds

were built in 29 hours and their clinical information sys- In this case report,55 the experience of accomplishing
tems were deployed within this time framework. the IT infrastructure of 20 cabin hospitals in in Wuhan,
• An online information exchange among medical institu- China, to receive patients with mild symptoms within
48 hours is described. The cabin hospitals were largely
tions in the external network (especially each fangcang
engaged in blood and PCR testing, mobile CT scanning,
hospital’s connection to their ‘host’ hospital) and oral medicines administration. In order to complete
• A rapid response of electronic health records (EHRs) to the IT system construction within 24 to 48 hours, it was
specifically respond to COVID-19. necessary to interconnect the cabin hospital within an
existing hospital’s information network. A 5G all-wireless
It is interesting to note that not only were the fangcang shel- solution to divide the overall network system of the cabin
ter-hospitals established within existing available large struc- hospital into multiple network units (i.e. the electronic
tures (e.g., stadiums, auditoriums, warehouses) within record medical records, a picture archiving and communication
time, but within the same time frame, an entire 5G wireless net- system, the laboratory information, the maintenance sys-
work was established throughout an entire fangcang shelter via tem, and other management information systems) was
software designed networks (SDN) with ubiquitous distribution implemented and each unit was independently connected
and access through ‘network slicing’ of the massive 5G band- to the host hospital’s data center over a VPN capable to
width, but was also linked to the nearest ‘host’ hospital for accept authenticated connections built on the 5G wireless
global access. Therefore, it is possible to use information tech- network. The network bandwidth was about 10 times
nology over 5-G networking to increase the near instantaneous faster than 4G, and that the intranet bandwidth exceeded
acquisition, communication and distribution of information for 50 MB, thus successfully conforming to the prerequisites
clinical purposes, but also as important, to provide transparency demand of the network. Thus, all data, plus the Internet-
of information about an epidemic to reduce public panic and assisted medical system of the host hospital, were inte-
enhance public confidence. grated and built a lightweight wireless information system
Experience from a multimodal telemedicine network in for the cabin hospital.
Sichuan Province in Western China 55 using a newly estab- The outcomes of this approach were: a rapid system con-
lished 5G service, a smartphone app, and an existing teleme- struction (within 48 hours for the system functional integration
dicine system during the COVID-19 pandemic. Three with the host hospital), zero maintenance of network and ter-
applications were developed: minal devices (as remote maintenance software was installed
on each computer), reduced chance of cross infection (as the
1. Physicians Tele-Education about COVID-19: More than whole information circulation was all electronic and paper
800,000 person-accesses have been implemented on was rarely used) and this implementation allowed minimum
prevention and control of the disease. physical interaction of the healthcare personnel with the
patients.
2. A 5G Dual Gigabit Network and a Multidisciplinary This networking mode is suitable for any emergency sce-
Medical Team: 424 remote consultations were con- narios where an intranet connection to the host organiza-
ducted through a new real-time video telemedicine tion is necessary to set up within a short time. There is a
system for consultations focused on severe and critical bright future of 5G wireless network to dwarf the conven-
COVID-19 patients. tional wired network. Additionally, the proposed solution
3. A 5G Dual Gigabit Network and Real-time Remote CT can be used for the multihospital network interconnection
Scanning on 152 patients with COVID-19 under the con- and rapid network recovery during the failure of wired
network.
trol and guidance of the host centrally located hospital.
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REVIEW ARTICLE

5G Use in Healthcare: The Future is Present

ABSTRACT applications, education and research in medicine and

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Records idenﬁed through Addional records idenﬁed

databases searching through other sources

Records aer duplicates removed

Records screened Records excluded

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for eligibility with reasons

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Naruse et al.38 2020 Japan Cardiotocogra- Ob/GynClinical - Successful transmission

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surgeon to communicate with the learners in the ‘audi- Clinical Telesurgery

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