Abstract:
A closed loop system for monitoring drug dose, intake and effectiveness includes a pill dispenser in data communications with at least one implantable medical device. The system is preferably implemented in a web-enabled environment in which a remote data center communicates with the implantable devices (IMDs) in a patient via a programmer or the pill dispenser. Th data center includes high speed computers and databases relating to patient history and device information. A physician or clinician may access the remote data center to review and monitor the IMDs remotely. More specifically, the IMDs are adapted to chronically monitor the pill dispenser to thereby log and document drug dose, patient compliance with prescriptive regimens and as well to monitor drug efficacy in the patient. The system further provides a dynamic drug management system, compatible with a web-enabled interactive data communication environment, that accurately monitors dose and specific drug effectiveness in a patient to enhance patient care.

Description:
This is a continuation of application Ser. No. 09/475,709, filed Dec. 30, 1999, now U.S. Pat. No. 6,471,645. 
    
    
     THE FIELD OF THE INVENTION 
     The present invention relates to implantable medical devices (IMDs). Specifically, the invention pertains to a remote bi-directional communications between the IMDs and a drug dispenser. More specifically the invention pertains to a closed loop system in which the IMDs monitor and determine the presence of a specific drug dose in the patient&#39;s body to send instructions to the drug dispenser or an interface medical unit (IMU) to implement a drug management scheme based on the monitored data. More specifically, the invention provides a dynamic drug management system in which the drug dose is chronically monitored by the IMDs to enhance drug effectiveness and as well monitor patient compliance with recommended drug administration regimen. The invention preferably utilizes a robust communication system integrated with a remote expert data center in a web-enabled environment to transmit the IMDs&#39; data to a physician for evaluation and review thereby enhancing the delivery of therapy and clinical care remotely. 
     BACKGROUND OF THE INVENTION 
     A technology-based health care system that fully integrates the technical and social aspects of patient care and therapy should be able to flawlessly connect the client with care providers irrespective of separation distance or location of the participants. While clinicians will continue to treat patients in accordance with accepted modern medical practice, developments in communications technology are making it ever more possible to provide a seamless system of remote patient diagnostics, care and medical services in a time and place independent manner. 
     Prior art methods of clinical services are generally limited to in-hospital operations. For example, if a physician needs to review the performance parameters of an implantable device in a patient, it is likely that the patient has to go to the clinic. Further, if the medical conditions of a patient with an implantable device warrant a continuous monitoring or adjustment of the device, the patient would have to stay in a hospital indefinitely. Further, if the patient with the IMDs is taking a drug, it is often clinically prudent to monitor the dose and its impact on the patient and, as well, on the IMDs. Such a continued treatment plan poses both economic and social problems. Under the exemplary scenario, as the segment of the population with implanted medical devices increases many more hospitals/clinics including service personnel will be needed to provide in-hospital service for the patients, thus escalating the cost of healthcare. Additionally the patients will be unduly restricted and inconvenienced by the need to either stay in the hospital or make very frequent visits to a clinic. 
     Yet another condition of the prior art practice requires that a patient visit a clinic center for occasional retrieval of data from the implanted device to assess the operations of the device and gather patient history for both clinical and research purposes. Such data is acquired by having the patient in a hospital/clinic to down load the stored data from the implantable medical device. Depending on the frequency of data collection this procedure may pose serious difficulty and inconvenience for patients who live in rural areas or have limited mobility. Similarly, in the event a need arises to upgrade the software of an implantable medical device, the patient will be required to come into the clinic or hospital to have the upgrade installed. Further, in medical practice it is an industry-wide standard to keep an accurate record of past and contemporaneous procedures relating to an IMD uplink with, for example, a programmer. It is required that the report contain the identification of all the medical devices involved in any interactive procedure. Specifically, all peripheral and major devices that are used in down linking to the IMD need to be reported. Currently, such procedures are manually reported and require an operator or a medical person to diligently enter data during each procedure. One of the limitations of the problems with the reporting procedures is the fact that it is error prone and requires rechecking of the data to verify accuracy. 
     A further limitation of the prior art relates to the management of multiple medical devices in a single patient. Advances in modern patient therapy and treatment have made it possible to implant a number of devices in a patient. For example, IMDs such as a defibrillator or a pacer, a neural implant, a drug pump, a separate physiologic monitor and various other IMDs may be implanted in a single patient. To successfully manage the operations and assess the performance of each device in a patient with multi-implants requires a continuous update and monitoring of the devices. As is often the case, patients with multi-implanted medical devices may take a variety of medications. It is therefore necessary to monitor drug intake and its effect on the oprerational and functional parameters of the IMDs. More importantly, chronic monitoring of drug intake and its effect on the physiological and clinical conditions of the patient enables a proactive intervention to change the course of an otherwise serious medical condition. Thus, there is a need to monitor drug delivery and effectiveness via IMDs. 
     Accordingly it is vital to have a drug dispenser unit that would establish a communication system with IMDs. The unique position of IMDs enables a real-time assessment of physiological conditions which may change or indicate a measurable variance due to drug dose and delivery. IMDs could be adapted to provide measurements relating to the physiological impact of drug therapy. Further, IMDs could be adapted to provide a quick evaluation of the effectiveness of a drug to support a clinical decision as to whether a given dose is a prudent course of therapy. 
     The proliferation of patients with multi-implant medical devices worldwide has made it imperative to provide remote services to the IMDs and timely clinical care to the patient. Frequent use of programmers to communicate with the IMDs and provide various remote services, consistent with co-pending applications titled “Apparatus and Method for Remote Troubleshooting, Maintenance and Upgrade of Implantable Device Systems,” filed on Oct. 26, 1999, Ser. No. 09/426,741; “Tactile Feedback for Indicating Validity of Communication Link with an Implantable Medical Device,” filed Oct. 29, 1999, Ser. No. 09/430,708; “Apparatus and Method for Automated Invoicing of Medical Device Systems,” filed Oct. 29, 1999, Ser. No. 09/430,208; “Apparatus and Method for Remote Self-Identification of Components in Medical Device Systems,” filed Oct. 29, 1999, Ser. No. 09/429,956; “Apparatus and Method to Automate Remote Software Updates of Medical Device Systems,” filed Oct. 29, 1999, Ser. No. 09/429,960; “Method and Apparatus to Secure Data Transfer From Medical Device Systems,” filed Nov. 2, 1999, Ser. No. 09/431,881; “Implantable Medical Device Programming Apparatus Having An Auxiliary Component Storage Compartment,” filed Nov. 4, 1999, Ser. No. 09/433,477; which are all incorporated by reference herein in their entirety, has become an important aspect of patient care. Thus, in light of the referenced disclosures, communication with IMDs enhances the delivery of therapy and clinical care in real time. Specifically, as the number of patients with IMDs increases globally, the need to manage drug delivery and intake remotely becomes an economic imperative. Further, IMDs which are communicable and operable in a web-enabled environment, as contemplated by the cited disclosures hereinabove, provide a unique platform to assess the efficacy of drugs and the compliance of patients with prescribed regimens. Further, it is vital to have a drug dispenser that is adapted to have data communications with the IMDs and other data centers to support the remote patient management system contemplated by the present invention. 
     The prior art provides various types of remote sensing and communications with an implanted medical device. One such system is, for example, disclosed in Funke, U.S. Pat. No. 4,987,897 issued Jan. 29, 1991. This patent discloses a system that is at least partially implanted into a living body with a minimum of two implanted devices interconnected by a communication transmission channel. The invention further discloses wireless communications between an external medical device/programmer and the implanted devices. 
     One of the limitations of the system disclosed in the Funke patent includes the lack of communication between the implanted devices, including the programmer, with a remote clinical station. If, for example, any assessment, monitoring or maintenance is required to be performed on the IMD the patient will have to go to the remote clinic station or the programmer device needs to be brought to the patient&#39;s location. More significantly, the operational worthiness and integrity of the programmer cannot be evaluated remotely thus making it unreliable over time as it interacts with the IMD. Further, in light of the present invetion, the Funke patent does neither suggest nor disclose the communications system between the IMD and a drug dispenser to monitor and assess in the effectiveness of the dose based on the physiological status of the patient. 
     Yet another example of drug management based on smart drug dispenser units is disclosed by Martindale et al in U.S. Pat. No. 4,360,125 issued on Nov. 23, 1982. In the disclosure, a medication dispenser in which medication to be dispensed is housed including a member operable to allow medication access. The dispenser provides a medication alert signal at preselected times in accordance with a desired medication regimen. A medication access signal is provided when medication access is obtained. Data representative of the relative timing between a medication alert signal and a medication access signal is written into readable memory whereby that data is available to a physician for evaluation. In the preferred embodiment, the data is representative of the time of occurrence of each medication alert signal and medication access signal. The interval between medication alert signals is selectively alterable. 
     Further, examples of drug management based on smart drug dispensers are disclosed in U.S. Pat. Nos. 4,768,176; 4,768,177; 5,200,891; 5,642,731; 5,752,235 and 5,954,641 all to Kehr et al. Generally all the patents relate to a drug dispensing system with various alert features to monitor and manage the administration of medication and medical treatment regimens. None of these patents suggest or disclose a communication between the drug dispensing systems and an IMD. 
     Yet another prior art reference provides a multi-module medication delivery system as disclosed by Fischell in U.S. Pat. No. 4,494,950 issued Jan. 22, 1985. The disclosure relates to a system consisting a multiplicity of separate modules that collectively perform a useful biomedical purpose. The modules communicate with each other without the use of interconnecting wires. All the modules may be installed intracorporeal or mounted extracorporeal to the patient. In the alternate, some modules may be intracorporeal with others being extracorporeal. Signals are sent from one module to the other by electromagnetic waves. Physiologic sensor measurements sent from a first module cause a second module to perform some function in a closed loop manner. One extracorporeal module can provide electrical power to an intracorporeal module to operate a data transfer unit for transferring data to the external module. 
     The Fischell disclosure provides modular communication and cooperation between various medication delivery systems. However, the disclosure does not provide an external pill dispenser which is in wireless communications with IMDs. Further, the system does neither teach nor disclose an external programmer for telemetrically interacting with the pill dispenser. 
     Accordingly, it would be advantageous to provide a pill dispenser that communicates with IMDs to implement an effective drug management system. Yet another desirable advantage would be to provide a high speed communications scheme to enable the transmission of high fidelity sound, video and data to advance and implement efficient remote drug management of a clinical/therapy system via a programmer thereby enhancing patient clinical care. As discussed herein below, the present invention provides these and other desirable advantages. 
     SUMMARY OF THE INVENTION 
     The present invention generally relates to a communications scheme in which a remote web-based expert data center interacts with a patient having one or more implantable medical devices (IMDs) via an associated external medical device, preferably a programmer, located in close proximity to the IMDs. The IMDs are adapted to communicate with a pill dispenser to monitor and log pill deposition and effectiveness. Some of the most significant advantages of the invention include the use of various communications media between the remote web-based expert data center and the programmer to remotely exchange clinically significant information and ultimately effect real-time drug intake and prescriptive changes as needed. 
     One of the many aspects of the present invention includes a real-time access of a programmer or a pill dispenser to a remote web-based expert data center, via a communication network, which includes the Internet. The operative structure of the invention includes the remote web-based expert data center, in which an expert system is maintained, having a bi-directional real-time data, sound and video communications with the programmer via a broad range of communication link systems. The programmer is in turn in telemetric communications with the IMDs such that the IMDs may uplink to the programmer or the programmer may down link to the IMDs, as needed. 
     Yet another feature of the invention includes a communications scheme that provides a highly integrated and efficient method and structure of clinical information management in which various networks such as Community access Television, Local area Network (LAN), a wide area network (WAN) Integrated Services Digital Network (ISDN), the Public Switched telephone Network (PSTN), the Internet, a wireless network, an asynchronous transfer mode (ATM) network, a laser wave network, satellite, mobile and other similar networks are implemented to transfer voice, data and video between the remote data center and a programmer. In the preferred embodiment, wireless communications systems, a modem and laser wave systems are illustrated as examples only and should be viewed without limiting the invention to these types of communications alone. Further, in the interest of simplicity, the applicants refer to the various communications system, in relevant parts, as a communications system. However, it should be noted that the communication systems, in the context of this invention, are interchangeable and may relate to various schemes of cable, fiber optics, microwave, radio, laser and similar communications or any practical combinations thereof. 
     Some of the distinguishing features of the present invention include the use of a robust web-based expert data center to collect drug therapy information based on data communication between the IMDs, the pill dispenser and the programmer. Specifcally the invention enables remote evaluation of drug performance in a patient. Although the present invention focuses on the remote real-time monitoring and management of drug therapy information, the system could advantageously be used to monitor clinical trials of drugs or collect clinical data relating to drug interaction or physiological impact of various doses on the patient. 
     Yet one of the other distinguishing features of the invention includes the use a highly flexible and adaptable communications scheme to promote continuous and real-time communications between a remote expert data center, a programmer and a pill dispenser associated with a plurality of IMDs. The IMDs are structured to share information intracorporeally and may interact with the programmer or the pill dispenser as a unit. Specifically, the IMDs either jointly or severally can be interrogated to implement or extract clinical information as required. In other words, all of the IMDs may be accessed via one IMD or, in the alternate, each one of the IMDs may be accessed individually. The information collected in this manner may be transferred to the data center via the programmer or pill dispenser by up linking the IMDs as needed. 
     The invention provides significant compatibility and scalability to other web-based applications such as telemedicine and emerging web-based technologies such as tele-immersion. For example, the system may be adapted to webtop applications in which a webtop unit may be used to uplink the patient to a remote data center for drug information exchange between the IMDs and the remote expert data center. In these and other web-based similar applications the data collected, in the manner and substance of the present invention, may be used as a preliminary screening to identify the need for further intervention using the advanced web technologies. 
     More significantly, the invention provides a system and method to remotely monitor drug effectiveness in a patient. Further, the invention enables a chronic evaluation of drugs in a patient on real time basis. The significance of this method includes the fact that the data collected in this manner could be used to influence the course of drug therapy. 
    
    
     BRIEF DESCRIPTION OF THE DRAWINGS 
     The present invention will be appreciated as the same becomes better understood by reference to the following detailed description of the preferred embodiment of the invention when considered in connection with the accompanying drawings, in which like numbered reference numbers designate like parts throughout the figures thereof, and wherein: 
     FIG. 1 is a simplified schematic diagram of major uplink and downlink telemetry communications between a remote clinical station, a programmer and a plurality of implantable medical devices (IMDs); 
     FIG. 2 is a block diagram representing the major components of an IMD; 
     FIG. 3A is a block diagram presenting the major components of a programmer; 
     FIG. 3B is a block diagram representing a laser transceiver for high speed transmission of voice, video and other data; 
     FIGS. 4A,  4 B and  4 C illustrate a perspective view, a side view and a schematic for the drug dispensing unit or interface medical unit, respectively; and 
     FIG. 5 is a block diagram representing the major data centers and the communication scheme according to the present invention. 
    
    
     DESCRIPTION OF THE PREFERRED EMBODIMENTS 
     FIG. 1 is a simplified schematic of the major components of the present invention. Specifically, a bi-directional wireless communications system between programmer  20 , pill dispenser  20 ′ and a number of implantable medical devices (IMDS) represented by IMD  10 , IMD  10 ′ and IMD  10 ″ is shown. The IMDs are implanted in patient  12  beneath the skin or muscle. The IMDs are electrically coupled to electrodes  18 ,  3   0 , and  3   6  respectively in a manner known in the art. IMD  10  contains a microprocessor for timing, sensing and pacing functions consistent with preset programmed functions. Similarly, IMDs  10 ′ and  10 ″ are microprocessor-based to provide timing and sensing functions to execute the clinical functions for which they are employed. For example, IMD  10 ′ could provide neural stimulation to the brain via electrode  30  and IMD  10 ″ may function as a drug delivery system that is controlled by electrode  36 . The various functions of the IMDs are coordinated using wireless telemetry. Wireless links  42 ,  44  and  46  jointly and severally couple IMDs  10 ,  10 ′ and  10 ″ such that programmer  20  may transmit commands or data to any or all the of IMDs via one of telemetry antennas  28 ,  32  and  38 . This structure provides a highly flexible and economical wireless communications system between the IMDS. Further, the structure provides a redundant communications system, which enables access to any one of a multiplicity of IMDs in the event of a malfunction of one or two of antennas  28 ,  32  and  38 . 
     Programming commands or data are transmitted from programmer  20  to IMDs  10 ,  10 ′ and  10 ″via external RF telemetry antenna  24 . Telemetry antenna  24  may be an RF head or equivalent. Antenna  24  may be located on programmer  20  externally on the case or housing. Telemetry antenna  24  is generally telescoping and may be adjustable on the case of programmer  20 . Both programmer  20  and pill dispenser  20 ′ may be placed a few feet away from patient  12  and would still be within range to wirelessly communicate with telemetry antennas  28 ,  32  and  38 . 
     The uplink to remote web-based expert data center  62 , hereinafter referred to as, interchangeably, “data center  62 ”, “expert data center  62 ” or “web-based data center  62 ” without limitations, is accomplished through programmer  20  or webtop unit  20 ′. Accordingly programmer  20  and webtop unit  20 ′ function as an interface between IMDs  10 ,  10 ′ and  10 ″ and data center  62 . One of the many distinguishing elements of the present invention includes the use of various scalable, reliable and high-speed wireless communication systems to bi-directionally transmit high fidelity digital/analog data between programmer  20  and data center  62 . 
     There are a variety of wireless mediums through which data communications could be established between programmer  20  or pill dispenser  20 ′ and data center  62 . The communications link between Programmer  20  or pill dispenser  20 ′ and data center  62  could be modem  60 , which is connected to programmer  20  on one side at line  63  and data center  62  at line  64  on the other side. In this case, data is transferred from data center  62  to programmer  20  via modem  60 . Alternate data transmission systems include, without limitations, stationary microwave and/or RF antennas  48  being wirelessly connected to programmer  20  via tunable frequency wave delineated by line  50 . Antenna  48  is in communications with data center  62  via wireless link  65 . Similarly, pill dispenser  20 ′, mobile vehicle  52  and satellite  56  are in communications with data center  62  via wireless link  65 . Further, mobile system  52  and satellite  56  are in wireless communications with programmer  20  or pill dispenser  20 ′ via tunable frequency waves  54  and  58 , respectively. 
     In the preferred embodiment a Telnet system is used to wirelessly access data center  62 . Telnet emulates a client/server model and requires that the client run a dedicated software to access data center  62 . The Telnet scheme envisioned for use with the present invention includes various operating systems including UNIX, Macintosh, and all versions of Windows. 
     Functionally, an operator at programmer  20  or an operator at data center  62  would initiate remote contact. Programmer  20  is down linkable to IMDs via link antennas  28 ,  32  and  38  to enable data reception and transmission. For example, an operator or a clinician at data center  62  may downlink to programmer  20  to perform a routine or a scheduled evaluation of programmer  20 . In this case the wireless communication is made via wireless link  65 . If a downlink is required from programmer  20  to IMD  10  for example, the downlink is effected using telemetry antenna  22 . In the alternate, if an uplink is initiated from patient  12  to programmer  20  the uplink is executed via wireless link  26 . As discussed herein below, each antenna from the IMDs can be used to uplink all or one of the IMDs to programmer  20 . For example, IMD  10 ,  10 ′,  10 ″ (which relates to neural implant  30 ) can be implemented to up-link, via wireless antenna  26 ′,  28 ′,  34 ′,  34 ′  40 ,  40 ′ or wireless antenna  24  of cellular phone  20 ′, any one, two or more IMDs to programmer  20 . Preferably bluetooth chips, adopted to function within the body to outside the body and also adopted to provide low current drain, are embedded in order to provide wireless and seamless connections  42 ,  44  and  46  between IMDs  10 ,  10 ′ and  10 ″. The communication scheme is designed to be broadband compatible and capable of simultaneously supporting multiple information sets arid architecture, transmitting at relatively high speed, to provide data, sound and video services on demand. 
     FIG. 2 illustrates typical components of an IMD, such as those contemplated by the present invention. Specifically, major operative structures common to all IMDs  10 ,  10 ′ and  10 ″ are represented in a generic format. In the interest of brevity, IMD  10  relative to FIG. 2 refers to all the other IMDs. Accordingly, IMD  10  is implanted in patient  12  beneath the patient&#39;s skin or muscle and is electrically coupled to heart  16  of patient  12  through pace/sense electrodes and lead conductor(s) (denoted by reference numeral  14  in FIG. 1) of at least one cardiac pacing lead  18  in a manner known in the art. IMD  10  contains therapy  1  monitor  70 , timing control  72  including operating system that may employ microprocessor  74  or a digital state machine for timing, sensing and pacing functions in accordance with a programmed operating mode. IMD  10  also contains sense amplifiers for detecting cardiac signals, patient activity sensors or other physiologic sensors for sensing the need for cardiac output, and pulse generating output circuits for delivering pacing pulses to at least one heart chamber of heart  16  under control of the operating system in a manner well known in the prior art. The operating system includes memory registers or RAM/ROM  78  for storing a variety of programmed-in operating mode and parameter values that are used by the operating system. The memory registers or RAM/ROM  76  may also be used for storing data compiled from sensed cardiac activity and/or relating to device operating history or sensed physiologic parameters for telemetry out on receipt of a retrieval or interrogation instruction via suitable telemetry circuitry  78 . All of these functions and operations are well known in the art, and many are generally employed to store operating commands and data for controlling device operation and for later retrieval to diagnose device function or patient condition. 
     Programming commands or data are transmitted between IMD  10  RF telemetry antenna  28 , for example, and an external RF telemetry antenna  24  associated with programmer  20 . In this case, it is not necessary that the external RF telemetry antenna  24  be contained in a programmer RF head so that it can be located close to the patient&#39;s skin overlying IMD 10 . Instead, the external RF telemetry antenna  24  can be located on the case of programmer  20 . It should be noted that programmer  20  can be located some distance away from patient  12  and is locally placed proximate to the IMDs such that the communication between IMDs  10 ,  10 ′ and  10 ″ and programmer  20  is telemetric. For example, programmer  20  and external RF telemetry antenna  24  may be on a stand a few meters or so away from patient  12 . Moreover, patient  12  may be active and could be exercising on a treadmill or the like during an uplink telemetry interrogation of realtime ECG or other physiologic parameters. Programmer  20  may also be designed to universally program existing IMDs that employ RF telemetry antennas of the prior art and therefore also have a conventional programmer RF head and associated software for selective use therewith. 
     In an uplink communication between IMD  10  and programmer  20 , for example, telemetry transmission  22  is activated to operate as a transmitter and external RF telemetry antenna  24  operates as a telemetry receiver. In this manner data and information may be transmitted from IMD 10  to programmer  20 . In the alternate, IMD  10  RF telemetry antenna  26  operates as a telemetry receiver antenna to downlink data and information from programmer  20 . Both RF telemetry antennas  22  and  26  are coupled to a transceiver comprising a transmitter and a receiver. 
     FIG. 3A is a simplified circuit block diagram of major functional components of programmer  20 . The external RF telemetry antenna  24  on programmer  20  is coupled to a telemetry transceiver  86  and antenna driver circuit board including a telemetry transmitter and telemetry receiver  34 . The telemetry transmitter and telemetry receiver are coupled to control circuitry and registers operated under the control of microcomputer  80 . Similarly, within IMD  10 , for example, the RF telemetry antenna  26  is coupled to a telemetry transceiver comprising a telemetry transmitter and telemetry receiver. The telemetry transmitter and telemetry receiver in IMD  10  are coupled to control circuitry and registers operated under the control of microcomputer  74 . 
     Further referring to FIG. 3A, programmer  20  is a personal computer type, microprocessor-based device incorporating a central processing unit, which may be, for example, an Intel Pentium microprocessor or the like. A system bus interconnects CPU  80  with a hard disk drive, storing operational programs and data, and with a graphics circuit and an interface controller module. A floppy disk drive or a CD ROM drive is also coupled to the bus and is accessible via a disk insertion slot within the housing of programmer  20 . Programmer  20  further comprises an interface module, which includes a digital circuit, a non-isolated analog circuit, and an isolated analog circuit. The digital circuit enables the interface module to communicate with interface controller module. Operation of the programmer in accordance with the present invention is controlled by microprocessor  80 . 
     In order for the physician or other caregiver or operator to communicate with the programmer  20 , a keyboard or input  82  coupled to CPU  80  is optionally provided. However the primary communications mode may be through graphics display screen of the well-known “touch sensitive” type controlled by a graphics circuit. A user of programmer  20  may interact therewith through the use of a stylus, also coupled to a graphics circuit, which is used to point to various locations on screen or display  84  which display menu choices for selection by the user or an alphanumeric keyboard for entering text or numbers and other symbols. Various touch-screen assemblies are known and commercially available. Display  84  and or the keyboard comprise means for entering command signals from the operator to initiate transmissions of downlink or uplink telemetry and to initiate and control telemetry sessions once a telemetry link with data center  62  or an implanted device has been established. Display screen  84  is also used to display patient related data and menu choices and data entry fields used in entering the data in accordance with the present invention as described below. Display screen  84  also displays a variety of screens of telemetered out data or real-time data. Display screen  84  may also display plinked event signals as they are received and thereby serve as a means for enabling the operator to timely review link-history and status. 
     Programmer  20  further comprises an interface module, which includes digital circuit, non-isolated analog circuit, and isolated analog circuit. The digital circuit enables the interface module to communicate with the interface controller module. As indicated hereinabove, the operation of programmer  20 , in accordance with the present invention, is controlled by microprocessor  80 . Programmer  20  is preferably of the type that is disclosed in U.S. Pat. No. 5,345,362 to Winkler, which is incorporated by reference herein in its entirety. 
     Screen  84  may also display up-linked event signals when received and thereby serve as a means for enabling the operator of programmer  20  to correlate the receipt of uplink telemetry from an implanted device with the application of a response-provoking action to the patient&#39;s body as needed. Programmer  20  is also provided with a strip chart printer or the like coupled to interface controller module so that a hard copy of a patient&#39;s ECG, EGM, marker channel of graphics displayed on the display screen can be generated. 
     As will be appreciated by those of ordinary skill in the art, it is often desirable to provide a means for programmer  20  to adapt its mode of operation depending upon the type or generation of implanted medical device to be programmed and to be compliant with the wireless communications system through which data and information is transmitted between programmer  20  and data center  62 . 
     FIG. 3B is an illustration of the major components of Wave unit  90  utilizing laser technologies such as for example the WaveStar Optic Air Unit, manufactured by Lucent Technologies or equivalent. This embodiment may be implemented for large data transfer at high speed in applications involving several programmers. The unit includes laser  92 , transceiver  94  and amplifier  96 . A first wave unit  90  is installed at data center  62  and a second unit is located proximate to programmer  20  or pill dispenser  20 ′. Data transmission between remote data center  62  and programmer unit  20  is executed via wave units  90 . Typically, the first wave unit  90  accepts data and splits it into unique wavelength for transmission. The second wave unit recomposes the data back to its original form. 
     FIGS. 4A,  4 B and  4 C represent various views of pill dispenser unit  20 ′. The structure includes pill containers  100  that protrude upwards from the surface for pill or drug containment. The structure also includes upper metalized layer  102 , superimposed on a plastic cover and lower metalized layer  104  superimposed on a plastic cover. Piezoelectric film  106  is disposed between the upper and the lower metalized layers. Further, microprocessor  108  is embedded between the upper and the lower layers. Telemetric antenna  110  is in electronic communications with microprocessor  108  and extends outward proximate therefrom. 
     Pill container  100  includes an indicator for the absence or presence of a pill in containers  100 . Pill dispenser unit  20 ′ is in preferably telemetric or equivalent wireless communications with IMDs  10 ,  10 ′ and  10 ″. In the alternate, pill dispenser unit  20 ′ is in data communications with programmer  20 . 
     Referring to FIG. 5, a communication scheme between remote data center  62 , physician station  120  and programmer  20  and/or pill dispenser unit  20 ′. As indicated hereinabove, data center  62  includes high-speed computers and is preferably web enabled to provide remote access. Communication links A, B, C, D, E and F are preferably wireless although any other communication system such as cable, fiber-optics or equivalent could be implemented. 
     Generally, the present invention provides drug delivery and management primarily based on the chronic communications between pill dispenser unit  20 ′ and IMDs  10 ,  10 ′ and  10 ″. Specifically, IMDs  10 ,  10 ′ and  10 ″ include a software program which would monitor the number of pills in pill dispenser  20 ′ via link B which is equivalent to telemetry  110 . In the alternate, the number of pills in dispenser  20 ′ may be tracked via link C which establishes the communication between pill dispenser  20 ′ and programmer  20 . Pill dispenser  20 ′ includes means for indicating the pill deposition from the package or container. Further IMDs  10 ,  10 ′ and  10 ″ include means for monitoring the deposition of the pills. A prescribed therapy schedule is preferably preprogrammed in the memory of IMDs  10 ,  10 ′ and  10 ″. The actual pill deposition in container  100  is known and correlates to one or more of the parameters programmed in IMDs  10 ,  10 ′ and  10 ″. Thus, the actual pill removal is assumed to be a precursor of administration of the pill by the patient consistent with the prescribed regimen. The relevant marker designating the time, dosage, and the type of medication is generated within a various diagnostic tables, and trend curves representing different physiologic parameters. 
     Further, IMDs  10 ,  10 ′ and  10 ″ chronically monitor the physiologic parameters of the patient and may alert the patient in cases, for example, when the drug does not influence a trend curve, causes the trends curve to oscillate, patient is not following the prescribed regimen or patient stops taking the medication altogether. Subsequently, IMDs  10 ,  10 ′ and  10 ″ could alert the physician or clinician to confer with the patient. This may be done via programmer  20  up-linking to data center  62 . The Physician at station  120  will be able to access the patient data from data center  62 . As shown in FIG. 5, Pill dispenser  20 ′ is in data communication with data center  62 . Thus the status of pill dispenser  20 ′ is registered in either device or patient databases for the clinician to investigate. 
     Pill dispenser  20 ′ is generally structured with a plurality of metal;lic layers such as  102  and  104 , preferably aluminum and plastic layers. Thus pill dispenser  20 ′ is a capacitor cell. Piezoelectric film  106  is similar to commercially available Kynar or equivalent, sandwithced between the two layers. Accordingly, whenever the patient manipulates pill dispenser  20 ′ to break container  100  and remove a pill, a voltage will be produced within the piezoelectric film. This voltage may be used as a signal to the IMDs indicating the removal of a pill. Specifically, the signal being different from ECG, EMG, EMI or any other body generated signal, is suited to be used as a signal from pill dispenser  20 ′ to IMDs  10 .  10 ′ and  10 ″. IMDs  10 ,  10 ′ and  10 ″ may be programmed to identify this signal as an indication that the seal has been opened and that a pill has been injested by the patient. In the alternate, pill dispenser  20 ′ may be used as a capacitor in a resonant circuit. Under this approach, when the patient presses the pill dispenser  20 ′ the impendance is changed due to the skin-metal impedance change and consequently the resonanace circuit may be closed by the patient&#39;s hands. Accordingly, IMDs  10 ,  10 ′ and  10 ″ are able to monitor dose data and related clinical parameters by communicating with pill dispenser  20 ′. The measurements performed by IMDs  10 ,  10 ′ and  10 ″ are specific to the type of preprogrammed criteria and determinants thereof. However, in the context of the present invention, IMDs  10 ,  10 ′ and  10 ″ could be programmed to monitor a given pill dispenser  20 ′ on a chronic basis. This will provide a stream of data that will indicate whether the patient has been following a prescribed dose and regimen. Further, IMDs  10 ,  10 ′ and  10 ″ may be programmed to monitor the efficacy of the drug by monitoring the physiological effects of the drug on the patient. Accordingly, a direct, real time assessment and interpretation of clinical status is obtained under the communication scheme advanced by the present invention. 
     Referring to programmer  20  in more detail, when a physician or an operator needs to interact with programmer  20 , a keyboard coupled to Processor  80  is optionally employed. However the primary communication mode may be through graphics display screen of the well-known “touch sensitive” type controlled by graphics circuit. A user of programmer  20  may interact therewith through the use of a stylus, also coupled to a graphics circuit, which is used to point to various locations on a screen/display to display menu choices for selection by the user or an alphanumeric keyboard for entering text or numbers and other symbols as shown in the above-incorporated &#39;362 patent. Various touch-screen assemblies are known and commercially available. The display and or the keyboard of programmer  20 , preferably include means for entering command signals from the operator to initiate transmissions of downlink telemetry from IMDs and to initiate and control telemetry sessions once a telemetry link with one or more IMDs has been established. The graphics display/screen is also used to display patient related data and menu choices and data entry fields used in entering the data in accordance with the present invention as described below. The graphics display/screen also displays a variety of screens of telemetered out data or real-time data. Programmer  20  is also provided with a strip chart printer or the like coupled to interface controller module so that a hard copy of a patient&#39;s ECG, EGM, marker channel or similar graphics display can be generated. Further, Programmer  20 &#39;s history relating to instrumentation and software status may be printed from the printer. Similarly, once an uplink is established between programmer  20  and any one of IMDs  10 ,  10 ′ and  10 ″, various patient history data and IMD performance data may be printed out. The IMDs contemplated by the present invention include a cardiac pacemaker, a defibrillator, a pacer-defibrillator, implantable monitor (Reveal), cardiac assist device, and similar implantable devices for cardiac rhythm and therapy. Further the IMD units contemplated by the present invention include electrical stimulators such as, but not limited to, a drug delivery system, a neural stimulator, a neural implant, a nerve or muscle stimulator or any other implant designed to provide physiologic assistance or clinical therapy. 
     Data center  62  represents a high speed computer network system having wireless bi-directional data, voice and video communications with programmer  20  and/or pill dispenser  20 ′ via wireless communications link  136 . Generally data center  62  is preferably located in a central location and is preferably equipped with high-speed web-based computer networks. Preferably, data center  24  is manned 24-hours by operators and clinical personnel who are trained to provide a web-based remote service to programmer  20  and/or pill dispenser  20 ′. In accordance with the present invention, data center may be located in a corporate headquarters or manufacturing plant of the company that manufactures programmer  20 . The wireless data communications link/connections can be one of a variety of links or interfaces, such as a local area network (LAN), an internet connection, a telephone line connection, a satellite connection, a global positioning system (GPS) connection, a cellular connection, a laser wave generator system, any combination thereof, or equivalent data communications links. 
     As stated hereinabove, bidirectional wireless communications D , E and F act as a direct conduit for information exchange between remote data center  62  and programmer  20 , pill dispenser  20 ′ and physician center  120 , respectively. Further, bi-directional wireless communications A and B provide an indirect link between remote data center  62  and IMDs  10 ,  10 ′ and  10 ″ via programmer  20  and pill dispenser  20 ′. In the context of this disclosure the word “data” when used in conjunction with bi-directional wireless communications also refers to sound, video and information transfer between the various centers. 
     Generally, in the context of the invention, all programmers located proximate to IMDs or patients with IMDs and distributed globally are connected to an expert data center to share software upgrades and access archived data. The programmer functions as an interface between the remotely located expert data center and the IMDs. Further, procedural functions such as monitoring the performance of the IMDs, upgrading software in the IMDs, upkeep and maintenance of the IMDS and related functions are implemented via the programmer. The preferably telemetric and yet local interaction between the programmer and the IMDs needs to be managed by a qualified operator. In order to facilitate the just-in-time patient care at the location of the patient, the invention provides pill dispenser  20 ′ that is preferably wirelessly linked to data center  62 . This scheme enables the dissemination of drug related clinical information worldwide while maintaining a high standard of patient care at reduced costs. 
     Although specific embodiments of the invention have been set forth herein in some detail, it is understood that this has been done for the purposes of illustration only and is not to be taken as a limitation on the scope of the invention as defined in the appended claims. It is to be understood that various alterations, substitutions, and modifications may be made to the embodiment described herein without departing from the spirit and scope of the appended claims.