Patent Publication Number: US-2010125174-A1

Title: Remote Support of Implantable Medical Devices

Description:
FIELD OF THE INVENTION 
     The subject matter presented herein generally pertains to providing remote support relating to implantable medical devices (IMDs). 
     BACKGROUND 
     Various implantable medical devices (IMDs) exist in the marketplace to treat a range of patient conditions. A variety of external medical devices are configured to communicate with the IMDs. For instance, a programmer can be utilized to retrieve data from an individual IMD. The data can be analyzed on the programmer and a clinician can change one or more parameter values in an attempt to enhance and potentially optimize a therapy supplied by the IMD. The described implementations provide support to the clinician in his/her programming decisions. 
     SUMMARY 
     Exemplary medical devices and systems for providing remote support relating to implantable medical devices (IMDs) are described. One method generates a graphical user-interface (GUI) relating to an IMD on a local medical device configured to interrogate the IMD. The method also recreates the GUI on a remote medical device effective that a cursor of the GUI can be manipulated from both the local medical device and the remote medical device while selection of IMD parameter values is available only at the local medical device. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       Features and advantages of the described implementations can be more readily understood by reference to the following description taken in conjunction with the accompanying drawings. In the description that follows, like numerals or reference designators will be used to reference like parts or elements wherever feasible. 
         FIG. 1  is a diagram of an exemplary system that includes a local device operated by a local clinician and a remote device operated by a remote clinician whereby information displayed locally is also displayed remotely. 
         FIG. 2  is a diagram of the system of  FIG. 1  where the remote clinician can control a cursor of the local device. 
         FIG. 3  is a diagram of the system of  FIGS. 1 and 2  illustrating a control operation. 
         FIG. 4  is a diagram of a device configured to communicate with an implantable medical device (IMD) and to program an IMD. 
         FIG. 5  is a diagram of a local device and associated graphical user interface (GUI) and a remote device and associated GUI where each GUI includes a text box for communication between operators of the local and remote devices. 
         FIG. 6  is a diagram of an exemplary system that allows a team of clinicians to participate in care of a patient with an IMD where the team includes at least one local clinician with exclusive control over programming of the IMD (see, e.g., the “program changes” control button  412  of  FIG. 4 ). 
         FIG. 7  is a functional block diagram of an exemplary external medical device illustrating basic elements that are operable to provide remote support relating to implantable medical devices (IMDs) in accordance with some implementations. 
         FIG. 8  is a flowchart of an exemplary method for providing remote support relating to implantable medical devices (IMDs) in accordance with some implementations. 
     
    
    
     DETAILED DESCRIPTION 
     Overview  
     Various exemplary techniques, methods, devices, systems, etc., described herein pertain to remote support scenarios involving implantable medical devices (IMDs). For instance, a clinician (hereinafter local or first clinician) can utilize an external medical device to interrogate an (IMD). The interrogation by the external medical device can acquire information indicative of a patient&#39;s condition, IMD settings, etc., and then display the information for review by the local clinician. Upon display, the local clinician may have questions about the patient&#39;s status. For example, the local clinician may have questions about how to interpret patient information and/or how to adjust patient therapies implemented by the IMD and answers to such questions may require contacting another clinician, a device representative, or other person. As described herein, various exemplary technologies allow content from a local external medical device to be displayed on a remote device with optional controls for manipulation of the information and with restrictions that require certain actions to be taken by a local clinician only. 
     For example, an exemplary system allows a clinician (hereinafter remote or second clinician) at a remote site to view information and graphics viewed by the local clinician. Such an approach can assist the local clinician to take an appropriate course of action, such as adjusting a patient&#39;s therapy. As many local clinicians welcome support if they can maintain ultimate control over the patient, various implementations allow the remote clinician only selective control (i.e., restricted control) over the local external medical device&#39;s display. According to this scheme, the local clinician retains sole authority to implement any programming changes to the IMD. To facilitate communication, a system may include a dialog box at the external medical device and a dialog box at the remote device to facilitate textual correspondence between the local clinician and the remote clinician. 
     Exemplary Systems 
       FIGS. 1-4  collectively illustrate a system  100  that enables remote support in implantable medical device (IMD) scenarios. System  100  includes an exemplary external medical device manifested as a programmer  102 . An IMD  104  is positioned in a patient  106 . The programmer  102  is configured to communicate with IMD  104  via a telemetry wand  108  or other mechanism. In this instance, IMD  104  functions as an implantable cardiac therapy device (ICTD) for a patient&#39;s heart  110 . Although the IMD  104  is illustrated as an ICTD, the IMD  104  may be configured in a variety of ways, such as an implantable cardiac monitor that monitors heart activity, an implantable neurological device that monitors and/or stimulates nerves, and other implantable devices used for diagnostic and/or therapeutic purposes. 
     During a programming session, a first clinician  112  of programmer  102  can interrogate the IMD  104  to obtain IMD-related data. A programming session can be thought of as anytime IMD-related or patient data is exchanged between the IMD and an external medical device. In some cases the IMD-related data can include data sensed by the IMD  104  and/or any other data related to the IMD and/or the patient. The programmer  102  can offer processing and analysis of the IMD-related data and/or can display various aspects of the IMD-related data. The first clinician  112  can control the programmer via various input devices such as keyboard  114 , touch pad or glide pad  116 , and left and right click buttons  118 ,  120  to have specific IMD-related data displayed. In this case, control of programmer  102  is achieved by controlling a cursor  122  via the keyboard, touch pad and/or the left and right click buttons. In other implementations a mouse or other mechanism can be utilized to control the cursor  122 . Still other implementations can employ a touch sensitive screen or display effective that the first clinician can engage the touch sensitive screen to control the programmer  102 . 
     Network  132  allows data transfer between programmer  102  and a second external medical device in the form of a server  134 . A second clinician  136  can view the data on server  134 . As will be described in more detail below, the second clinician can selectively manipulate the data via an input device. In this case, the second clinician&#39;s input device is in the form factor of mouse  138 . Implementations can alternatively or additionally include other input devices for the second clinician. As used herein descriptive terms are employed relative to the patient. For instance, programmer  102  is local to the patient and server  134  is remote relative to the patient. 
       FIG. 1  offers an example of a graphical user-interface (GUI) that can be generated from IMD-related data. In this case the GUI can be generated on a display area  140  of programmer  102  during a programming session of the patient&#39;s IMD. The GUI is manifested as a basic parameters screen  142  that includes a base rate parameter window  144 . Three base rate parameter values “50”, “60”, and “70” are listed in base rate parameter window  144  in individual selectable dialog boxes. Further, the present base rate parameter value is “60” as indicated by shading designated generally at  146 . 
     The display area  140  of programmer  102  is also shown on server  134  in a support window  148 . In this case, support window  148  occupies a subset of the server&#39;s display area so that a portion  150  of the server&#39;s display area remains visible for the server&#39;s content. In other configurations, the support window can occupy all of the server&#39;s display area. 
     Assume for purposes of explanation that patient  106  is complaining of feeling poorly when exercising and that clinician  112  has brought up the basic parameter screen  142  responsive to the patient&#39;s complaints. Further, the first clinician  112  is considering changing the base rate parameter value to address the patient&#39;s complaints but is unsure of an appropriate strategy. The first clinician can communicate with the second clinician about the patient&#39;s clinical scenario. For instance, the clinicians can communicate orally or in writing over network  132  or via an independent mechanism. Assume for purposes of example that second clinician  136  recognizes that the base rate parameter value should be changed from “60” to “70” to address the patient&#39;s complaints. This scenario is continued below in relation to  FIG. 2 . 
       FIG. 2  illustrates movement of cursor  122  on basic parameter screen  140  on both the programmer  102  and the server  134 . The cursor movement is indicated generally at  202  on programmer  102  and on server  124 . The cursor movement culminated with the cursor being positioned over the “70” dialog box of the base rate window  144 . The cursor movement can be accomplished from the programmer  102  and/or from the server  124 . Assume that in this instance, the cursor movement was made by the second clinician on server  134  to aid the first clinician in addressing the patient&#39;s symptoms. 
       FIG. 3  illustrates selection of the value “70” dialog box within base rate parameter window  144  to alter the patient&#39;s treatment. The selection is evidenced on both the programmer  102  and the server  134 . In this case the selection is indicated by shading of the dialog box associated with the parameter value of “70” and the removal of shading from the dialog box associated with the parameter value of “60”. In contrast to cursor movement which can be accomplished via either of the programmer  102  or the server  134 , in this implementation, selection of an element such as a dialog box can be accomplished only on the programmer  102 . Accordingly, while the second clinician can aid the first clinician in the decision making process ultimate authority and responsibility for any changes to the patient&#39;s therapy remains with the first clinician. 
     In another implementation, selection of elements such as parameter values and/or other programming changes can be made from either the programmer  102  or the server  134 . For instance, selection of the “70” base rate value can be achieved on the programmer via the left or right click buttons  118 ,  120  or a key such as a “return” key of the keyboard  114 . Similarly, the selection can be made via the server&#39;s mouse  138  or the server&#39;s keyboard (not shown). In this configuration final approval of the selections is reserved for the first clinician  112 . An example relating to final approval of the selections is described in relation to  FIG. 4 . 
       FIG. 4  shows an example of a screen  402  on programmer  102  that allows the first clinician final approval for pending programming changes. Screen  402  lists the pending programming changes in a preview window  404 . In this case the pending changes include the base rate parameter indicated at  406 . A current value of “60” is listed for the base rate parameter at  408 . A new or pending value of “70” is listed for the base rate parameter at  410 . The first clinician can review the pending changes. The first clinician can either program the changes via a program changes dialog box  412  or cancel the changes via a cancel dialog box  414 . Screen  402  also can be displayed on server  134 , but selection of the program changes and cancel dialog boxes  412 ,  414  can only occur via programmer  102 . This implementation can offer more extensive control to the second clinician than is offered in some other implementations while maintaining the final decision making responsibility for the first clinician. Accordingly the second clinician can provide additional assistance to the first clinician. For instance, the second clinician can select various display elements such as icons and/or dialog box(es) to reach a relevant screen rather than only being able to move the cursor and then relying on the first clinician to “click” at the appropriate times. Accordingly, in this case the second clinician utilizing the server can walk the first clinician through a series of steps to change the IMD&#39;s programming while the first clinician maintains final control to implement or cancel the parameter changes. In one such case where the programmer&#39;s screen  402  is a touch sensitive screen, both the first and second clinicians can be allowed to manipulate the cursor etc, but final selections can only be made by physically engaging the touch sensitive screen. In such a case only the first clinician is actually proximate the touch sensitive screen and can thereby make the final selections. 
     In a particular example, the local programmer  102  is the only device configured to display a control such as the “Program Changes” button  412 . This approach ensures that the ultimate decision to program an IMD occurs locally and risk of error by a remote care provider is non-existent as any remote device is either prohibited or otherwise not configured to display such a programming control option. In another example, a remote device may display the button  412  but only as an inactive graphic. In this example, the local device includes the only active control, in the system, for making any changes to an IMD (e.g., setting a programmable parameter for delivery of a cardiac resynchronization therapy, disabling a feature, adjusting a shock energy, etc.). 
       FIG. 5  shows another implementation relating to remote support. As described previously, content from the programmer  102 , such as the basic parameters screen  142 , can be displayed on both the programmer  102  and the server  134 . Further, in this implementation a dialog box  502  is displayed on both the programmer  102  and the server  134 . Dialog box  502  allows either of the first and second clinicians to type in text that can be seen by the other of the clinicians. Allowing text correspondence to be exchanged between the local and remote medical devices (in this case the programmer and the server) regarding the patient&#39;s IMD can enhance patient treatment. For instance, if the first clinician that is operating the programmer encounters a patient scenario that he/she is unsure how to treat, then the first clinician may want to be able to discretely obtain advice from the second clinician. For example, in some cases the first clinician may be uneasy about making a telephone call to the second clinician in front of the patient. 
     Dialog box  502  allows the clinicians to engage in a textual conversation while viewing the patient information on the respective programmer  102  and server  134 . Such an implementation may increase a likelihood of the first clinician utilizing the expertise of the second clinician thereby enhancing patient treatment and decreasing mistakes and/or underutilization of the features of the IMD that the first clinician may not fully understand. For instance, in the illustrated example, as indicated generally at  504  the first clinician has described the patient&#39;s condition and requested suggestions from the second clinician. The second clinician responds “let&#39;s adjust the base rate parameter” as indicated at  506 . In such a scenario, the dialog box can allow the second clinician to inform the first clinician what he/she intends to do prior to taking any action relating to the programmer&#39;s display such as switching screens and/or selecting parameter values. Accordingly, the dialog box can facilitate a meeting of the minds of the first and second clinicians about what they are trying to accomplish via the programmer&#39;s display. 
     In this case, text dialog box  502  is displayed on areas of programmer  102  and server  134  that are not presently utilized in displaying other IMD related content. In other configurations, the text dialog box can be superimposed over other GUI content related to the IMD. In some instances the text dialog box can be established in a fixed location on the display. In other configurations, the text dialog box is configured to be moved as desired such as by dragging-and-dropping. 
       FIG. 6  shows a system  600  for providing remote support to a patient who has an IMD. In this case patient  602  has an IMD  604 . System  600  includes external medical devices that can communicate with the IMD and/or process IMD-related data. In the present example, the system  600  includes three external medical devices (e.g., a device manager  606  or a cell-phone device  606 ′, the programmer  608  and the server  610 ). The device manager  606  or the cell-phone device  606 ′ is in close enough proximity to patient  602  to interrogate the patient&#39;s IMD  604 . The device manager  606  or the cell-phone device  606 ′ can communicate with a remote medical device in the form of programmer  608  and/or a centralized medical device in the form of server  610  via a network  612 . The device manager, programmer and server include display areas  614 ,  616 , and  618  respectively for displaying IMD-related data. 
     Device manager  606  (or cell-phone device  606 ′) can be utilized to communicate IMD-related data to and from the IMD  604  sufficient to allow the device manager to reprogram the IMD. In this case, device manager  606  (or cell-phone device  606 ′) is configured to display IMD-related data on a GUI  620  that occupies display area  614 . In this case, GUI  620  occupies all of display area  614 . In other instances, the GUI can occupy a lesser subset of the display area. For purposes of example, the illustrated GUI  620  relates to a base rate parameter. The current base rate parameter value is listed as “60”. The GUI also includes a user-selectable up button  622  for increasing the base rate parameter value and a user-selectable down button  624  for decreasing the base rate parameter value. 
     The device manager&#39;s GUI  620  and/or display area  614  can also be displayed on both programmer  608  and server  610  as indicated generally at  626  and  628 , respectively. In this case, the GUI occupies all of the display area so the two terms can be used interchangeably. Further, programmer  608  can be configured to display other IMD-related data in addition to the device manager&#39;s GUI  620 . In this case, the additional IMD-related data is represented as rates window  630 . For the cell-phone device  606 ′, the GUI  620  may be appropriately sized and displayed with various options for scrolling or paging (e.g., CSS or other form of display techniques). 
     Server  610  can be configured to display the display areas of both the device manager  606  (or cell-phone device  606 ′) and the programmer  608  on its display area  618 . In this case, the device manager&#39;s display area  614  is displayed on the server as indicated at  628  and the programmer&#39;s display area  616  is displayed on the server as indicated generally at  634 . In other configurations, the server can display only GUI&#39;s occupying the display area  614  of the device manager and/or the display area  616  of programmer rather than the entire display area. For instance, the GUI indicated generally at  636  can be included on server  610  rather than the programmer&#39;s entire display area that is indicated at  634 . Stated another way, the server can be configured to display content and/or display area of both the device manager  606  (or cell-phone device  606 ′) and the programmer  608 . 
     In some cases the device manager  606  (or cell-phone device  606 ′) can be utilized to provide a first or basic level of support for the patient&#39;s IMD, while the programmer  608  and the server  610  provide enhanced secondary and tertiary levels of support. For example, consider a usage scenario where the device manager is employed by an emergency room (ER) doctor  640  at a rural hospital. In this usage scenario the programmer is employed by the patient&#39;s electrophysiologist (EP)  642  and the server is employed by a specialist  644  in IMD function at a facility operated by the manufacturer of the IMD. In such a scenario, the device manager  606  offers a basic functionality that allows the ER doctor to view and/or adjust at least some patient-related data. For instance, the device manager can allow the ER doctor to adjust various parameter values of the IMD, such as the illustrated base rate parameter value. In some scenarios, the device manager provides a relatively robust functionality relative to the IMD, while in other scenarios the device manager offers a limited functionality, 
     In this case, the programmer  608  can offer a more robust functionality for processing and/or displaying IMD-related data than the device manager  606  (or cell-phone device  606 ′). In the illustrated configuration the programmer shows both the display of the device manager  606  (or cell-phone device  606 ′) as well as the rate information indicated at  630 . Accordingly, the EP  642  can view patient related data that may not be accessible on the device manager. Finally, the server  610  allows the specialist  644  to view the content displayed on the device manager  606  (or cell-phone device  606 ′) as well as the content displayed on the programmer  608 . 
     In some implementations, either or both of the EP  642  and the specialist  644  can control device manager  606  (or cell-phone device  606 ′) to aid the ER doctor  640  in making appropriate programming changes to the IMD  604 . For example, the device manager  606  can be controlled via either the programmer  608  or the server  610 . In some instances, the device manager can be selectively controlled via the server and/or the programmer. For instance, the device manager  606  (or cell-phone device  606 ′) can be selectively controlled via interaction with the device manager&#39;s GUI that is displayed on programmer  608  and the server  610 . Manipulations received at the server or programmer are relayed to the device manager via network  612 . Ultimate authority to implement IMD programming changes can be reserved for one of the ER doctor, the EP, or the specialist. For instance, the patient&#39;s EP may be most familiar with the patient&#39;s condition. In such a scenario, approval of any programming changes to the IMD can only be received at the programmer  608  so that the EP  642  retains ultimate authority and responsibility for the patient. In another case, ultimate authority for programming changes to the IMD can be reserved for the device manager  606  (or cell-phone device  606 ′) since it is proximate the patient. In this latter configuration, the ER doctor  640  is treating the patient and retains ultimate authority and responsibility for the patient. 
     Exemplary External Medical Device Configuration 
       FIG. 7  describes functional components of an exemplary external medical device in the form of a programmer  702  in more detail. The described components can also be implemented in other external medical device configurations such as programmer  102 , server  134 , and/or device manager  606  described in relation to  FIGS. 1-6 , among others. The skilled artisan should recognize other devices that are compatible with the concepts described above and below. In this instance, programmer  702  includes a processing or control unit  704  and memory  706 . The control unit  704  controls operations carried out by the programmer  702 , such as programming an IMD, gathering data from the IMD, and/or carrying out various testing or diagnostic functions. Memory  706  includes both volatile memory  708  (e.g., RAM) and non-volatile memory  710  (e.g., ROM, EEPROM, Flash, disk, optical discs, persistent storage, etc.). 
     Programs, operating parameters, and algorithms  712 , which are used in controlling the programming and testing functions, may be stored in memory  706 . When a program is running, various instructions are loaded into volatile memory  708  and executed by control unit  704 . IMD-related data or device data  714  collected from the IMD may be stored in memory  706  for subsequent analysis and/or transfer to other medical systems. 
     In this particular configuration, a parameter module  716  and a remote support module  718  are also stored in memory  706 . Parameter module  716  is configured to determine a current parameter setting of the IMD as well as alternative values to which the parameter can be adjusted. 
     Remote support module  718  is configured to exchange data between programmer  702  and other medical devices to enable remote support. Examples of other medical devices include servers  134 ,  610  described in relation to  FIGS. 1-3  and  5 - 6  and device manager  606  described above in relation to  FIG. 6 . In some configurations, the remote support module exchanges actual IMD-related data that is displayed on the programmer to other medical devices to allow the IMD-related data to be recreated on the other medical devices. In other configurations, the remote support module can send image data sufficient to recreate a GUI displayed on the programmer without sending the underlying IMD-related data conveyed by the GUI. In other words image data is sent sufficient to recreate the “look” of the GUI and not actually the GUI itself. Still other configurations can send some combination of image data and underlying IMD-related data. 
     The remote support module  718  can further be configured to receive input from a remote medical device such as a server and to cause the display of the programmer to be updated to reflect the received input. In some instances the remote support module can offer a degree of selectivity relating to the input received from another medical device. For instance, the remote support module can distinguish received input relating to cursor movement from received input relating to parameter value selection. In such a case, the remote support module can implement the cursor movement, but disallow the parameter value selection. The skilled artisan should recognize other variations. Further, while the current implementation involves remote support modules operating on individual medical devices, other implementations may be web-based where data processing tends to occur at a centralized location. Medical devices having various degrees of robustness can function as input/output devices for the processed data communicated from the central location. 
     The programmer  702  may further be equipped with a network I/O connection  730  to facilitate communication with a network and/or other medical devices such as a server(s). The network I/O  722  may be a wire-based connection (e.g., network card, modem, etc.) or a wireless connection, such as a Bluetooth device. 
     The programmer  702  can be equipped with a telemetry sub-system  732  that manages communications between programmer  702  and an IMD. The telemetry sub-system  732  can include telemetry hardware such as telemetry wands and/or other telemetry mechanisms for communicating with the IMD. 
     The programmer  702  may also include a user interface  740  which includes one or more user input mechanism(s)  742  and one or more output mechanisms  744 . Input mechanisms allow user input to be received by the programmer. Examples of mechanisms for user input include, but are not limited to keypads, buttons, selection wheels, touch pads, touch screens or touch-sensitive screens, and voice recognition systems, among others. Output mechanisms  744  allow information to be provided from the programmer for user observation. The output mechanisms generate signals such as audio and/or visual signals that convey IMD-related data. Examples of output mechanisms include, but are not limited to, monitors, LEDs, speakers, and/or printing mechanisms, among others. For purposes of characterization, distinct input and output mechanisms are described, but in some instances, a single mechanism performs both functions. For instance, the user interface can be manifested as a touch-sensitive screen which performs both input and output functions. 
     The components illustrated in  FIG. 7  are interconnected via one or more buses (not shown) and are powered by a power supply  750 . Further, while aspects of programmer  702  are described in relation to modules implemented by programmer  702 , various modules could alternatively or additionally be implemented as freestanding components such as application specific integrated circuits (ASIC). Additionally, various aspects of the methods and systems described throughout this disclosure may be implemented in computer software or firmware as computer-executable instructions. The instructions can be stored on any computer-readable storage media. When executed, these instructions direct the programmer to perform various functions and tasks described above and below. 
     Operation 
       FIG. 8  shows an exemplary method or technique  800  for providing remote support relative to programming an implantable medical device (IMD). This method  800  may be implemented in connection with any suitably configured external medical devices and/or systems of external medical devices and/or IMDs. Non-limiting examples of devices and/or systems upon which the method can be implemented are described above in relation to  FIGS. 1-7 . 
     The order in which the method  800  is described is not intended to be construed as a limitation, and any number of the described blocks can be combined in any order to implement the method, or an alternate method. Furthermore, the methods can be implemented in any suitable hardware, software, firmware, or combination thereof such that a computing device can implement the method. In one case, the method is stored on a computer-readable storage media as a set of instructions such that execution by a computing device, such as an external medical device, causes the computing device to perform the method. 
     At block  802 , a first graphical user-interface (GUI) that relates to an implantable medical device (IMD) is generated on a local medical device configured to interrogate the IMD. The local medical device can be any medical device configured to communicate with the IMD. For instance, the local medical device can be in the form factor of a device manager, personal computer, programmer, or the like. The GUI can show various parameters that relate to the IMD. In some instances, a first clinician or user of the local medical device can change values of one or more parameters. The local medical device can then communicate the changed parameter values to the IMD. Stated another way, the IMD can be reprogrammed to reflect the changed parameter values. 
     At block  804 , a second GUI relating to the IMD is generated on a remote medical device. In some scenarios the remote medical device is configured to be operated in a supporting role to the local medical device. For instance, a second clinician operating the remote medical device may be more highly trained and/or potentially more knowledgeable about IMD functioning and/or the patient&#39;s condition than the first clinician. To this end, the remote medical device can be configured to allow the second clinician to offer remote support to the first clinician regarding the patient&#39;s IMD. In some cases, the GUI of the local medical device is recreated on the remote medical device effective that at least some GUI features or elements are controllable from either or both of the local medical device and the remote medical device. For instance, in some configurations a cursor of the GUI can be manipulated from both the local medical device and the remote medical device. In another example, a window relating to a particular parameter can be opened from either the local or remote medical devices. 
     Control of other GUI features can be restricted to the local medical device to maintain ultimate decision making authority with the first clinician. For example, in some configurations while cursor manipulation is shared, selection of IMD parameter values is available only at the local medical device. Still other configurations allow cursor movement and selection of GUI elements from both the local and remote medical devices. However, any resulting parameter changes to the IMD&#39;s programming can only be selected via the local medical device. For instance, the parameter changes can be listed on a summary screen which offers the option of programming the parameter changes or cancelling the changes. Selection at the summary screen can only be made via the local medical device. 
     Blocks  806  and  808  offer two variations on the concepts described above. At block  806  a dialog box can be displayed on both the local and remote medical devices concurrently with the GUI. The dialog box can allow text correspondence to be exchanged between the local and remote medical devices regarding the IMD. The dialog box facilitates communication between the first and second clinicians to promote appropriate patient therapy. Further, the dialog box offers discreet communication between the first and second clinicians in the presence of the patient. The first clinician is more likely to be candid and/or to request help from the remote clinician when using the dialog box compared to a telephone conversation between the two clinicians in the presence of the patient. 
     At block  808  the method simultaneously displays both the first and second GUIs on a server medical device effective that both of the first and second GUIs can be selectively controlled from the server medical device. As used herein the term “server” simply means a medical device associated with or operated by a user skilled in IMD function and/or patient therapy. In some configurations the server medical device displays all of the displayed content of the local and remote medical devices. In other implementations only the GUIs from the local and remote medical devices are displayed on the server. Displaying the content of the local and remote medical devices on the server allows the server&#39;s user to oversee the actions of the first and second clinicians and/or allows the server&#39;s user to aid in reprogramming the patient&#39;s IMD. For instance, in some scenarios, the server&#39;s user has selective or unlimited control of both the local and remote medical devices via the server medical device. 
     CONCLUSION 
     Exemplary techniques, methods, devices, systems, etc., for providing remote support relative to programming an implantable medical device (IMD) are described above. Although techniques, methods, devices, systems, etc., have been described in language specific to structural features and/or methodological acts, it is to be understood that the subject matter defined in the appended claims is not necessarily limited to the specific features or acts described. Rather, the specific features and acts are disclosed as exemplary forms of implementing the claimed methods, devices, systems, etc.