Flinders University Telehealth in the Home Video Strategy Discussion Paper 2 October 2013 Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 1 of 14
A AUTHORS A.1 Project Technical Lead Name: Colin Carati Business Area: Information Services Position: A.2 Project Manager Executive Director (ICT Strategy and Integration) Contact No: +61882015887 Name: Alan Taylor Business Area: School of Medicine Position: NBN Telehealth Project Manager Contact No: 0409 415 486 A.3 Technical Support Officer Name: Greg Morris Business Area: School of Medicine Position: Technical Support Project Officer Contact No: 0430 367 300 Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 2 of 14
TABLE OF CONTENTS 1. INTRODUCTION... 4 1.1. CONTEXT... 4 1.2. VIDEO AND VOICE TECHNOLOGY... 4 1.3. TELECOMMUNICATIONS TECHNOLOGY... 4 1.4. DEVICE TECHNOLOGY... 4 1.5. WEB TECHNOLOGY... 6 2. VIDEO CONFERENCING INITIATIVES... 6 2.1. NATIONAL INITIATIVES... 7 2.2. INTERNATIONAL INITIATIVES... 7 3. VIDEO CONFERENCING FOR TELEHEALTH IN THE HOME... 9 3.1. TECHNOLOGY CONTEXT... 9 3.2. USER REQUIREMENTS... 9 3.3. ASSESSMENT... 10 4. VIDEO CONFERENCING IMPLEMENTATION (FLINDERS NBN TELEHEALTH)... 11 4.1. BUSINESS CONTEXT... 11 4.2. MANAGEMENT OF VIDEO CONFERENCING... 11 4.3. INTEROPERABILITY OF VIDEO CONFERENCING... 11 4.4. TECHNOLOGY OPTIONS... 12 4.5. ASSESSMENT... 13 4.6. TESTING... 13 4.7. ROLLOUT... 14 Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 3 of 14
1. INTRODUCTION Discussion Paper, Video Applications in Health Care This paper explores the issues and challenges of deploying video communications to support the delivery of video conferencing for the Flinders NBN Telehealth in the home project. The paper outlines the development of video conferencing technology, its application in the healthcare sector, and the factors to consider when selecting and testing appropriate video conferencing technology for this project 1.1. Context Video communications systems are not new. Widespread availability of video communications using public telecommunication networks commenced in the 1980s. The first wave of video conferencing terminals implemented in hardware, and connected to the public telecommunications network using the circuit switched ISDN system. In the 1990s adapter cards became available that provided video conferencing on personal computers. Video conferencing products were based on International telecommunication Union H.320 standards. 1.2. Video and Voice Technology Subsequently video algorithms improved and a new series of standards H.323 were introduced. This improvement coincided with a more widespread availability of Internet Protocol (IP) networks, so H.323 products were also able to be used on computer networks. An often forgotten component of a video application is voice. Voice transmission technology has changed greatly. Voice is very time sensitive so implementation of voice on unreliable computer networks has been difficult. Voice systems also need to work with the international telephone system. The Session Initiation Protocol (SIP) was developed to manage the connection of voice calls but can also be used to connect video conferencing calls. Further development of video and voice encoding and transmission built on the standards used by H.323 products and systems added a SIP capability. Because video conferencing and audio (phone) conferencing require a real time two way connections the capacity of the intervening telecommunications networks are very important. 1.3. Telecommunications Technology The highest grade telecommunications networks are those used by telecommunications carriers such as Telstra and the NBN. These networks are costly because they are carefully designed for reliability, performance and capacity. Large organisations such as Flinders University and SA Health run enterprise networks, which are not quite so reliable and cost less. The least reliable network is the home network, which is cheap, and works most of the time. There has been a significant growth in the use of wireless networks in the home, enterprise and public domains. These networks are by nature and design, best effort networks. Depending on the geography or building structure good performance may be achieved,, although saturation of the wireless network is likely to have a detrimental effect on the performance. 1.4. Device Technology Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 4 of 14
In the early development of video conferencing the large amount of information contained in a video stream demanded the implementation of video conferencing systems on purpose built hardware with custom software. Examples are the video conferencing room systems which are still in production today. Because they are purpose built, higher levels of reliability and quality can be achieved. However as the processing power of consumer computers has grown and encoding systems have improved, it has become possible to process video and voice data in real time on a personal computer. This has led to the emergence of video applications for consumer use that work most of the time over the internet such as Skype and YouTube. Software video conferencing applications cannot be as reliable as hardware based video applications because they: Have limited control over computer operating system and hardware on which they depend resulting in situations where they may work properly on one computer and not on another Compete with other applications for underlying resources on the computer May depend on the services of distant systems, for instance Skype application depend on the directory name services for Skype users. Are often written as consumer grade applications which have not been tested and debugged to the same extent as some industrial software may be Can provide lower quality video or audio due to processing, display, or ambient environmental factors The evolution of video technology is shown below (1): Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 5 of 14
1.5. Web Technology The application of Web technology to video conferencing is increasing. There are a number of proprietary Web based video services such as FaceTime and Skype ID, or Yahoo and Google+. Some vendors have also built web based interoperability environment where subscribers can not only call other subscribers but can call someone with, for instance a Skype account. Open source implementation of Web based video systems has spawned one project which seems to become quite successful, with several vendors promising to support WebRTC implementations. WebRTC is a free, open project that enables web browsers with Real-Time Communications (RTC) capabilities via simple Javascript APIs and HTML5. The WebRTC initiative is a project supported by Google, Mozilla and Opera. WebRTC operation is shown below (1) and allows: secure calls between any device with a web browser secure data exchange between parties calls to and from telecoms based video conference systems and telephones 2. VIDEO CONFERENCING INITIATIVES The health system is no stranger to video conferencing use. In 1997, Queensland Health had about 200 video conferencing systems connected by ISDN and was testing high definition systems running over networks faster than a home connection on the NBN. Australia has been in the forefront of video conferencing for medical purposes, through a number of state based, academic (AARNet) and standardisation initiatives. Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 6 of 14
2.1. National Initiatives In Australia the listing of telehealth (video) health service delivery as a Medical Benefits Scheme Item has created an opportunity for specialists, GPs and patients to consult using video conferencing. However it is largely not possible for a specialist or doctor to place a video call to a colleague in another organisation without manual intervention. This situation is analogous to the manual telephone switchboard era were all phones calls had to be placed through an operator. When organisations use different video conferencing products across different networks the difficulties of connecting users across organisational boundaries are increased. Currently video conferencing technology used in healthcare includes: Hardware based conferencing based on the International Telecommunications Union H.320 and H.323 standards running over ISDN telecommunications connections or Internet Protocols Hardware and software based video conferencing based on the Internet Engineering Taskforce recommendations using the Session Initiated Protocol (SIP) over computer networks using Internet Protocols Software based clients running on personal computing devices using SIP protocols Software based clients running on personal computing devices using proprietary protocols and user directories, the best known of which is Skype Software based clients from major software vendors running on personal computing devices using proprietary protocols and user directories, the best known of which is Microsoft Lync Web browser based clients using a variety of proprietary and standards based protocols. The most promising web based client using open source W3C software is called Web Real Time Communications (RTC) All of these technologies require special arrangements to communicate and share user directories. Consequently national initiatives to improve the interoperability of video systems used in health care have emerged, which include: a current national tender to provide a national video connection service the commencement (in August 2013) of a Health Direct Video service where callers can use a Web browser to initiate a video conference with a Health Direct health care advisor. a Standards Australia working group preparing a discussion paper on interoperability issues Commonwealth Government guidelines on the use of telehealth technology and professional guidelines such as the RACGP Guidelines for use of telehealth 2.2. International Initiatives International level ISO standards are also emerging to provide guidelines on the use of technology in health care. The ISO 80001 standard Application of risk management for ITnetworks incorporating medical devices provides an extensive guide to managing the risks to health care when using technology operating over computer networks. The ISO draft standard Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 7 of 14
ISO/DTS 13131, Health Informatics -- Quality criteria for services and systems for telehealth defines quality control process for telehealth. Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 8 of 14
3. VIDEO CONFERENCING FOR TELEHEALTH IN THE HOME 3.1. Technology Context The provision of telehealth in the home requires the operation of video technologies and systems across a number of hardware platforms, operating systems within and across enterprise and consumer environments. Cisco, Vydeo, Polycom, WebRTC, Skype Cisco, Vidyo, Polycom, WebRTC, Skype, Facetime Dedicated Video Endpoints Intel (Microsoft) Hardware and Operating Systems IoS, Android, Windows Apple Hardware and Operating Systems Tablets Enterprise Environment Consumer Environment NBN Telehealth Project Environment Technology View 3.2. User Requirements A clear definition of user requirements for supportive technology is especially important in health care. Technology may not work well if the role for the technology supporting a particular activity within a health care workflow has not been well designed. There are several key user requirements to address: Whether the use of video brings any added value over a face to face consultation? What quality of video and audio is actually required (due to environmental, human or clinical factors). For instance the best quality technology may deliver very bad quality if being used on a busy and noisy ward? Can the health care being delivered using video conferencing be delivered in any other way? At what point does the use of video conferencing become cost effective or time effective? What happens when a video connection cannot be established for any reason? Which clinicians need to be involved in the health care process, when and how? In what ways does the use of video conferencing make health workers working life better? Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 9 of 14
3.3. Assessment Once the user requirements, workflow context and the potential environmental scenarios are clear the assessment of potential solutions is possible. This may require an organisationally sanctioned procurement process to be followed. An assessment process will include: Feature comparison against user requirements Quality usability and performance claims Platform (device, operating system) availability Supporting infrastructure required (networks, servers, directories) Interoperability with local and national systems Degree of lock-in that could be created to one supplier Are other organisations using the product satisfactorily Dependencies on other systems not within an organisations control Lastly, but not least, an assessment of the level of local support available from a manufacturer or supplier, and the cost across a lifetime cycle, including maintenance costs is needed. Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 10 of 14
4. VIDEO CONFERENCING IMPLEMENTATION (FLINDERS NBN TELEHEALTH) 4.1. Business Context Our aim is to provide video conference solutions which are compatible with existing SA Health, Country Health SA systems, and private health care providers, since care provision crosses all these sectors. GPs Residenti al Aged Care Teaching, Research SA Health Outpatient Service Providers Specialists Patients in their homes Teaching and Research Flinders University NBN Telehealth in the Home Project Organisational View There is a need for a management system or switchboard to seamlessly make video connections and manage user / contact directories for video users across organisations. 4.2. Management of Video Conferencing A video management layer should include a number of functions shown below: Specialists GPs Carers Provider can access other Video Networks via Gateways Patient can call Provider Outpatient Providers Patient or Provider can make a Booking Provider can access Directories and Contact lists Patients in their homes Provider can Schedule calls Provider can collect Call Statistics 4.3. Interoperability of Video Conferencing Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 11 of 14
Interoperability between video clients provided by different vendors and enterprise style room systems and clinical systems is a major issue. Health care providers working in community health settings need to be able to set up, book, schedule video calls with other providers in a range of settings and organisations. Specialists Patients in Homes Patients in Residential Care Patients in Acute Care Outpatient Services The Switchboard GPs Families Carers Switchboard View A number of management systems from several vendors will be assessed for interoperability. At this stage in the development of video technology, it is unlikely that complete interoperability can be provided at a reasonable cost, so pragmatic decisions may be required. Currently both SA Health and Flinders University operate a Cisco / Tandberg environment focussed on service provision within the enterprise boundary. 4.4. Technology Options Currently there are four major options available for video conferencing: Hardware and software based video conferencing based on the Internet Engineering Taskforce recommendations using the Session Initiated Protocol (SIP) over computer networks using Internet Protocols Software based clients running on personal computing devices using proprietary protocols and user directories, the best known of which is Skype. Software based clients from major software vendors running on personal computing devices using proprietary protocols and user directories, the best known of which is Microsoft Lync, Cisco Jabber, Vidyo, Apple Facetime, and Polycom which use SIP based protocols to a greater or lesser degree. Software based clients running on personal computing devices using open source, SIP based protocols such as WebRTC. Users of video conferencing in the health system could be characterised as demanding. The reliability, usability and quality of video systems are especially important to these users. For this reason health organisations such as Queensland Health chose to base their video conferencing systems on: Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 12 of 14
Dedicated hardware based products Carrier or enterprise grade reliable telecommunication networks Networks which can prioritise the transmission of audio and video (quality of service aware networks) Controlled room environments so that high quality video and audio can be maintained Products that can use dedicated multipoint conferencing bridges The proliferation of consumer grade video conferencing products has posed challenges for health care organisations because: It is difficult to maintain quality of service and hence video and audio quality to these products Demand is difficult to control, potentially impinging on other health application performance on the same network Many products use distantly located public directories thus raising privacy concerns and network connectivity issues The audio, video, lighting and privacy environments in which the products can be used are more varied 4.5. Assessment On grounds of cost and complexity (an additional device in the home) the use of hardware based video products has not been prioritised. The Flinders University NBN Telehealth in the Home project requires video conferencing to operate from personal mobile devices in homes on portable devices. Consequently the project is investigating software video based clients. The selection of software based products need to take into account the following: functionality and usability of the management platform adequate video and audio quality over a variety of networks ease of use availability for major mobile devices extent to which additional supporting infrastructure is required able to interoperate with Flinders and SAHealth video networks based on international standards, reducing the risk of product lock-in to one supplier level of support required and available locally and from the vendor licencing arrangements 4.6. Testing Once a product has been assessed and selected design and testing is required. Testing needs to be based on test plans, use a controlled environment to ensure repeatability of test results, and be documented. Good supplier relationships are important in this phase. A supplier that is not able to be present on the ground, and assist with testing is unlikely to be able to provide long term support for the product. Testing needs to include: management platform features Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 13 of 14
a limited number of user and technology operating scenarios performance tests reliability tests usability functionality Tests long term availability tests 4.7. Rollout The IT world is no different to any other field. A new product and technology should be introduced gradually, into a defined and controlled environment. In this phase further assessment, testing, repeat of tests done in the testing phase, and change management issues will be documented. Industry standard ITIL (Information Technology Infrastructure Library) process should followed to reduce risks. Subsequently a gradual release of the new product into different environments (networks, platforms or physical environments) will be possible. New problems can then be isolated and resolved on a step by step basis. References (1) Health Direct Australia Some Telehealth Insights (Presentation) Further information: Alan Taylor, Project Manager alan.taylor@flinders.edu.au Page 14 of 14