“Rampart Hospital, this is Squad 51. Dixie, you read me? Out.”
The sultry cool nurse Dixie McCall, complete with white nursing uniform
and hat, calmly coos, “Rampart, copy.
What’s your situation 51?” And with that, many Americans were introduced
to telemedicine by the TV show Emergency. It seems that in every episode, paramedics Gage
and Desoto arrive on scene to treat a patient with chest pain, open up their
toolbox, screw in a silver antenna, and start communicating with Rampart
Hospital. The paramedics talk with the unflappable Dr. Kelly
Brackett, and eventually send an ECG over their radio unit to Rampart Hospital
where it’s read by Dr. Brackett. “Squad
51, this is Brackett. Give the patient 2
units Ringers Lactate, stabilize and get him here STAT. Out.”
Pretty cool stuff back in 1972.
In this post I’ll explore some of the telemedicine
technology available today. Remember my
focus is on solo and small group practices, so I’m not going to discuss
enterprise level technology in detail. Or
emergency medicine (sorry Emergency fans).
For unfamiliar technical terms, try referring to my prior
post, Telemedicine: Terminology LINK.
I’m going to break this down into the following components:
telecommunications (audio/video); diagnostic devices and information; patient
record; and aggregation tools (which bring together or combine capabilities of
the other components).
The “tele” part
So how does the audio and video move between the doctor and
the patient? Well, it most likely is not
over POTS service. POTS stands for Plain
Old Telephone Service, and it is the type of telephone service in most homes
and many small businesses. It’s the basic
analog service that has been around almost unchanged since the late 19th
century. In allows for two-way voice
communication, and with a modem allows a user low-bandwidth access to the
Internet. It’s good for voice, but too
slow for video and data.
Most likely the “tele” will be provided by a digital
service. This is due to the larger
bandwidth requirements for video. So
what are our digital options?
From a network perspective, there are three possible topologies
when deploying a teleconference system: 1) Private internal network; 2) Teleconference
service network provider; and 3). Public Internet.
Private internal network
A private internal network requires that the doctor and
patient sites all be on one network. This is called a wide area network (WAN) and
is more typical of a hospital system with outside clinics and multiple
locations. This is not normally the case for a solo or
small group practice. For a private
internal network the owner must make sure there is enough bandwidth to support
video teleconferencing and configure the network to optimize the teleconference
network traffic. They will typically
purchase dedicated video teleconferencing equipment such as Polycom RealPresence or Cisco TelePresence. These systems enable group video teleconferences
as well as one-to-one.
Teleconference service
network provider
In this scenario the teleconference network, hardware and
software needs are handled by a vendor.
Teleconferencing will typically run as a service they overlay onto the
Internet using their servers, and they may sell or lease and support the teleconferencing
equipment. Think of it as a turnkey
solution. This may be used in a
situation where a practice doesn’t have a WAN or the technical resources to
support teleconferencing, but needs to have robust teleconferencing
capabilities.
The same type of
dedicated video teleconference equipment could be used here as we discussed
above. However, if one-on-one patient encounters are the primary purpose
for teleconferencing, then less expensive desktop devices can be
used. Desktop devices incorporate a
codec unit with audio and video capabilities.
It can take the form of a telephone with video screen, or a high quality
monitor with built in camera, codec and networking hardware. Or, instead of a separate piece of hardware it
could even be a software application installed on a computer with microphone
and video camera capabilities.
Whichever desktop device is ultimately chosen, the
technology behind the scenes is the same.
In fact, it could be that the patient station has a standalone desktop
device, and the provider station has a computer application. You just need to determine which device best
suites your needs, which is a topic we’ll address in the next post.
Public Internet
Our third option is the public Internet. The teleconference will run on the doctor’s
internal network, travel over the public Internet, and be connected to the
internal network at the patient location. This is a likely scenario for small
business and medical practices.
The advantage of using the public Internet is that it’s less
expensive and requires less technical knowledge. The disadvantage is there is less control
over the performance of the network. And
that’s important because video requires an orderly and consistent network. Video, just like everything else on the
Internet, is broken into little pieces called “packets”. These packets travel willy-nilly across the
Internet, sometimes traveling different paths.
But because they have delivery address information imbedded in them,
they get to their destination. Once
there, the packets are reassembled into video.
For video, the order the packets arrive in is important because the 30th
second of video must run before the 31st second and not before the
29th second. If the 30th
second is delayed, you see a jerky image.
On a private internal network and vendor supported network, the network
administrator can give the video packets priority so they always move in the
fast lane. But the public Internet is the
Wild West. More often than not this
works fine, but sometimes it doesn’t.
So what are our options when using the public Internet?
Well, first let’s look at a common Internet program, Skype. Skype is an online service which provides
audio and video communication between subscribed users. Computers at both ends need Internet access, the Skype software, video camera, microphone and speakers.
Skype has limited video capabilities (low definition) which
are dependent on the bandwidth available at both ends of the call. And while the call is encrypted, there are
still questions as to whether Skype is HIPAA compliant. So Skype could be an option for a specialty
such as mental health which may not require “medical quality” video. “Medical quality” video refers to video of a high
enough quality to enable the viewer to perform assessment and diagnosis.
While mental health has been using of Skype for a few years,
a specialty such as dermatology, with its need for medical quality video, would
not be appropriate for Skype.
Skype is just one of a whole marketplace of teleconference
applications. Another one is Cisco
WebEx.
For higher quality audio and video, we look to desktop
teleconferencing devices. A desktop
teleconferencing device consists of a user station with audio and video
capability at both the doctor and patient sites, and the audio/video signal is
compressed and decompressed as it passes from one station to the other. This type of equipment is typically used with
a high speed Internet connection such as DSL or T1. Another option, ISDN, is available, but is typically
cost prohibitive for smaller applications.
The teleconference session is just like a standard phone
call. At one station the user calls the
other station, either using a phone number, an IP number (a device’s unique
Internet address), MAC (a device’s unique hardware address), a user name, or
some other unique identifier. The person
on the receiving end is notified and answers the call, thereby initiating the
session. Typically the teleconferencing
equipment is preset with a directory so users know how to initiate a session.
Polycom and Cisco are two of the leading manufacturers of
video teleconferencing products. Typically a customer will with work with a
local teleconferencing vendor who will sell and install the equipment.
It’s important to remember that the teleconference will run
over the doctor’s network and the doctor’s Internet connection, as well as the
network and Internet connection at the patient’s end. Be sure to follow manufacturer
recommendations on bandwidth requirements, this is not the place to skimp. Both sides of the call need sufficient
bandwidth.
With the booming popularity of mobile devices, their
improving audio/video capabilities, and faster mobile and wireless networks,
Polycom, Cisco and other venders are rolling out robust mobile device apps
which integrate into the video teleconferencing ecosystem.
Confused yet? Don’t
worry, we’ll look at how to make technology decisions in the next post.
Diagnostic devices and information
If you can think of a diagnostic tool, someone has probably configured
it to connect to a computer. And if it
can connect to a computer, it can be used for telemedicine.
Here is a list of diagnostic tools I recently found at AMD GlobalTelemedicine’s website: colposcope, dermascope, Otoscope, Ophthalmoscope, General
exam camera, ECG, Spirometer, Vital sign spot monitor, Medication dispenser,
Non-mydriatic retinal camera, high definition (HD) camera and illumination, standard
definition (SD) camera and illumination, x-ray, x-ray scanner, ultrasound
system, ultrasound probes, endocavity probe, stethoscope, dental camera, nasopharyngoscope,
vital sign continuous monitor, vital sign spot monitor, microscope w/ video
and/or camera output, and weight scale.
Connecting a diagnostic tool to a computer or computing
device is accomplished with a physical connection (USB, serial port), network
connection (Ethernet port and cable) or wirelessly (BlueTooth, wireless
network). For more detail on this, refer
back to my posts on connecting medical devices LINK.
So how do we get the diagnostic information from the patient
site to the provider? That answer will
depend on how you handle patient information in general. Ideally that information will be aggregated into
a patient electronic medical record (EMR) which is available to the provider. Another option is to use an aggregation device
or software application which pulls all the patient data together and makes it accessible
to the provider. The next two sections
address these area in more detail.
Lacking an EMR or means of aggregation, we can fall back on the
good old fax for low resolution diagnostics.
HIPAA compliant email is an option, but not a good option. The need for security and passwords makes
this cumbersome. Another option could be
a secure file storage site on the Internet where files can be placed and later
accessed by a provider. Again, this must
be HIPAA compliant, and is still cumbersome, especially if storing large files
such as radiology images.
Patient Record
At some point the telemedicine provider will want to review
the patient’s history. Optimally, both
the provider and patient sites will have access to the same EMR software, or
the doctor will have access to a portal containing the patient’s medical record. Lacking that, the patient helper will need to
transmit the patient record to the doctor via fax or HIPAA-compliant email.
A benefit of an EMR is that it can incorporate diagnostic
information gathered at the patient site.
To access a provider-supplied EMR, the patient site would need access to
the EMR. That would require either an
EMR hosted outside the provider’s network, or configuring the provider’s
network and EMR to allow outside access. Appropriate licensing and user training would
also need to be addressed.,
Aggregation tools - Bringing it all together
Aggregation tools are hardware and software tools which
bring together the audio/video conference, diagnostic information, and the
patient record.
Aggregation software is the software which unifies
the on-screen presentation of the video conference, patient record, and diagnostic
information. For example, at the patient
end an ECG is connected to the computer and the reading is captured in the ECG
software. The patient helper enters
chief complaint and HPI into the EMR. At
the doctor’s location, the user has a menu which allows her to select what information
to view: live video, EMR, ECG software, or tile some combination of these on
the screen. The specific functionality
varies between software packages, but you get the idea.
Aggregation appliances are equipment which physically
incorporates communications, diagnostic, and medical record access into one
package. Typically these are carts which
can be wheeled around as needed and include batteries and wireless
communications.
So what now?
Now that we’ve surveyed the telemedicine technology landscape,
we need to figure out how to select the appropriate technology. In my next post I’ll look at some scenarios
and discuss how I would approach the technology selection process.
As always, if you have corrections, clarifications or additions,
please feel free to let me know. As I
said in the first post of this series, I’m not a telemedicine expert. I’m just passing along what I’m learning.
http://en.wikipedia.org/wiki/Plain_old_telephone_service
http://ctel.org/
http://www.cms.gov/Medicare/Medicare-General-Information/Telehealth/index.html
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