Norton Community Hospital. Pulaski Community Hospital

1
Virginia Telehealth NetworkInfrastructure Work
Group White Paper

• Consensus Conference"Developing a Vision and
  Strategic Plan for Telehealth in Virginia
• May 26, 2005

2
Infrastructure Work Group (IWG)

• Examine current Telehealth capabilities in
  Virginia
• Identify current issues and future requirements
• VA Telehealth site survey ( Fall 03)
• Present options to the Committee
• Facilitate next steps

3
Infrastructure Work Group Members

• Kathy Wibberly, Virginia Department of Health
• Steve Gillis, Telehealth Solutions Group, LLC
• David Heise, Telehealth Solutions Group, LLC
• John Hughes, Virginia Department of Health
• Debbie Justis, VCU Health System
• John Lawson, Virginia Tech
• Mary Claire OHara, VA DMHMRSAS
• Dixie Tooke-Rawlins, Edward Via VA College of
  Osteopathic Medicine

4
Site SurveyResponding Organizations

• Blue Ridge Regional Medical Center
• Buchanan General Hospital
• Edward Via VA College of Osteopathic Medicine
• Lewis-Gale Medical Center
• Louisvile Medical Center
• Montgomery Regional Hospital
• Norton Community Hospital

• Pulaski Community Hospital
• Sentara Home Care Services
• VCU Health System
• VCU Medical School
• VDH
• VDMHMRSAS
• VA Primary Care Association
• VA Medical Center Salem
• UVA
• Wythe County Community Hospital

5
Site Survey Findings
6
Telehealth Services

• Most respondents that have Telehealth/
  Telemedicine currently use video over ISDN for
  video conferencing
• Several of the larger networks use video
  conferencing over IP without Quality of Service
  (QoS) which could cause quality issues
• Several sites use satellite broadcast for
  Tele-education and training
• 75 have Telemedicine (band-width intensive
  clinical) applications
• 50 inter-connect with other networks
• Several larger institutions connect nationally
  and internationally
• 50 use multi party bridging

.
7
Sites
U.V.A.
X hub
point of presence (POP)
Community Service Board
V.D.H.
Winchester
D.O.C.
Leesburg
Arlington
RAHCE
Falls Church
EVTN
Front Royal
Woodstock
Fairfax
VA Dept. of Mental Health (VDMHMRSAS)
Alexandria
(2)
VCU.
Manassas
VT/VCOM
Warrenton
Harrisonburg
Culpepper
Monterey
Colonial Beach
Fredericksburg
Dahlgren
(2)
(2)
Craigsville
Staunton
Montross
Mitchells
Olney
Warsaw
Charlottesville
Hot Springs
Accomac
St Stephens Church
Callao
Bowling Green
Troy
Clifton Forge
Heathsville
Ashland
(2)
Coving-
Aylett
Tappanahanock
Nassawadox
(4)
(3)
Glen Allen
Kilmarnock
Low Moor
Goochland
ton
Belle Haven
Dillwyn
Franktown
Saluda
Lexington
Vinton
(2)
Lancaster
(2)
Richmond
New Castle
Powhatan
Grundy
(11)
Hartfield
Chesterfield
Lynchburg
(3)
Blacksburg
Roanoke
Farmville
Cheriton
Charles City
X
Vansant
Madison Heights
(2)
Petersburg
X
Salem
Clintwood
(2)
Bastion
Williamsburg
Tazewell
Christianburg
Hayes
Pound
Pearsburg
Blackstone
Hampton
Cedar Bluffs
Bland
Dungannon
Newport News
Newport News
Wise
St. Paul
Radford
Burkeville
Wytheville
Big Stone Gap
(17)
Virginia Beach
Portsmouth
Catawba
Norfolk
Lebannon
Saltville
Jarratt
Pulaski
Blacksville
Boydton
(3)
2-H
Norton
Floyd
Martinsville
Marion
(2)
Abington
South Boston
Laurel Fork
Chesapeake
Hillsville
Suffolk
Pennington Gap
Gate City
Konnarock
Galax
Danville
Stuart
Bristol
8
Networks are Isolated
9
Hard to Generalize- But Capacity is Already
Constrained at Some Network Sites

• Applications
• 2 Video channels (384kbps)
• Internet/Email channel (256k)
• Web application (256kbps)
• T1 local loop (1536kbps usable bandwidth)

Chesterfield VDH site survey
10
Issues

• Service quality
• Cost
• Scheduling of remote consultations
• Training
• Needs of remote location not always met
• New services implemented too slowly

11
Example Current Process to Establish Video
Conference
12
Note on Video Quality

• To ensure video quality Industry standard is
  Quality of Service (QoS) Protocol
• Controls network congestion through bandwidth
  management
• Video over IP without QoS is not reliable.
  Network congestion degrades quality (latency and
  jitter)
• see technical annex for information on QoS

13
Respondents Future Plans

• Increased use of Telehealth/Telemedicine
  applications
• Increased use of clinical Tele-Education
• Increased connectivity within networks in
  Virginia and nationally.
• Increased home health monitoring

14
Optimal Virginia Telehealth Network
Hospitals
Home patients
15
Future Network Functional Requirements(Optimal)

• Ensure video quality
• Ability to support bandwidth intensive video and
  data applications
• Support private users
• Open Network (standards based)
• Sustainable

16
Optimal Technologies Services

• IP based video conferencing using QoS
• Multipoint conferencing capabilities
• Data Collaboration
• Store Forward, Streaming Media Broadcast
  Video
• VPN and LAN capability (PC Based)
• Ability to interface via any local access method
  (ex. ISDN, ATM. Frame Relay, Internet, Private
  line and DSL).
• Emergency response capability
• Open network interoperability
• Compliant with HIPAA /HL7

17
Options

• Status Quo
• Integrate existing networks
• Build a new network

18
Status Quo

• Cons
• Bandwidth congestion
• Networks do not communicate seamlessly
• Limited exchange of data
• High administrative overhead
• New technology adoption difficult
• Many needy communities and organizations will
  remain underserved
• Does not support identified future plans

• Pros
• Least effort

19
Integration

• Pros
• All networks can communicate with each other
• Not as expensive as a new network
• MAY! be implemented in less time than new network

• Cons
• Coordination
• Technology Standards
• Ex. IP
• Ex. Video
• Security Policy
• Firewalls/VPN
• IT Policy
• No central governance for infrastructure
  maintenance
• New technology adoption is difficult
• Biggest stakeholders have the most clout
• Many needy communities and organizations remain
  underserved
• Re-imbursement for network services difficult
• Security issues

20
For an Integrated Network to Succeed

• All participating network administrators/IT
  departments MUST
• Open their networks to all potential public and
  private users!!!

21
New Network

• Cons
• Most expensive to implement

• Pros
• Centralized technology/ policy coordination
• New Technologies can be adopted
• All Networks communicate together
• most flexible
• Volume discounts
• All stakeholders are equal
• Facilitate service to underserved communities and
  organizations
• Billing and support available
• Security can be implemented

22
Next Step

• Detailed requirements analysis to support network
  envisioned by strategic plan.
• Define revenue streams, cost savings and
  sustainability.

23
Questions?

• Steve Gillis
• [phone]
• steve_at_telehealthsolution.com
• Technical Annex
• David Heise
• [phone]
• david_at_telehealthsolution.com

24
Technical Annex(TeleHealth Solutions Group, LLC)

• Requirements
• Network Requirements
• Equipment Capacity Requirements
• Network Design ( Current vs. Optimal)
• IP over ATM
• MPLS
• Technology Review and Comparison
• IP over ATM vs. MPLS
• Why IPv6
• Why QoS
• HIPPA
• Site Survey

25
TeleHealth/Telemedicine NetworkTechnical
Requirements

• Services
• VoD (Video on Demand)
• Data Collaboration
• Streaming Media
• Multicast capability (unicast webcasting)
• Lowest possible Latency and Jitter for Video
  Broadcast services to ensure service quality
• Network Facilities to support these services
• Local Access requirements
• Backbone requirements
• Network security
• Layer 2 VPN Capability
• Firewall
• VPLS (Virtual Private LAN Service) (GigE)
• mVPN (Multicast VPN)
• Network Address Translation
• Secure Email

26
Technology Requirements

• Transmit IP using MPLS with IPv6 protocol
• Control Latency and Jitter through QoS
  Bandwidth management
• Support the new video standard H.264
• Translate from ISDN (H.320) to IP (H.323)
• Secure VPN service over the public Internet for
  local loop DSL service
• Provide Encryption and password security features
• IP Address translations and assignment device to
  device
• Support multiple local access (ex. ISDN, ATM,
  Frame Relay, Private Line, Gig E)
• Vender and Facility provider independent
• Support manageability (use H.323 Beacon)

27
Equipment and Capacity Requirements
28
Required Video Components

• Video Terminals (Stations) (At Remote site
  Location)
• Gatekeeper (At Hub site location)
• Performs all address resolutions
• Gateway (At Hub site location)
• Provides interoperability between H.323(IP) to
  H.320 (ISDN)
• Multipoint Conference Unit (MCU) (At Hub site
  location)
• Proxy (Some times combine with the Gatekeeper)
  (At Hub site location)
• Call processing agent (QoS)

29
Video Equipment Requirements

• Network Standard
• H.323
• Video Standards
• H.261, All H.263 (To communicate with older
  units)
• The new H.264 (Same quality video using half the
  bandwidth)
• Audio Standards
• G.711, G.722
• G.728
• Security Features
• Passwords
• Encryption (DES, AES)
• H.233, H.234, H.235V3
• Data Collaboration
• QoS capabilities
• LAN connection at 100 Mbit
• IPv6 compatible

30
Remote Site Router/LAN switches Requirements

• Support Video traffic
• Support QoS services
• RSVP, DiffServ FPC
• Support IPv6 protocol
• LAN connection minimum speed 100Mbit
• LAN switch supports minimum of two queues
• Pass encryption data
• Password protection

31
Video Capacity Planning Metrics

• Video data rate 20 Bandwidth required
• No more than 33 of the link capacity should be
  used for Video Conferencing
• Video Date should not exceed 75 of the Link
  capacity

Cisco recommended for IP Video
32
Capacity Examples for Video
33
Network Design
34
Currently Sites in Virginia Connect Using IP over
ATM
Regional Site
Gatekeeper proxy
Gatekeeper proxy
DATA Switch
Regional Site
Headquarters Site
Gatekeeper proxy
35
IPv6 with MPLS is becoming Industry Standard
AccessType 1, 2 3
Private IPEdgeRouter
AccessType 1, 2, 3
Private IPEdgeRouter
Customer Edge
Customer Edge
Private IP Core
T1, NxT1, T3, OC3
T1, NxT1, T3, OC3
MPLS (IPv6) IP Core
FR, ISDN or ATM
FR, ISDN or ATM
Provider Edge
Provider Edge
Other MPLS networks (Internet 2)
Video MCU/Gateway Gatekeeper
36
Technology Review and Comparison
37
IP over ATM Issues

• IP over ATM has the potential to create
  bottlenecks leading into the core resulting from
  the lack of segmentation and reassembly (SAR)
  functional on OC-48 and faster interfaces.
• IP over ATM results in an inefficient use of
  network bandwidth due to the traditional ATM cell
  tax.
• The IP differentiated Services (DiffServ)
  approach to class of service (CoS) does not map
  well to existing ATM quality of service (QoS)
  mechanisms.
• TCP/IP is an inherently inefficient protocol to
  run over an ATM transport, because the
  transmission of a single ACK requires not one but
  two ATM cells.

38
Comparison between IP and MPLS

• IP forwarding (for Video) lacks path control and
  deterministic resiliency as with MLPS services.
• MPLS provides rapid failure recovery across IP
  routing devices.
• MPLS includes traffic engineering (For
  performance and high availability), quality of
  service (QoS), resource optimization and
  security.
• MPLS can reallocate lower traffic class bandwidth
  resources to provide video services
• MPLS provides FRR (Fast Reroute) which can
  provide reroute capability in the range of 50ms,
  and is similar to SONET/SDH technology.
• MPLS can perform an efficient replication within
  the network, to eliminate duplication traffic
  over the same link making efficient use of
  bandwidth.
• Some of the new QoS features supported by MPLS
  are RSVP-TE (Resource Reservation Protocol
  traffic engineering and DiffServ-TE)
• MPLS used by US government today

39
Network Cost Efficiencies and Simplification
Realized in MPLS Network
Network Cost Efficiencies and Simplification
Host 1
Host 2
Host 1
Host 2
Any-to-Any IP Connectivity (MPLS)
Traditional Frame Relay, ATM or Private Line
Networks
MPLS Network
40
Why IPv6?

• Better Quality of service
• Better security services through VPNs
• Moves data packets across the backbone faster and
  more efficient
• IPv6 can implement multi-cast in the IP protocol
  unlike IPv4
• IPv6 has a new class of service called any cast
  which routes data to and from the nearest host.
  "Shortest Route
• IP protocol running on Internet 2 backbone

41
Why QoS?

• Controls Latency sensitive data such as Video and
  Voice
• Admission control bandwidth control and policy
  control
• Resource Allocation Queuing and scheduling
  Traffic flows and traffic classes
• Gatekeepers Network administer manages the
  pool of available bandwidth
• Types
• IP Precedence
• Differentiated services (Diffserv)
• Integrated services (IntservRSVP)
• QoS must be available all the way to the end
  equipment

42
Optimized Queuing Using QoS
Video Traffic
1
1
Transmit ring
LAN Traffic
2
3
2
1
1
2
2
Internet Traffic
3
3
3
43
HIPAA

• Code of Federal Regulations 21 CFR-11
• 21 CFR-11 took effect on 08/20/1997 and was
  intended to permit the widest possible use of
  electronic technology
• Part 11 requirements for electronic records
• Section 11.10 and 11.30 define controls for
  closed and open systems