System Requirements for Delivery of Telemedicine Services

Abstract

The objectives of this chapter are to review the system requirements of delivery telemedicine services for the clinical implementation of a Telemanagement of Inflammatory Bowel Disease (IBD) program. The concept of developing a successful and sustainable telemedicine program is a significant undertaking that includes purchasing and deploying a telemedicine platform, testing and training all clinical and support staff, creating documentation for clinician and patients participating in the program, and finally creating a support structure to troubleshoot and resolve any technical challenges that might occur during a telemedicine encounter. The creation of a scope of work document and technology assessment review also play major parts in the system development of the program. These factors, while all are very important, also hinge on the telemedicine endorsement and adoption of the technology with physicians, nurses, executive leadership, and patients. Technical simplicity is also a major factor in the success of the program. The chapter provides the necessary requirements to protect the privacy of the patient and clinicians during a telemedicine visit. The chapter also provides recommendations on video etiquette or the “dos and don’ts” of where and how the attendees should be participating using the video technology. The chapter stresses interoperability of the video technology as well as devices utilized to keep the costs at a minimum for the patient. Lastly, this chapter provides some insight on building a support structure to provide technical support for hardware and software for the clinicians and patients.

Appendices

Appendix 10.1: Existing Digital Imaging Standards

This is not meant to be a comprehensive list of all existing standards, but rather provides a description of the standards most relevant to the practice of telemental health.

International Telecommunications Union (ITU-T)

The International Telecommunications Union (ITU-T) has established a series of standards (H.300) for VTC. It includes such sections as the H.320 series for circuit-switched, n × 64 (i.e., ITU-T); the H.323 series: packet-switched/network, IP; and the H.324: plain old telephone service (POTS).

Session Initiation Protocol (SIP)

The Internet Engineering Task Force RFC 3261 also applies to VTC. SIP is a text-based protocol for initiating interactive communication sessions between users, including voice, video, chat, and virtual reality.

JPEG/TIF/WAV

Some of the most common compression methods used for still images include the following. The method used depends on the achievable compression ratio and the number and types of artifacts created during compression. Lossless compression allows for the reconstruction of the exact original data prior to compression without any loss of information. Lossy compression refers to methods that lose data once the image has been compressed and uncompressed. The level of compression and method used affects the amount of data lossand whether or not it is visually perceptible. The type and level of compression may vary depending on the type of examination. Different compression algorithms will achieve different compression ratios with varying degrees of artifacts. The choice of compression method and level should be reviewed periodically for each image and examination type, to insure that artifacts are not perceptible. It should be noted that lossy compression can affect the colors in an image.

• JPEG (2000): JPEG 2000 uses wavelet technology that allows an image to be retained without any distortion or loss. File extensions for JPEG 2000 are either.jp2 or.j2c (for traditional JPEG it is either.jpg or.jpeg).

• TIF: Tagged Image File Format is used for formatting and compressing images. It can be lossy or lossless. The file extension for TIF is.tiff or.tif.

• WAV: It is a method of compression using wavelets transforms (mathematical functions that divide data based on frequency components). There are a variety of file extensions depending on the wavelet method used. It can be lossy or lossless.

Health Level Seven (HL7)

Health Level Seven (HL7) is one of the several American National Standards Institute (ANSI) Standards Developing Organizations (SDOs) operating in the healthcare arena. HL7s domain is clinical and administrative data.

United Sates Health Insurance Portability & Accountability Act (US HIPAA)

The United Sates Health Insurance Portability & Accountability Act (US HIPAA) of 1996 (Public Law 104–191) calls for improved efficiency in healthcare delivery by standardizing electronic data interchange, and the protection of confidentiality and security of health data through setting and enforcing standards. It has rules for:

• Standardization of electronic patient health, administrative and financial data

• Unique health identifiers for individuals, employers, health plans, and healthcare providers

• Security standards protecting the confidentiality and integrity of “individually identifiable health information,” past, present, or future.

JCAHO

The Joint Commission evaluates and accredits nearly 15,000 healthcare organizations and programs in the USA. It is an independent, not-for-profit organization, and is a standards-setting and accrediting body in healthcare. Since 1951, it has maintained state-of-the-art standards that focus on improving the quality and safety of care provided by healthcare organizations. The Joint Commission’s comprehensive accreditation process evaluates an organization’s compliance with these standards and other accreditation requirements. Its accreditation is recognized nationwide as a symbol of quality that reflects an organization’s commitment to meeting certain performance standards. To earn and maintain the Joint Commission’s Gold Seal of Approval™, an organization must undergo an on-site survey by a Joint Commission survey team at least every 3 years. (Laboratories must be surveyed every 2 years.)

Appendix 10.2: Telemedicine/Telehealth Glossary

The following is a list of terms and definitions that are commonly used in telemedicine and telehealth. The list was assembled for the purpose of encouraging consistency in employing these terms in ATA related documents and resource materials. The list is not all-inclusive and may be augmented by specialty areas as deemed appropriate.

Application Service Provider (ASP): An ASP hosts a variety of applications on a central server. Customers are charged a fee to access applications over secure Internet connections or a private network. This means that they do not need to purchase, install, and maintain the software themselves; instead they rent the applications they need from their ASP. Even new releases, such as software upgrades, are generally included in the price.

Asynchronous: This term is sometimes used to describe store and forward (S&F) transmission of medical images or information because the transmission typically occurs in one direction in time. This is the opposite of synchronous (see below).

Authentication: A method of verifying the identity of a person sending or receiving information using passwords, keys, and other automated identifiers.

Bandwidth: A measure of the information carrying capacity of a communications channel; a practical limit to the size, cost, and capability of a telemedicine service.

Bluetooth wireless: Bluetooth is an industrial specification for wireless personal area networks (PANs). Bluetooth provides a way to connect and exchange information between devices, such as mobile phones, laptops, PCs, printers, digital cameras, and video game consoles over a secure, globally unlicensed short-range radio frequency. The Bluetooth specifications are developed and licensed by the Bluetooth Special Interest Group.

Broadband: Communications (e.g., broadcast television, microwave, and satellite) capable of carrying a wide range of frequencies; refers to transmission of signals in a frequency-modulated fashion, over a segment of the total bandwidth available, thereby permitting simultaneous transmission of several messages.

Clinical information system: Relating exclusively to the information regarding the care of a patient, rather than administrative data, this hospital-based information system is designed to collect and organize data.

CODEC: Acronym for coder-decoder. This is a videoconferencing device (e.g., Polycom, Tandberg, Sony, Panasonic, etc.) that converts analog video and audio signals to digital video and audio code and vice versa. CODECs typically compress the digital code to conserve bandwidth on a telecommunications path.

Compressed video: Video images that have been processed to reduce the amount of bandwidth needed to capture the necessary information so that the information can be sent over a telephone network.

Computer-based patient record (CPR): An electronic form of individual patient information that is designed to provide access to complete and accurate patient data.

Data compression: A method to reduce the volume of data using encoding to reduce image processing, transmission times, bandwidth requirements, and storage space requirements. Some compression techniques result in the loss of some information, which may or may not be clinically important.

Diagnostic equipment (scopes, cameras and other peripheral devices): Diagnostic equipment is a hardware device not part of the central computer (e.g., digitizers, stethoscope, or camera) that can provide medical data input to or accept output from the computer.

Digital camera (still images): A digital camera is typically used to take still images of a patient. General uses for this type of camera include dermatology and wound care. This camera produces images that can be downloaded to a PC and sent to a provider/consultant over a network.

Digital Imaging and Communication in Medicine (DICOM): A standard for communications among medical imaging devices; a set of protocols describing how images are identified and formatted that is vendor-independent and developed by the American College of Radiology and the National Electronic Manufacturers Association.

Disease management: A continuous coordinated healthcare process that seeks to manage and improve the health status of a carefully defined patient population over the entire course of a disease (e.g., CHF and DM). The patient populations targeted are high-risk, high-cost patients with chronic conditions that depend on appropriate care for proper maintenance.

Distance learning: The incorporation of video and audio technologies, allowing students to “attend” classes and training sessions that are being presented at a remote location. Distance learning systems are usually interactive and are a tool in the delivery of training and education to widely dispersed students, or in instances in which the instructor cannot travel to the student’s site.

Distant site: The distant site is defined as the telehealth site where the provider/specialist is seeing the patient at a distance or consulting with a patient’s provider. (CMS) Others common names for this term include—hub site, specialty site, provider/physician site, and referral site. The site may also be referred to as the consulting site.

Document camera: A camera that can display written or typed information (e.g., lab results), photographs, graphics (e.g., ECG strips) and in some cases X-rays.

Electronic data interchange (EDI): The sending and receiving of data directly between trading partners without paper or human intervention.

Electronic patient record: An electronic form of individual patient information that is designed to provide access to complete and accurate patient data, alerts, reminders, clinical decision-support systems, links to medical knowledge, and other aids.

Encryption: A system of encoding data on a Web page or e-mail where the information can only be retrieved and decoded by the person or computer system authorized to access it.

Firewall: Computer hardware and software that block unauthorized communications between an institution’s computer network and external networks.

Full-motion video: This describes a standard video signal that allows video to be shown at the distant end in smooth, uninterrupted images.

Guideline: A statement of policy or procedures by which to determine a course of action, or give guidance for setting standards.

H.320: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via T1 or ISDN connections.

H.323: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via the IP (see below).

H.324: This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via POTS.

Health level 7 Data Communications Protocol (HL7): This communication standard guides the transmission of health-related information. HL7 allows the integration of various applications, such as bedside terminals, radiological imaging stations, hospital census, order entries, and patient accounting, into one system.

HIPAA: Acronym for Health Information Portability Act.

Home healthcare and remote monitoring systems: Home healthcare is care provided to individuals and families in their place of residence for promoting, maintaining, or restoring health; or for minimizing the effects of disability and illness, including terminal illness. In the Medicare Current Beneficiary Survey and Medicare claims and enrollment data, home healthcare refers to home visits by professionals including nurses, physicians, social workers, therapists, and home health aides. Using remote monitoring and interactive devices allows the patient to send in vital signs on a regular basis to a provider without the need for travel.

Informatics: The use of computer science and information technologies to the management and processing of data, information, and knowledge.

Integrated Services Digital Network (ISDN): This is a common dial-up transmission path for videoconferencing. Since ISDN services are used on demand by dialing another ISDN-based device, per minute charges accumulate at some contracted rate and then are billed to the site placing the call. This service is analogous to use the dialing features associated with a long distance telephone call. The initiator of the call will pay the bill. ISDN permits connections up to 128 Kbps.

Interactive video/television: This is analogous with videoconferencing technologies that allow for two-way, synchronous, interactive video and audio signals for the purpose of delivering telehealth, telemedicine, or distant education services. It is often referred to by the acronyms—ITV, IATV, or VTC (video teleconference).

Internet Protocol: The Internet Protocol (IP) is the protocol by which data is sent from one computer to another on the Internet. Each computer on the Internet has at least one address that uniquely identifies it from all other computers on the Internet. IP is a connectionless protocol, which means that there is no established connection between the end points that are communicating. The IP address of a videoconferencing system is its phone number.

Interoperability: Interoperability refers to the ability of two of more systems* to interact with one another and exchange information in order to achieve predictable results (*refers to more than technical systems) (Bergman, Ulmer and Sargious, 2001). There are three types of interoperability: human/operational; clinical; and technical (Canadian Society for Telehealth, 2001) . Interoperability refers to the ability of two or more systems (computers, communication devices, networks, software, and other information technology components) to interact with one another and exchange data according to a prescribed method in order to achieve predictable results (ISO ITC-215).

ISDN Basic Rate Interface (BRI): This is an ISDN interface that provides 128 k of bandwidth for videoconferencing or simultaneous voice and data services. Multiple BRI lines can be linked together using a multiplexer (see below) to achieve higher bandwidth levels. For instance, a popular choice among telehealth networks is to combine three BRI lines to provide 384 k of bandwidth for videoconferencing. It should be noted that BRI services are not available in some rural locations. One should check with their telecommunications providers on the availability of BRI service before ordering videoconferencing equipment that uses this type of service.

ISDN Primary Rate Interface (PRI): This is an ISDN interface standard that operates using 23, 64 k channels and one 64 k data channel. With the proper multiplexing equipment the ISDN PRI channels can be selected by the user for a video call. For instance if the user wants to have a videoconference at 384 k of bandwidth then they can instruct the multiplexer to use channels one through six (6 × 64 k = 384 k). This is important because the user typically pays charges based on the number of 64 k channels used during a videoconference. The fewer channels used to obtain a quality video signal the less expensive the call.

JCAHO: Acronym for Joint Commission on Accreditation of Healthcare Organizations.

Lossless: A format of data compression, typically of an order of less than 2:1, in which none of the original data information is lost when the image is reproduced.

Lossy: A process of data compression at a relatively high ratio, which leads to some permanent loss of information upon reconstruction.

Medical/nursing call center: A call center is a centralized office that answers incoming telephone calls from patients. Such an office may also respond to letters, faxes, e-mails, and similar written correspondence. Usually staffed by nurses, call centers provide basic health information and instructions to callers but do not provide an official diagnosis of conditions or prescribe medicine. Call centers act as an initial triage point for patients.

Mobile telehealth: The provision of healthcare services with the assistance of a van, trailer, or other mobile unit in which the healthcare provider might provide patient services at a distance from a normal medical facility. Services may also be provided through mobile technologies that allow a mobile vehicle equipped with medical technologies to attach to an existing healthcare facility, such as mobile CT, MRI, or teledentistry .

Multiplexer (MUX): A device that combines multiple inputs (ISDN PRI channels or ISDN BRI lines) into an aggregate signal to be transported via a single transmission path.

Multi-point Control Unit (MCU): A device that can link multiple videoconferencing sites into a single videoconference. An MCU is also often referred to as a “bridge.”

Multi-point teleconferencing: Interactive electronic communication between multiple users at two or more sites which facilitates voice, video, and/or data transmission systems: audio, graphics, computer, and video systems. Multi-point teleconferencing requires a MCU or bridging device to link multiple sites into a single videoconference.

Network integrators: Organizations specializing in the development of software and related services that allows devices and systems to share data and communicate to one another.

Originating site: The originating site is where the patient and/or the patient’s physician is located during the telehealth encounter or consult (CMS). Other common names for this term include—spoke site, patient site, remote site, and rural site.

Patient examination camera (video): This is the camera typically used to examine the general condition of the patient. Types of cameras include those that may be embedded with set-top videoconferencing units, handheld video cameras, gooseneck cameras, camcorders, etc. The camera may be analog or digital depending upon the connection to the videoconferencing unit.

Peripheral devices: Any device that is attached to a computer externally, that is, Scanners, mouse pointers, printers, keyboards; and clinical monitors, such as pulse oximeters, weight scales, are all examples of this.

Pharmacy solutions: The use of electronic information and communication technology to provide and support comprehensive pharmacy services when distance separates the participants.

POTS: Acronym for plain old telephone service.

Presenter (patient presenter): Telehealth encounters require the distant provider to perform an examination of a patient from many miles away. In order to accomplish that task an individual with a clinical background (e.g., LPN, RN, etc.) trained in the use of the equipment must be available at the originating site to “present” the patient, manage the cameras and perform any “hands-on” activities to successfully complete the examination. For example, a neurological diagnostic examination usually requires a nurse capable of testing a patient’s reflexes and other manipulative activities. It should be noted that in certain cases, such as interview-based clinical consultations such as Telemental Health or Nutrition Services, that a licensed practitioner such as an RN or LPN, might not be necessary, and a non-licensed provider such as support staff, could provide telepresenting functions.

Regional Health Information Organization (RHIO): RHIO and Health Information Exchange (HIE) are often used interchangeably. RHIO is a group of organizations with a business stake in improving the quality, safety, and efficiency of healthcare delivery. RHIOs are the building blocks of the proposed National Health Information Network (NHIN) initiative at the Office of the National Coordinator for Health Information Technology (ONCHIT).

Router: This device provides an interface between two networks or connects sub-networks within a single organization. It routes network traffic between multiple locations and it can find the best route between any two sites. For example, PCs or H.323 videoconferencing devices tell the routers where the destination device is located and the routers find the best way to get the information to that distant point.

Standard: A statement established by consensus or authority, that provides a benchmark for measuring quality, that is aimed at achieving optimal results (NIFTE Research Consortium, 2003).

Store and forward (S&F): S&F is a type of telehealth encounter or consult that uses still digital images of a patient for the purpose of rendering a medical opinion or diagnosis. Common types of S&F services include radiology, pathology, dermatology, and wound care. Store and forward also includes the asynchronous transmission of clinical data, such as blood glucose levels and ECG measurements, from one site (e.g., patient’s home) to another site (e.g., home health agency, hospital, and clinic) .

Switch: A switch in the videoconferencing world is an electrical device that selects the path of the video transmission. It may be thought of as an intelligent hub (see hub above) because it can be programmed to direct traffic on specific ports to specific destinations. Hub ports feed the same information to each device.

Synchronous: This term is sometimes used to describe interactive video connections because the transmission of information in both directions is occurring at exactly the same period.

System/network integration: The use of software that allows devices and systems to share data and communicate to one another.

T1/DS1: A digital carrier or type of telephone line service offering high-speed data, voice, or compressed video access in two directions, with a transmission rate of 1.544 Mbps. T3/DS3: A carrier of 45 Mbps.

Transmission control protocol/Internet protocol (TCP/IP): The underlying communications rules and protocols that allow computers to interact with each other and exchange data on the Internet.

Telecommunications providers: An entity licensed by the government (the Federal Communications Commission in the USA) to provide telecommunications services to individuals or institutions.

Teleconferencing: Interactive electronic communication between multiple users at two or more sites which facilitates voice, video, and/or data transmission systems such as: audio, graphics, computer, and video systems.

Telehealth and telemedicine: Telemedicine and telehealth both describe the use of medical information exchanged from one site to another via electronic communications to improve patients’ health status. Although evolving, telemedicine is sometimes associated with direct patient clinical services and telehealth is sometimes associated with a broader definition of remote healthcare services .

Telematics: The use of information processing based on a computer in telecommunications, and the use of telecommunications to permit computers to transfer programs and data to one another.

Telementoring: The use of audio, video, and other telecommunications and electronic information processing technologies to provide individual guidance or direction. An example of this help may involve a consultant aiding a distant clinician in a new medical procedure.

Telemonitoring: The process of using audio, video, and other telecommunications and electronic information processing technologies to monitor the health status of a patience from a distance.

Telepresence: The method of using robotic and other instruments that permit a clinician to perform a procedure at a remote location by manipulating devices and receiving feedback or sensory information that contributes to a sense of being present at the remote site and allows a satisfactory degree of technical achievement. For example, this term could be applied to a surgeon using lasers or dental hand pieces and receiving pressure similar to that created by touching a patient so that it seems as though she/he is actually present, permitting a satisfactory degree of dexterity.

Teleradiology and picture archiving and communications systems (PACs): The electronic transmission of radiological images, such as X-rays, CTs, and MRIs, for the purposes of interpretation and/or consultation. Digital images are transmitted over a distance using standard telephone lines, satellite connections, or local area networks (LANs). Teleradiology also is beginning to include the process of interfacing with the hospital information systems/radiology information systems (HIS/RIS) in the transport of digital images. PACs provide centralized storage and access to medical images over information systems.

Ultrasound: A device that uses high-frequency sound waves to examine structures inside the body. It can rapidly detect tumors and other abnormalities, often right in the physician’s office.

Universal Service Administrative Company (USAC): The Universal Service Administrative Company administers the Universal Service Fund (USF), which provides communities across the country with affordable telecommunication services. The Rural Health Care Division (RHCD) of USAC manages the telecommunications discount program for healthcare.

Videoconferencing systems: Equipment and software that provide real-time, generally two-way transmission of digitized video images between multiple locations; uses telecommunications to bring people at physically remote locations together for meetings. Each individual location in a videoconferencing system requires a room equipped to send and receive video.

Videoconferencing: Real-time, generally two-way transmission of digitized video images between multiple locations; uses telecommunications to bring people at physically remote locations together for meetings. Each individual location in a videoconferencing system requires a room equipped to send and receive video.

Wi-Fi: Originally licensed by the Wi-Fi Alliance to describe the underlying technology of wireless local area networks (WLAN) based on the IEEE 802.11 specifications. It was developed to be used for mobile computing devices, such as laptops, in LANs, but is now increasingly used for more services, including the Internet and VoIP phone access, gaming, and basic connectivity of consumer electronics, such as televisions and DVD players, or digital cameras. (Wikipedia)

Appendix 10.3: Telemedicine Room Assessment and Design Worksheet

Appendix 10.4: Patient and Referring Healthcare Provide Satisfaction Surveys