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Virginia Telehealth Network Infrastructure Work Group White Paper

Virginia Telehealth Network Infrastructure Work Group White Paper. Consensus Conference: "Developing a Vision and Strategic Plan for Telehealth in Virginia” May 26, 2005 . Infrastructure Work Group (IWG). Examine current Telehealth capabilities in Virginia

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Virginia Telehealth Network Infrastructure Work Group White Paper

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  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 Infrastructure Work Group

  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 O’Hara, VA DMHMRSAS • Dixie Tooke-Rawlins, Edward Via VA College of Osteopathic Medicine Infrastructure Work Group

  4. 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 Site SurveyResponding Organizations Infrastructure Work Group

  5. Site Survey Findings Infrastructure Work Group

  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 . Infrastructure Work Group

  7. Sites X= hub U.V.A. = point of presence (POP) Community Service Board V.D.H. Winchester D.O.C. Leesburg Arlington RAHCE Falls Church EVTN Woodstock Front Royal Fairfax VA Dept. of Mental Health (VDMHMRSAS) (2) Alexandria VCU. Manassas VT/VCOM Warrenton Harrisonburg Culpepper Monterey Colonial Beach Fredericksburg Dahlgren (2) (2) Craigsville Montross Staunton 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 Saluda Franktown Lexington Vinton (2) (2) Lancaster Richmond New Castle Powhatan Grundy (11) Hartfield Chesterfield Lynchburg (3) Blacksburg Roanoke Farmville Cheriton Charles City X Vansant (2) Madison Heights 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 Big Stone Gap Wytheville (17) Virginia Beach Catawba Portsmouth Lebannon Norfolk Saltville Jarratt Blacksville Pulaski 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 Infrastructure Work Group

  8. VDMHMRSAS/CSB VDH VT/VCOM Others VCU UVA Dept. of Corrections Networks are Isolated Infrastructure Work Group

  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 Infrastructure Work Group

  10. Issues • Service quality • Cost • Scheduling of remote consultations • Training • Needs of remote location not always met • New services implemented too slowly Infrastructure Work Group

  11. Example: Current Process to Establish Video Conference Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  14. Virginia Telehealth Network VT/VCOM VDH VCU UVA Dept. of Corrections VDMHMRSAS/CSB Other Networks Provider offices EMS- Satellite Geriatric facilities Optimal Virginia Telehealth Network Hospitals Home patients Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  17. Options • Status Quo • Integrate existing networks • Build a new network Infrastructure Work Group

  18. Pros Least effort 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 Status Quo Infrastructure Work Group

  19. 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 Integration Infrastructure Work Group

  20. For an Integrated Network to Succeed All participating network administrators/IT departments MUST: Open their networks to all potential public and private users!!! Infrastructure Work Group

  21. 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 Cons Most expensive to implement New Network Infrastructure Work Group

  22. Next Step • Detailed requirements analysis to support network envisioned by strategic plan. • Define revenue streams, cost savings and sustainability. Infrastructure Work Group

  23. Questions? Steve Gillis (703) 869-3085 steve@telehealthsolution.com Technical Annex: David Heise (703) 477-5456 david@telehealthsolution.com Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  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) Infrastructure Work Group

  27. Equipment and Capacity Requirements Infrastructure Work Group

  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) Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  32. Capacity Examples for Video Infrastructure Work Group

  33. Network Design Infrastructure Work Group

  34. Video Infrastructure Gatekeeper proxy Gateway MCU M PSTN ISDN C U Currently Sites in Virginia Connect Using IP over ATM Regional Site Gatekeeper proxy Gatekeeper proxy DATA Switch Regional Site Headquarters Site Gatekeeper proxy Infrastructure Work Group

  35. IPv6 with MPLS is becoming Industry Standard Access:Type 1, 2 3 Private IPEdgeRouter Private IPEdgeRouter Access:Type 1, 2, 3 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 Infrastructure Work Group

  36. Technology Review and Comparison Infrastructure Work Group

  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. Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  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 Infrastructure Work Group

  42. Optimized Queuing Using QoS Video Traffic 1 1 Transmit ring LAN Traffic 2 2 1 1 3 2 2 Internet Traffic 3 3 3 Infrastructure Work Group

  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 Infrastructure Work Group

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