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.

With the lack of medical students heading into the healthcare field, the access to quality specialists continues to decrease as is the case of physicians providing the needed level of care for diseases like Crohn’s, colitis, and inflammatory bowel disease (IBD). Patients are performing local, nationwide, and even international website searches to find specialists in their field who can provide both the needed level of care and follow-up care at a distance using technologies such as telemedicine. Telemedicine continues to grow in popularity for health systems, hospitals, specialists, account care organizations (ACOs), and even start-up companies that can provide both the technical platform via cloud technology and access to specialists. In years past, Internet access, bandwidth speed, and wireless were all very cumbersome and expensive but this has changed significantly in the last 5 years. The telemedicine technical platform requirements have become less complex and the ability to use consumer grade equipment like laptops, tablets, and smartphones is on the rise. The cost of purchasing, leasing, and even renting a video solution via software as a service (SaaS) platform has decreased to drive the increased adoption for creating a telemedicine program using the consumer electronics market technologies. In this section, the system requirements will be reviewed to build a telemedicine program for the delivery of telemedicine services.

Scope of Work

A telemedicine program is only as good as the foundation that has been created around the scope of work on how the program will be organized and delivered to the patients . In this manner, the administrative and clinical leadership teams should create a scope of work around how the program will be delivered, funded, and ultimately staffed by internal or external specialists. Senior management must define operational policies and deliver strategic aims of the program, as well as clearly define roles and responsibilities for everyone who will be involved in direct contact with the patient population [1]. A typical mechanism of attaining the scope of a program is creating a concept sheet or a scope of work document. Many organizations have an information technology (IT) department that have certain standards in place around project management and documentation. A scope of work document may already be available for a project, but with a telemedicine program, there is more than just IT requirements that have to be detailed. See Fig. 9.1 for suggested questions that should be included into a telemedicine concept sheet or scope of work .

Fig. 9.1

Telemedicine consult concept sheet

Once the telemedicine concept has been outlined in the document and all parties have agreed on the program, a project charter should be developed to spell out the telemedicine program, a contact list of all involved participants, a project plan to show tasks and delivery dates, risks and concerns if the project is not delivered on time, and finally the project charter will need to have sign-off from senior leadership, departmental administration, physicians, and finally the telemedicine department. The funding or budget component of the scope of work must be worked out before the program moves too far. Without the necessary funding or finance department agreeing to allocate capital funds for the program, the telemedicine program should only be considered in a conceptual phase. Depending on the structure of the program, the finance department may require a split-funded program or fully departmental-funded approach. This will all be something that must be agreed upon prior to any major progress on program development .

Types of Telemedicine Services

Once the telemedicine concept has been properly documented for the telemedicine department to review internally, a separate meeting should take place with the physician or administrative leader who is requesting the telemedicine program to review the concept and to figure out what is the most appropriate type of service to embark upon since a “one-size-fits-all” technology is rarely appropriate for every concept .

The delivery of remote health services is used for a variety of purposes:

• Specialist referral services typically involve a specialist assisting a general practitioner in rendering a diagnosis. This may involve a patient “seeing” a specialist over a live, remote consult or the transmission of diagnostic images and/or video along with patient data to a specialist for viewing later.

• Direct patient care such as sharing audio, video, and medical data between a patient and health professional for use in rendering a diagnosis, treatment plan, prescription, or advice. This might involve a patient located at a remote clinic , a physician’s office, or home .

• Remote patient monitoring uses devices to remotely collect and send data to a monitoring station for interpretation. Such “home telehealth” applications might include using telemetry devices to capture specific vital sign or other biometric data, such as blood pressure, glucose, electrocardiogram (ECG), and weight. Such services can be used to supplement the use of visiting nurses and other payer-led supportive services.

• Medical education and mentoring, which range from the provision of continuing medical education credits for health professionals and special medical education seminars for targeted groups to interactive expert advice provided to another professional performing medical procedure. This can range from video teleconference meetings to surgical telementoring for complex Crohn’s cases .

• Consumer medical and health information includes the use of the Internet for consumers to obtain specialized health information and online discussion groups to provide peer-to-peer support [2].

Most programs may involve a specialist referral service or direct patient care service; there could be a combination of one, two, or even three services depending upon the concept and end result that has been presented by the physician or administrative leader .

Technology Audit and Assessment

The biggest concern around technology and telemedicine has been the lack of knowledge if the physical equipment is onsite and installed in a particular location or for public clinical use. It is the “you don’t know what you don’t know” type of mentality. A technology audit should be conducted on the entire campus or healthcare setting to see what types of equipment are in use as well as what can be utilized for a telemedicine program. The audit should be documented in a spreadsheet so that it lists all manufacturers, model numbers, current firmware version, current Internet Protocol (IP) addresses, main point of contact to book the room or equipment, and any other details about the equipment or conference room. Figure 9.2 is an example of what a typical audit spreadsheet should catalog during the inventory process. This process limits the challenge of multivendor complexity seen with disconnected purchasing and deployment of various vendors.

Fig. 9.2

Technology audit spreadsheet

If the conference room is used for standard audio meetings including content sharing and slide presentations but does not have any videoconferencing capabilities, this room should not be used for any potential telemedicine consults unless the budget will fund the necessary technology for the room. If the room has the necessary video technology, it should be reviewed for setup, configuration, and ease of use with a particular focus on microphone placement and audio challenges. All equipment, no matter if in a conference room or mobile equipment, should be easy for nontechnical people to use [3]. This is where the simplistic approach comes in because if the equipment is too difficult to use, it will not be used for anything including telemedicine.

Conference room design impacts the quality of the telemedicine services and it should not be overlooked during the development of a telemedicine program. Good telemedicine room design will accomplish two major functions: it will create the visual and audio clarity and accuracy that is necessary to support clinical examination and diagnosis from a distance and a connection between the patient and the remote provider sites where the patient–clinician interaction, not the technology, is the focal point. The patient and provider’s location should ensure privacy to prevent any unauthorized access or distractions to take away from the virtual consultation—in particular, windows with bright light and loud noises from hallways or mechanical doors .

The challenge in creating a telemedicine room is to integrate the technology into the regular flow of an examination and to reproduce the images at the consulting clinician site with clarity and accuracy. There are a number of aspects to consider when designing a telemedicine examination room. The most important design considerations are room location, room size, placement of equipment/furniture, electrical and telecommunications connections, lighting, acoustics, and wall color. Since most patient sites will be adapting an existing room for telemedicine, it is important to select the best possible fit and to budget, if necessary, for room modifications [4]. A well-created telemedicine room assessment guide should be developed, including all of the necessary design considerations, and should be utilized during any type of construction reviews with all of the necessary impacted parties.

Telemedicine Infrastructure: Videoconferencing/Collaboration Systems

Once a telemedicine audit has been performed, the telemedicine department should be able to get a sense of what type of technology is currently being deployed and utilized across the network. If a telemedicine audit renders a long list of consult or conference rooms that have been enabled with videoconferencing , the telemedicine department should work with the physicians providing the teleconsult service to see if this approach would be the best for the program along with adding in desktop videoconferencing for the physicians and a model solution for patients. Patients should be given a clear hardware and software solution that requires little to no investment or a bring your own device (BYOD) strategy. If the patients have a device that is capable of using the software for a teleconsult, this will be a much desired solution since there will not be a large expense. The complexity of the telemedicine infrastructure is one of the factors that either grows the adoption of a telemedicine program or fundamentally challenges it [5].

Traditional videoconferencing solutions are equipped with a type of video codec for compression and transmission of video. The following are a few of the more popular video protocols that are being used today over the Internet:

• H.323—This is the technical standard for videoconferencing compression standards that allow different equipment to interoperate via the IP.

• SIP—This is a technical protocol for signaling and controlling multimedia communication sessions like internet telephony for voice/video calls as well as instant messaging via the IP.

• H.264—This is a video compression format that was created to provide good video quality at lower bit rates than previous video protocols which is used by Blu-ray.

• H.265—This is a high efficiency video coding protocol which doubles the data compression ratio at the same level of video quality.

• webRTC—A newer free, open protocol that provides browsers and mobile application with real-time communication (RTC) capabilities via simple application program interfaces (APIs) to perform voice calling, video chat, and P2P file sharing without any internal or external plugins [6].

For more information on the telemedicine and telehealth standards along with definitions of some of the common terms, see Appendix 10.1 and 10.2 at the end of the chapter [7].

During the telemedicine audit, if a very old, archaic technology is no longer under support warranty or cannot be placed under any type of support contract, a short-cycle telemedicine strategy session is imperative. A roadmap of how to put a cohesive solution in place and who is going to be funding this initiative will need to be decided upon during program development. If an entire videoconferencing solution needs to be purchased and will be available for clinicians and administrators, a telemedicine executive planning committee should be formed with the top leaders in the organization driving telemedicine adoption to put the standards in place. If the remote specialist does not want to wait for a larger initiative to be funded and installed by the telemedicine and IT departments, they may want to purchase or lease a cloud-based videoconferencing solution that is rapidly becoming commoditized.

Cloud-based solutions typically come in two different models: hosted within customer’s location for security and privacy sake, or at the vendor’s site for a better scalabilty and less expense. The second model is called a “software as a service” model or SaaS. Most cloud-based vendors operating as a truly virtual model will price their solutions based on the number of participants in a telemedicine consult as well as if the remote specialist needs audio and video as well as interoperability to H.323 or SIP endpoints, mobile/tablet solution, as well as far-end camera control (FECC). A cloud-based solution can be a much more reasonable investment for a provider or even a smaller remote specialist group. It can be expanded as the telemedicine program grows with more remote specialists and patients, as well as the exchange of collaborative efforts between customer and vendor to expand the cloud-based platforms, electronic medical record interface, and other possibilities.

The most important aspects to remember when selecting the proper technology to use for your telemedicine consult solution are:

• 1. What is the current clinical workflow?

• 2. How will the current clinical workflow change with telemedicine?

• 3. What solutions are available that are easy to use for both clinicians and patients?

• 4. What is the return on investment (ROI) of the solution?

• 5. Invest in a large videoconferencing solution or a cloud-based SaaS solution?

• 6. What is the support model for the teleconsultation service program?

While the technology is typically the most talked about and most desired solution from the clinical environment, the scope of the program must be clearly defined of which how a technical solution using video will be implemented to enhance, not replace, the clinician-to-patient relationship.

Interoperability

Most of the original plain old telephone service (POTS) and integrated services digital network (ISDN) videoconferencing systems were originally built to communicate among other videoconferencing systems on the same network. This is an example of a closed-network program that relied on a great deal of security and privacy, which is a topic that will be discussed later in this chapter. For the government and military, this solution works and everyone else who wants to communicate with them needs to have interoperable solutions that scale down to these levels. This level of scalability is also known as interoperability. While most federal government and military videoconferencing infrastructure solutions are not always used for telemedicine purposes, the same level of security and privacy for the patient should be kept to the same standard as well as being able to provide interoperable infrastructure video solutions that are flexible and cost-effective. This issue goes back to the building of a telemedicine infrastructure that can be scaled for one or multiple programs by a tiered approach .

Most videoconferencing systems or even off-the-shelf components are adequate for their intended function, but being able to add new features tends to be costly and time-consuming. The closed-network designs from one vendor may not be able to communicate or talk the same video language to another vendor [8]. In order to provide an interoperable video solution for remote specialists, patients, and many of the telemedicine programs, the telemedicine infrastructure must be designed and built with virtual bridges to handle the necessary video protocols from one system to another. These virtual bridges can be very expensive to purchase after the original video infrastructure has been implemented; so it is very important to consider interoperable codecs when making the initial purchase. If the virtual bridge must be purchased after the telemedicine design, a proper technology requirements document should be presented to the finance team for consideration of this capital investment.

Another possible solution to the interoperability problems of a telemedicine program is adding a middleware solution (possible software and network engineering) to act as the glue that enables incompatible systems to talk among each other [9]. This can be accomplished by purchasing a middleware software solution to be added to the current environment. Another possibility is leasing a solution from a third-party vendor who has already built this into their cohosted environment. A final optional solution would be to find a third-party vendor who can host an entire interoperable solution in the cloud for a per month fee .

Interoperability among the most recognizable videoconferencing infrastructures is one of the main factors that has limited the early adoption and expansion of telemedicine. Remote specialists experience frustration when they try to perform a telemedicine consult with a patient who does not have either the proper software or hardware. Patients experience frustration when the remote specialist’s office does not relay the proper information about the telemedicine software/hardware or cannot complete the consultation without having a technical person guide them through the controls of the system. In order to grow telemedicine programs and their popularity, a telemedicine department must be able to provide an interoperable solution that is cost-effective, not time-consuming, and can work on any technical platform without any problems .

Network Connectivity

The connection between remote specialist and patient should appear as if everyone was in the same room together. In order to provide this type of appearance, the telemedicine equipment should be connected at the highest, acceptable network speed as well as to the most reliable connection—wired at all times if possible and wireless when needed using mobile carts, tablets, and smartphones. Reliability of the networks and the telemedicine connections must be kept at the highest regard since the remote specialists and patients will be surveyed on their telemedicine experience. The most common delivery mechanisms for remote healthcare and data delivery are dependent on the reliability of the network. The list below is the most common delivery mechanisms:

• Network programs—Also known as closed-network programs, these link tertiary care hospitals and clinics with outlying clinics and community health centers in rural or suburban areas through either hub-and-spoke or integrated network systems. The links may use dedicated high-speed lines or the Internet for telecommunication links between sites. It is estimated that there are 200 telemedicine networks in the USA involving close to 3500 medical and healthcare institutions throughout the country.

• Point-to-point connections—Using private networks are used by hospitals and clinics that deliver services directly or contract out (outsourced) specialty services to independent medical service providers at ambulatory care sites.

• Health provider to the home connections—This involves connecting primary care providers, specialists, and home health nurses with patients over single-line phone-video systems for interactive clinical consultations. Such services can also be extended to a residential care center, such as nursing homes and assisted living facility.

• Direct patient to monitoring center—Links are used for pacemaker, cardiac, pulmonary, or fetal monitoring and related services and provide patients the ability to maintain independent lifestyles.

• Web-based e-health patient service sites—These provide direct consumer outreach and services over the Internet [10].

Most health systems and hospitals have preferred to outfit an examination room or conference room with the necessary equipment and to use a wired data connection for the remote specialists to communicate with their patients. Examination and conference rooms can be designed with standard-based videoconferencing systems or off-the-shelf high-definition webcams and headsets just as long as the wired data connection has been set up on the local area network (LAN) with the proper network speed. The elimination of audio feedback or video jitter is among what is typically seen via pixelated images or the sound from a person not matching their mouth movements. The networks of most health systems and hospitals are also set up with quality of services (QOS) network protocol to provide the most reliable network experience without sacrificing network speed.

As technology has advanced over the years, many people have set up their own home personal wireless networks to provide portability and accessibility of their laptops and tablets. These wireless networks, while acceptable but not the most preferred connection type, must be robust enough to allow the video and audio traffic from a telemedicine consultation to be communicated to the remote specialists in an acceptable manner. If the patient is utilizing a smartphone or cellular-enabled tablet and using their data plan for connectivity, a mock telemedicine event using this technology should be tested prior to the actual telemedicine consult to verify that remote specialist acceptance of the network connection. If the remote specialist requires a more reliable connection, the patient may need to find a wireless access point in their area or direct the patient to reschedule the telemedicine service when they have a more reliable and robust network. In turn, if the remote specialist is on call and is in the midst of traveling, they need to provide a reliable network connection and a secure location to the patient so that they are seen and heard over their mobile device. Being able to provide the most reliable and trusted network connection will enhance the telemedicine experience for both the remote specialist and the patient. Reliability in network connectivity will also help increase the use and adoption of telemedicine for remote specialists and patients, which will hopefully be reflected in telemedicine survey results.

Network Bandwidth

When a patient’s survey is returned and they state that the best part about the telemedicine consult was that they felt like they were in the same room as the remote specialist, a large amount of this is credited to the network bandwidth that is supplied to the network. The video hardware that is being used for the telemedicine experience should be isolated from the rest of the traffic on the network. In a small office with little to no IT staff, this might be very difficult, but in a hospital environment this is very feasible. With the amount of equipment on a hospital network, the networking team should be able to build a video network to isolate the traffic off so that it does not collide with all of the other computers, wireless phones, and even the mobile carts that are deployed throughout the hospital.

The higher the transmission speed is, the better performance on the network will be seen on the telemedicine consult. For optimal evaluations, a minimum of 768 Kbps transmission speed is needed for the video system; however, many telemedicine consults have functioned at 384 Kbps [11]. Many telemedicine programs base their network bandwidth speeds on preexisting practice standards as described by the governing body of telemedicine, that is, the American Telemedicine Association (ATA). Per the ATA, the minimum bandwidth for adequate bandwidth, resolution, and speed for a clinical consultation is 384 Kbps in both downlink and uplink directions. They also state in their practice guidelines that the resolution should be set at a minimum of 640 × 360 and have a speed at 30 frame per second [16]. When possible to troubleshoot network issues found during a previous telemedicine consult, network test tools should be utilized for troubleshooting. These network test tools will run any number of bandwidth algorithms to test dropped packets, network jitter, audio issues, or to detect any issues that might be compromising the network.

In the event of any network deactivations or emergency management protocols, there should be a downtime procedure set in place for both the remote specialist and the patient. This downtime procedure should be documented for the remote specialist and their care team as well as provided to the patient in paper and electronic form and provided to all prior to telemedicine consultation. For remote specialists and care team troubleshooting, an audio line can be utilized to walk through troubleshooting steps or possibly implementing a remote desktop software to take control of the needed equipment. The downtime procedure should have the necessary phone numbers and support staff identified for normal business hours and after-hours support. [12].

Security and Privacy

Privacy and confidentiality, much like in the banking industry, has always been a concern in healthcare where patient health information (PHI) has been and will continue to be a concern for health systems, their clinicians, and the patients. With the advancements in technology over the years, the use of encryption software has been able to protect information from unauthorized access. The encryption software is located at both ends of the telemedicine communication and effectively encodes the video, sound, and data during transmission and reconstitutes the information at the other end. Even if someone were able to intercept the transmission, the software would prohibit anyone but an authorized user from reconstructing the encrypted video, sound, and data [13].

The privacy and confidentiality requirements for clinical and healthcare organizations to follow are properly outlined by the Health Insurance Portability and Accountability Act (HIPAA) as well as other applicable state and local laws. As with an in-person office visit, a provider must document in the patient’s medical record either on paper or electronically the visit. Accessing the patient’s medical record should follow standard HIPAA privacy provisions. For those providers or telemedicine departments utilizing a third-party vendor for an electronic medical record (EMR) or videoconferencing solution, a business associate agreement (BAA) should be executed as stipulated under the HIPAA Act of 1996 and the HITECH Act of 2009. When it comes to security and privacy , the encryption standard should include FIPS 140-2, known as the Federal Information Processing Standard (FIPS) as well as the American Encryption Standard (AES) [14].

Most healthcare organizations have a department(s) specializing in network connectivity and security. These departments should be included during the telemedicine program development so that the necessary precautions are put in place to protect all parties. Videoconferencing systems, computers, and mobile devices should also be encrypted by either software running locally on the device to secure the connection or by logging into a virtual private network (VPN) with the proper credentials to use the telemedicine software and hardware. The authentication process of entering a unique username and password should be a requirement to the technical architecture as well as setting up timeout thresholds when the software programs lay in an idle state. Devices should be configured to utilize an inactivity timeout function that requires a passphrase to access the device after timeout threshold has been exceeded. This timeout should not exceed 15 min mode [15]. The use of generic usernames and passwords should not be allowed nor endorsed by the telemedicine department for ease of use by the providers.

Patients should be educated about the technologies available to use regarding computer and mobile device security, as well as be informed about the privacy and security options. Videoconferencing privacy features should be available to both the provider and the patient. Privacy features should include audio muting, video muting, and the ability to easily change from public to private audio mode [16]. If a provider is sending out a “click to join” e-mail to the patient, the provider should have the ability to assign a passcode for the patient as well as the “lock” or secure the teleconsult to only those required to participate in the session. This will ensure that the proper patient has entered the teleconsult as well as to prevent previous or future teleconsults happening without the provider’s knowledge. At the end of a teleconsult, the provider should have the ability to disconnect all parties from the session.

Providers, using mobile devices to perform the teleconsult visit with their patient, should keep devices in their possession when traveling or in an uncontrolled environment. Providers should have the capability to remotely disable or wipe their mobile device in the event it is lost or stolen [17]. The organization’s mobile device governing body should educate and deploy a mobile device management (MDM) solution. A MDM solution provides the loading of appropriate and warranted applications to the user’s job description as well as deactivating or remotely wiping the device for security purposes. While this might deter some providers of receiving a free device from an organization and using their own device, the MDM solution should provide peace of mind to the provider and information technology group who must support and upkeep these devices.

Patient Documentation/Patient Portal

As stated earlier in this chapter, a provider must document the teleconsult visit as if the patient participated in an in-person visit. Most healthcare organizations are planning or have already transitioned to an EMR and are even allowing patients to view their records online, modify their own demographic data, upload radiology images, and even communicate electronically over a secure e-mail system via a patient portal. The patient portal provides further involvement of the patient in their own healthcare as well as the ability to review the provider’s notes and the exact treatment plan. Patients should be advised of security risks of attempting to upload information from mobile devices. As described above in the Security and Privacy section, patients are also required to authenticate their user credentials and must accept the same timeout thresholds.

During a telemedicine consult, the telemedicine physician should work off a checklist to assure that the collection of all needed information from the patient has been received and recorded within the patient’s EMR. In a typical hub and spoke telemedicine program, a remote site uses a provided patient documentation checklist to capture and record all of the patient’s information prior to the telemedicine consult start so that the remote specialist has all required information prior to evaluating the patient. This will assure the most informative package of information is provided to the remote specialist so that the best diagnosis can be offered to the patient. As telemedicine systems and health information systems continue to merge, it will become easier to integrate these checklists and required patient demographic fields into the software interfaces for the telemedicine system as well as a referring provider will be able to assemble all the necessary information and transmit it to the consulting provider instantly [18].

While telemedicine has its own barriers with technology and risk, there is an even larger barrier with providers and healthcare systems allowing patients to access their own information. The patient has the right to see their EMR and now these patient portals are providing the necessary gateway regardless of provider acceptance. Many organizations have to provide this patient portal access because of meaningful use (MU). At the current time, while the Veterans Administration nationwide is on a single EMR platform, VistA, many hospitals and healthcare systems are running different EMRs; some interoperate or communicate with each other and some are silo solutions. For more information on patient documentation, patient portals, and MU, it would be best for those providers and clinicians to connect with their information technology departments that support these areas.

Recording/Archiving

Security and privacy has already been discussed in this chapter, but the topic of recording and archiving these consults is another area of concern when it comes to telemedicine that must be addressed early during a telemedicine program creation. Many years ago, physicians who were just starting to use videoconferencing for telemedicine services could use videocassette recorders (VCRs) to tape their conferences with other physicians. Some sessions were recorded for teaching purposes for residents or incoming students to understand how patients would react to the use of video during an examination. These sessions would also be recorded for legal purposes so that if a patient were to ever come back and sue the physician for malpractice, the physician would be able to pull a recording to provide to their legal counsel for assistance in the court proceedings. As technology has changed and evolved, VCRs were replaced by compact disc (CD) burners, and now they have been replaced by content sharing servers.

In today’s evolving world of telemedicine, hospitals and health systems are averse to any potential leak of PHI. The legal counsels and compliance departments are concerned about malpractice based on a recording that the patient has no knowledge ever took place. Any clinical user taking part in a recorded session will need to announce their name, position, and intention of why they are taking part in the consult as well as getting the verbal and written consent from the patient that they are approving the recording of their telemedicine consult.

Clinicians and patients should discuss any intention to record a telemedicine consult, how this session is to be stored and how privacy will be protected. Recording should be encrypted for maximum security. Recording should be streamed to protect from accidental or unauthorized file sharing and/or transfer. The physician may also want to discuss his or her policy with regard to the patient sharing portions of this information with the general public. Written agreements pertaining to this issue can protect both the patient and the clinicians. If consults are recorded, the recordings should be stored and archived in a secure location. Access to these recordings should only be granted to authorized users [19].

Mock Training Events

The success of a telemedicine program will rely on minimizing failure, reducing the difficulties in providing technical support , and constantly testing the hardware and software. It is important to achieve a high level of reliability and performance. Reliability and performance should be approximately 99 % or better to attract and retain physicians and patients satisfied that telemedicine is a viable process for delivering medical care. It is often difficult to regain credibility with either physicians or patients if the systems or networks perform unreliably [20]. Not only should a working model for delivering telemedicine support be developed, but also the clinical end users should perform mock events to test the hardware, software, video speed, and the reliability of their physical location among their own team as well as those identified patients.

The physician champion identified to run the telemedicine program and their administrative staff should take the lead on identifying dates and times when the mock events should be scheduled within the organization. Departmental technical staff, if identified as hardware resources, should also take part in the mock training events so that they are available to identify, troubleshoot, and resolve the hardware or software. Administrative staff identified to communicate with the patients should be provided the necessary set of instructions, weblinks, documentation, and e-mail templates by the telemedicine support team for testing purposes. Once all the information has been gathered and received operational approval, a select number of patients should be identified as “beta-testers” who can follow installation and testing documentation provided by the telemedicine team.

A week prior to the actual telemedicine consult, the administrative staff should schedule a mock training event with the patient to test the installation and any configuration of the software (unless a telemedicine device is provided to the patient for home use). During this mock event, the administrative staff should communicate with the patient and verify video and audio on both sides to see if the patient can see and hear the end user communicating with them. If the hardware and software allow for FECC, the testing of remote pan-tilt-zoom (PTZ) functions should be tested and communicated by the telemedicine technical team. Once the mock event between administrative staff member and patient is concluded and everyone signs off that audio and video were successful, the telemedicine physician or clinical end user who will be contacting the patient for a telemedicine consult should perform the same mock training event with their hardware and software setup. All results of administrative, clinical, and patient testing should be recorded in a checklist and provided back to the telemedicine technical team for further troubleshooting and potential custom documentation edits. The constant testing and retesting with the three groups identified will build reliability and accuracy for the successful launch and proliferation of the telemedicine program.

Video Etiquette for Remote Specialists and Patients

During a teleconsultation session, both the provider and patient locations are considered a patient examination room regardless of the location’s intended use. The room should be of sufficient size to accommodate not only the patient and/or family member/significant other who is participating in the teleconsultation but also the necessary equipment. The room should be safe, adequately lit, have minimal external noise, and provide comfortable seating. The room should be designed with audio and visual privacy and be able to accommodate posture and movement visualization. Pagers, cell phones (unless being used as the device for the teleconsultation) , and other electronic devices that could cause a disturbance should be turned off if remaining in the room or removed from the room during the length of the teleconsultation.

For the provider, the telemedicine room should be in a quiet location, minimizing exposure to home or office noise, busy corridors, stairwells, parking lots, waiting rooms, restrooms, or other sources of house (i.e., children and/or pets). Such noise can be picked up by microphones which can make it difficult for the patient to hear. Rooms without windows are better for quality image transmission with less camera glare. Rooms with windows should have shared or blinds to reduce the light and glare. The environment needs to be designed to enhance the quality of the video and audio interactions and to accommodate the equipment that might not normally be in an examination room [21].

The California Telemedicine and eHealth Center (CTEC) have created a Telemedicine Room Design Program Guide that addresses many of the current video etiquette and environmental concerns regarding teleconsultation. In this guide, they have discussed the need to integrate the technology into the regular flow of an examination room and to reproduce the images at the patient’s site with clarity and accuracy. They focused much attention in their guide to addressing the following aspects: location, placement of equipment and furniture, electrical and telecommunications connections, lighting, acoustics, and wall color. Rather than trying to recreate the wheel on a telemedicine program and how to change the culture within an organization, a recommendation would be to perform research on video etiquette and environment concerns before creating custom documentation for a telemedicine program. Another recommendation would be to download the Telemedicine Room Design Program Guide document and adapt it to a clinical program since it seems to address many known and unknown areas. The location of this document download is: http://www.telehealthresourcecenter.org/sites/main/files/file-attachments/09-0824-2_ctec_program_guide-room_design_w_cm_edits.pdf. An example of the CTEC’s Telemedicine Room Assessment and Design Worksheet is included in Appendix 10.3 for reference.

Telemedicine Deployment and Management

The mission of the telemedicine program should be driven by clinical leadership but the deployment and management of that program should be a collective effort including the clinical and technical leadership from the telemedicine team. Since telemedicine is considered to be a new way of delivering medicine, the implementation of a new program may change the workflow of existing practices. Planned and sensitive change management is therefore central to the successful introduction of telemedicine services. Other critical success factors include the organization of hub and remote sites (otherwise known as “spokes”), data collection and performance indicators, development plans, and marketing communication [22].

All telemedicine conceptual ideas should be vetted through a Telehealth Executive Committee in which the clinical leadership presents the idea, provides a current volume of patient that could be affected by a telemedicine program, funding for the needed hardware for the program, discussion on reimbursement and credentialing areas, and, lastly, how the clinical program envisions the program to impact their current patient population. The Telehealth Executive Committee should provide critique to the clinical program and ask any questions before making their recommendations to approve the program to move into development stage. The telemedicine program should operate with the current telemedicine technology that has been deployed across the health system or hospital to leverage the return on investment. Any additional equipment needed for the program will need to be recommended to the telemedicine team for evaluation before agreeing to include them into the operation of the telemedicine program. Once approval of the telemedicine program has been reached, the telemedicine team can move this program into development stage.

The telemedicine team and the clinical champion will need to develop a project plan including all steps and responsible parties who need to be assigned tasks within this project plan. The telemedicine team will assign a project manager to manage the project plan, schedule weekly meetings with all parties, set up testing and training plans, and ultimately give the “thumbs-up” on when the program has reached 100 %assigned task completion making it ready to move to the “go live” stage. While the telemedicine program might be ready for “show time,” the clinical champion who created the idea must get the approval from the clinical chairperson to move the project from concept into production. They will need to verify that all billing, credentialing, and malpractice issues have been resolved prior to recruiting the first round of patients to be evaluated using telemedicine.

Once the program has moved into a “live” status, the telemedicine team will use collected data and surveys to perform some monthly management meetings with the clinical champions. The required information will be disseminated among the group to review and discuss how to resolve challenging situations, as well as to review if the program has met the clinical champions’ goals. Monthly and quarterly management meetings and check-ins should be scheduled so that strategic goals are continued to being met, as well as program expansion can be considered for other services lines.

Support Structure

The support and upkeep of a telemedicine program is very important to the success and longevity to both the end users and the patients. The technology will require infrastructure support, repair service, and preventive maintenance, as well as a training and marketing to all stakeholders. Ongoing technology maintenance and repair is often best managed through an in-house technical support center [23]. A technical support group should have the ability to create custom documentation for any end user to follow, either clinical or a regular patient, in order to step through the installation of software as well as testing with the technical or end user community. The documentation should be created in layman’s terms to avoid any confusion from those following the step-by-step instructions.

The in-house technical support center should have a mechanism in place to receive incoming phone calls, the ability to open service tickets, as well as a the funding to repair and replace broken or out of service equipment in a timely fashion. When technical support resources are limited, the ability to cross train internal “super users” or the technical staff of another department should also be included in program development. When the clinical users and patients require technical support for mock events and during actual teleconsults, the program must include a matrix level of support that can be included in the program creation. Any telemedicine programs that also requires after hours or 24-7-365 support, an on-call schedule must be created so that a dedicated technical and clinical support team can provide the needed support in a timely manner. If additional technical or clinical support resources are needed to provide support to the program, a special operational budget request should be delivered to the financial team requesting these funds. If the request is denied due to lack of operational budget, the required resource costs, either daily or on-call after hours, should be paid for by the department that is setting up the telemedicine program. These additional resources will help drive adoption of telemedicine in the department as well as provide satisfaction to the clinical telemedicine team members and those patients utilizing the solution.

Telemedicine Program Go-Live

A clearly identifiable go-live date is needed to be established by the telemedicine team project manager during the development of the project plan. While this date can be changed anytime during the project, a firm date should be established during the program. A proof of concept or pilot project in telemedicine has been created by many organizations but they have never moved past the pilot stage. Recurrent pilot programs that are never moved into major products are due to many issues like: reimbursement, rurality, remote site technical issues, staff turnover, lack of patient interest, adoption issues, risk of malpractice, and security concerns.

The go-live tasks should be clearly identified in the project plan including assigned responsible parties who will be available both onsite for clinical champion and administrative support as well as the support structure to assist patients from their remote offices. Since many of these telemedicine programs are being offered during normal office hours, the ability of having technical and clinical support from the telemedicine team should be identified during a pre-go-live meeting with the clinical leaders. If the go-live and the go-live date need to be adjusted for some clinical or administrative reasoning, this change should be echoed during the program development meeting and cleared by the telemedicine team.

Telemedicine Survey/Data Analytics

Telemedicine has numerous participants, each with unique needs and expectations. Patients desire effective and compassionate care that precedes in as expeditious a manner as possible. Primary caregivers desire effective consultation but are also interested in the time spent preparing and presenting a case. Consultants are concerned about the duration of the visit and quality of presentation. The system collectively is concerned with cost-effectiveness and patient-management issues. A complete assessment of telemedicine satisfaction must have all perspectives in mind [24]. Since all telemedicine programs learn from each other, the program must survey all participants to get their feedback on the effectiveness of the telemedicine consult.

For the patient, they should be asked if the consult is what they expected out of the program. The survey should address the effectiveness of patient’s overall medical care, any technical limitations during mock events or actual visit, and any fears concerning patient privacy and security. Finally, the patient should provide any timeliness or inconvenience of the teleconsult visit with the standard in-person visit at the hospital or clinic. The physician or clinical end user should also be surveyed on many of the same factors that are explained above about the patient. In addition, they should be asked if the visits were helpful or more harmful to the patient as well as address any patient consent concerns. The clinical end user should also be asked if future teleconsults would decrease the number of in-person consultations by a certain percentage freeing up more clinic time for new patients to be seen by the staff. Examples of patient and provider surveys are located below in Appendix 10.4 at the end of this chapter.

As for data analytics and recordkeeping, the same methodology should apply for a telemedicine consult as with a hospital or clinical networking topology. The telemedicine support team should be able to provide a tracking report or a log of when the telemedicine consults took place, who joined the telemedicine video call, if they joined from within the hospital/clinic or from the outside world, when the participants started and ended their video session, and finally a figure of how many minutes the video consults lasted with the attendees.

Figure 9.3 below provides an example of a typical reporting log for a telemedicine consult.

Fig. 9.3

Example of analytical reporting log for a telemedicine consult

The use of this report or log can be used to correlate survey results back to a particular session, show ROI of the video technology for future or expansion of telemedicine program, or to provide to a network security team or legal counsel if patient privacy were to come in question or possibly a malpractice lawsuit. Surveys and reporting logs should be backed up and archived in a safe and secure location for any potential server outages or data loss. Also the reporting process should take place on a weekly, monthly, and annual process and presented to the clinical end users for validation of metrics and to discuss survey results.

Marketing a Telemedicine Program

The success and further adoption of a telemedicine program should be published so that the results can encourage others to enter the telemedicine space. With the data analytics and patient surveys, it would best to use this data to market a telehealth program to a group of physicians or other patients after a reasonable amount of time (i.e., 3–6 months of data is best for marketing and promoting a new telemedicine program). The patients from your successful telemedicine program launch can provide accounts to marketing or public affairs departments so that articles can be written on how the telemedicine program have benefited them and that no anticipated adverse patient privacy consequences exist [25]. The public affairs department should also consider sending a video crew to the patient’s house to capture their reaction of a first time teleconsultation on video for internal website marketing.

The clinical champions should also be interviewed to address any questions or concerns regarding technical feasibility, ROI, and lastly if they suffered financially or lost personal prestige by migrating away from tradition face-to-face consults. For both patients and other clinical leaders, they can be swayed to try something new for their own healthcare if they see or hear about other people’s experiences. This marketing plan could potentially help motivate others to enter into the world of telemedicine and create a new experience for their patients to receive better access to care via the electronic age of the Internet.

Summary

Over the course of this chapter, there has been a discussion on terminology and methodology necessary to set up a technical telemedicine platform. For a newcomer to telemedicine, the discussion shows that setting up a telemedicine platform can be very challenging since most of the program development is not just concentrating on the technology that enables a telemedicine program. Technology is usually only about 20 % of the program. The remainder of a telemedicine program tends to deal with current clinical workflows and protocols and how a telemedicine program can fit into these current workflows and protocols. There are many tips available on how to create a successful telemedicine program but Nirav Desai, the CEO and Founder of Hands On Telehealth , LLC, said it best in his e-Book [26] which describes 10 secrets to drive success in a telemedicine program:

• 1. Have a strategy

• 2. Dedicate resources

• 3. Ensure clinical satisfaction

• 4. Keep it simple

• 5. Identify and develop champions

• 6. Foster consistent use

• 7. Provide ongoing training

• 8. Measure and assess performance

• 9. Setup repeatable processes

• 10. Always be marketing

While system requirements, technology, interoperability, network bandwidth, privacy and security, cloud-based solutions, SaaS, and other areas covered within this chapter are important to the program architecture and program development of a telemedicine program, the primary objective of the program is not to replace a face-to-face relationship between physician and patient. The program goal must be to provide better access to patient care when and where the patient needs it with the proper clinical resources and specialists.

Telemedicine should be viewed as part of a diversified approach to the new models of providing medical care. As telemedicine continues to evolve, legislative and regulatory safeguard maturation will increase efficiency, cut costs, and help assure that medical care delivered via telemedicine networks meets the standards of “in-person” medical care. Telemedicine is not a total solution to shortages of primary care physicians and specialists, but it has demonstrated the potential to address factors that affect physicians’ decisions regarding practice as well as to extend, geographically, care through mid-level health personnel. Once these potential contributions to the resolution of the problem are adequately demonstrated and continue to satisfy that delivery medical care via telemedicine is equal to that delivered in person, telemedicine will become an essential and constant factor in the delivery of medical care in the USA [27].

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