Virginia Telehealth Network Infrastructure Work Group White Paper Consensus Conference: "Developing...

Virginia Telehealth NetworkInfrastructure Work Group

White Paper

Consensus Conference:"Developing a Vision and Strategic Plan for Telehealth in Virginia”

May 26, 2005

Infrastructure Work Group 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 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


Site SurveyResponding Organizations

Blue Ridge Regional Medical Center

Buchanan General Hospital Edward Via VA College of

Osteopathic Medicine Lewis-Gale Medical Center Louisvile Medical Center Montgomery Regional

Hospital Norton Community Hospital

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

Hospital


Site Survey Findings


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 .


Sites

Pound

Norfolk

WiseCedar Bluffs

Abington

Wytheville

Coving-ton

Blacksburg

MartinsvilleSouth Boston

LynchburgFarmville

Williamsburg

Newport News

Portsmouth

Petersburg

Richmond

Fredericksburg

Alexandria

Culpepper

Leesburg

Winchester

Fairfax

Harrisonburg

Charlottesville

Staunton

Pennington Gap

Big StoneGap

Norton

Clintwood

Gate City

Grundy

Vansant

Tazewell

Saltville

Dungannon

Konnarock

St. Paul

Marion

Bland

Bastion

Pulaski(2)

Salem

Pearsburg

BlacksvilleLebannon

Radford

Christianburg

Floyd

StuartGalax

Hillsville

Clifton Forge

Hot Springs

Monterey

Low Moor

New Castle

Laurel Fork

Craigsville

Danville

Troy

Madison Heights

Goochland

Powhatan

Dillwyn

Blackstone

BoydtonCatawba

Warrenton

Manassas

Mitchells

Burkeville

Bowling Green

Colonial Beach

Jarratt

Dahlgren

ArlingtonFalls Church

Warsaw

AylettGlen AllenAshland

Tappanahanock

St Stephens Church

Chesapeake

Heathsville

Suffolk

Callao

Hayes

Cheriton

Accomac

Franktown

Hampton

Virginia Beach

KilmarnockSaluda

Charles City

Vinton

Chesterfield

MontrossOlney

HartfieldLancaster

Nassawadox

(17)

(2) (2)

(2)

(2)(3)

(2)

(4)

(3) 2-H

(2)

Belle Haven

Roanoke

Bristol

Front Royal

(2)

(11)(3)

(2)

Woodstock

Lexington

Newport News

U.V.A.

Community Service Board

V.D.H.

D.O.C.

RAHCE

EVTN

VA Dept. of Mental Health (VDMHMRSAS)

VCU.

VT/VCOM

X= hub

= point of presence (POP)

XX


VCU VDH

UVA

Dept. of Corrections

Networks are Isolated

VT/VCOM

VDMHMRSAS/CSB

Others


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)

0 500 1000 1500 2000

TotalUsable

ExampleTraffic

Max.Suggested Video

Internet

WEB Data

Signaling

* Chesterfield VDH site survey


Issues

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


Example: Current Process to Establish Video Conference

Video Conferenceneeds to be scheduled

Video Conferenceneeds to be scheduled

Remote end respondsif available

Remote end respondsif available

Contact remote end foravailability

Contact remote end foravailability

Video operator is scheduledto assist in video conference

setupCan cost

up to $150 per hour

Video ConferenceIs manually connected

Video ConferenceIs manually connected


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


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


Optimal Virginia Telehealth Network

VCUVDH

UVA

Dept. of Corrections

Virginia Telehealth Network

Provider offices

HospitalsHome patients

Other Networks

VT/VCOM

VDMHMRSAS/CSB

EMS-Satellite

Geriatric facilities


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


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


Options

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


Status Quo

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


Integration

Pros All networks can

communicate with each other

Not as expensive as a new network

MAY! be implemented in less time than new network

Cons Coordination

Technology Standards Ex. IP Ex. Video

Security Policy Firewalls/VPN IT Policy

No central governance for infrastructure maintenance

New technology adoption is difficult Biggest stakeholders have the most clout Many needy communities and

organizations remain underserved Re-imbursement for network services

difficult Security issues


For an Integrated Network to Succeed

All participating network administrators/IT departments MUST:

Open their networks to all potential public and private users!!!


New Network 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


Next Step

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

sustainability.


Questions?

Steve Gillis

(703) 869-3085

[email protected]

Technical Annex:

David Heise

(703) 477-5456

[email protected]


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


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


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)


Equipment and Capacity Requirements


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)


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


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


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


Capacity Examples for Video

Speed Max. amount of Video

Signaling overhead

T1 (1.544mbps) 1 x 384kbps

1 x 256kbps

3 x 128kbps

384kbps

DS-3

(45mbps)

32 x 384kbps

48 x 256kbps

96 x 128kbps

11,250kbps


Network Design


Currently Sites in Virginia Connect Using IP over

ATM

Gatekeeperproxy

DATA Switch

PSTNISDN

Video InfrastructureGateway

MCU

Gatekeeperproxy

MCU

Gatekeeperproxy

Regional Site

Headquarters Site

Gatekeeperproxy

Regional Site


Customer Edge

Access:Type 1, 2 3

Private IPEdge

Router

Private IP Core

Access:Type 1, 2, 3

Customer Edge

Private IPEdge

Router

MPLS (IPv6) IP

CoreProvider Edge

FR, ISDN or ATM

FR, ISDN or ATM

T1, NxT1, T3, OC3

Provider Edge

Video MCU/GatewayGatekeeper

Other MPLS networks

(Internet 2)

T1, NxT1, T3, OC3

IPv6 with MPLS is becoming Industry Standard


Technology Review and Comparison


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.


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


Network Cost Efficiencies and Simplification Realized in MPLS Network

Network Cost Efficiencies and Simplification

MPLS Network

Any-to-Any IP Connectivity (MPLS)

Host #1 Host #2

Traditional Frame Relay, ATM or Private Line Networks

Host #1 Host #2


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

Why IPv6?


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


Optimized Queuing Using QoS

11VideoTraffic

22LAN

Traffic

33 3InternetTraffic

23 2 11

Transmitring


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

Virginia Telehealth Network Infrastructure Work Group White Paper Consensus Conference: "Developing...

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