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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 3
Infrastructure Work Group Members
Kathy Wibberly, Virginia Department of Health
Steve Gillis, Telehealth Solutions Group, LLC David Heise, Telehealth Solutions Group, LLC John Hughes, Virginia Department of Health Debbie Justis, VCU Health System John Lawson, Virginia Tech Mary Claire O’Hara, VA DMHMRSAS Dixie Tooke-Rawlins, Edward Via VA College of Osteopathic
Medicine
Infrastructure Work Group 4
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
Infrastructure Work Group 5
Site Survey Findings
Infrastructure Work Group 6
Telehealth Services Most respondents that have Telehealth/ Telemedicine currently use video
over ISDN for video conferencing
Several of the larger networks use video conferencing over IP without Quality of Service (QoS) which could cause quality issues
Several sites use satellite broadcast for Tele-education and training
75% have Telemedicine (band-width intensive clinical) applications
50% inter-connect with other networks Several larger institutions connect nationally and internationally
50% use multi –party bridging .
Infrastructure Work Group 7
Sites
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
Infrastructure Work Group 8
VCU VDH
UVA
Dept. of Corrections
Networks are Isolated
VT/VCOM
VDMHMRSAS/CSB
Others
Infrastructure Work Group 9
Hard to Generalize- But Capacity is Already Constrained at Some
Network Sites * Applications
2 Video channels (384kbps)
Internet/Email channel (256k)
Web application (256kbps)
T1 local loop (1536kbps usable bandwidth)
0 500 1000 1500 2000
TotalUsable
ExampleTraffic
Max.Suggested Video
Internet
WEB Data
Signaling
* Chesterfield VDH site survey
Infrastructure Work Group 10
Issues
Service quality Cost Scheduling of remote consultations Training Needs of remote location not always met New services implemented too slowly
Infrastructure Work Group 11
Example: Current Process to Establish Video Conference
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
Infrastructure Work Group 12
Note on Video Quality
To ensure video quality Industry standard is Quality of Service (QoS) Protocol*
Controls network congestion through bandwidth management
Video over IP without QoS is not reliable. Network congestion degrades quality (latency and jitter)
*see technical annex for information on QoS
Infrastructure Work Group 13
Respondents Future Plans
Increased use of Telehealth/Telemedicine applications
Increased use of clinical Tele-Education
Increased connectivity within networks in Virginia and nationally.
Increased home health monitoring
Infrastructure Work Group 14
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
Infrastructure Work Group 15
Future Network Functional Requirements(Optimal)
Ensure video quality Ability to support bandwidth intensive
video and data applications Support private users Open Network (standards based) Sustainable
Infrastructure Work Group 16
Optimal Technologies & Services
IP based video conferencing using QoS Multipoint conferencing capabilities Data Collaboration Store & Forward, Streaming Media & Broadcast Video VPN and LAN capability (PC Based) Ability to interface via any local access method (ex. ISDN,
ATM. Frame Relay, Internet, Private line and DSL). Emergency response capability Open network interoperability Compliant with HIPAA /HL7
Infrastructure Work Group 17
Options
• Status Quo• Integrate existing networks• Build a new network
Infrastructure Work Group 18
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
Infrastructure Work Group 19
Integration
Pros All networks can
communicate with each other
Not as expensive as a new network
MAY! be implemented in less time than new network
Cons Coordination
Technology Standards Ex. IP Ex. Video
Security Policy Firewalls/VPN IT Policy
No central governance for infrastructure maintenance
New technology adoption is difficult Biggest stakeholders have the most clout Many needy communities and
organizations remain underserved Re-imbursement for network services
difficult Security issues
Infrastructure Work Group 20
For an Integrated Network to Succeed
All participating network administrators/IT departments MUST:
Open their networks to all potential public and private users!!!
Infrastructure Work Group 21
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
Infrastructure Work Group 22
Next Step
Detailed requirements analysis to support network envisioned by strategic plan.Define revenue streams, cost savings and
sustainability.
Infrastructure Work Group 23
Questions?
Steve Gillis
(703) 869-3085
Technical Annex:
David Heise
(703) 477-5456
Infrastructure Work Group 24
Technical Annex(TeleHealth Solutions Group, LLC)
Requirements Network Requirements Equipment & Capacity Requirements
Network Design ( Current vs. Optimal) IP over ATM MPLS
Technology Review and Comparison IP over ATM vs. MPLS Why IPv6 Why QoS
HIPPA Site Survey
Infrastructure Work Group 25
TeleHealth/Telemedicine NetworkTechnical Requirements
Services VoD (Video on Demand) Data Collaboration Streaming Media Multicast capability (unicast & webcasting)
Lowest possible Latency and Jitter for Video & Broadcast services to ensure service quality
Network Facilities to support these services Local Access requirements Backbone requirements
Network security Layer 2 VPN Capability Firewall VPLS (Virtual Private LAN Service) (GigE) mVPN (Multicast VPN)
Network Address Translation Secure Email
Infrastructure Work Group 26
Technology Requirements
Transmit IP using MPLS with IPv6 protocol Control Latency and Jitter through QoS & Bandwidth management Support the new video standard H.264 Translate from ISDN (H.320) to IP (H.323) Secure VPN service over the public Internet for local loop DSL
service Provide Encryption and password security features IP Address translations and assignment device to device Support multiple local access (ex. ISDN, ATM, Frame Relay, Private
Line, & Gig E) Vender and Facility provider independent Support manageability (use H.323 Beacon)
Infrastructure Work Group 27
Equipment and Capacity Requirements
Infrastructure Work Group 28
Required Video Components
Video Terminals (Stations) (At Remote site Location)
Gatekeeper (At Hub site location) Performs all address resolutions
Gateway (At Hub site location) Provides interoperability between H.323(IP) to H.320 (ISDN)
Multipoint Conference Unit (MCU) (At Hub site location)
Proxy (Some times combine with the Gatekeeper) (At Hub site location) Call processing agent (QoS)
Infrastructure Work Group 29
Video Equipment Requirements Network Standard
H.323 Video Standards
H.261, All H.263 (To communicate with older units) The new H.264 (Same quality video using half the bandwidth)
Audio Standards G.711, G.722 G.728
Security Features Passwords Encryption (DES, AES)
H.233, H.234, H.235V3 Data Collaboration QoS capabilities LAN connection at 100 Mbit IPv6 compatible
Infrastructure Work Group 30
Remote Site Router/LAN switches Requirements
Support Video traffic Support QoS services
RSVP, DiffServ & FPC Support IPv6 protocol LAN connection minimum speed 100Mbit LAN switch supports minimum of two queues Pass encryption data Password protection
Infrastructure Work Group 31
Video Capacity Planning Metrics*
Video data rate + 20% = Bandwidth required
No more than 33% of the link capacity should be used for Video Conferencing
Video + Date should not exceed 75% of the Link capacity
*Cisco recommended for IP Video
Infrastructure Work Group 32
Capacity Examples for Video
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
Infrastructure Work Group 33
Network Design
Infrastructure Work Group 34
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
Infrastructure Work Group 35
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
Infrastructure Work Group 36
Technology Review and Comparison
Infrastructure Work Group 37
IP over ATM Issues IP over ATM has the potential to create bottlenecks leading
into the core resulting from the lack of segmentation and reassembly (SAR) functional on OC-48 and faster interfaces.
IP over ATM results in an inefficient use of network bandwidth due to the traditional ATM cell tax.
The IP differentiated Services (DiffServ) approach to class of service (CoS) does not map well to existing ATM quality of service (QoS) mechanisms.
TCP/IP is an inherently inefficient protocol to run over an ATM transport, because the transmission of a single ACK requires not one but two ATM cells.
Infrastructure Work Group 38
Comparison between IP and MPLS
IP forwarding (for Video) lacks path control and deterministic resiliency as with MLPS services.
MPLS provides rapid failure recovery across IP routing devices. MPLS includes traffic engineering (For performance and high
availability), quality of service (QoS), resource optimization and security.
MPLS can reallocate lower traffic class bandwidth resources to provide video services
MPLS provides FRR (Fast Reroute) which can provide reroute capability in the range of 50ms, and is similar to SONET/SDH technology.
MPLS can perform an efficient replication within the network, to eliminate duplication traffic over the same link making efficient use of bandwidth.
Some of the new QoS features supported by MPLS are RSVP-TE (Resource Reservation Protocol traffic engineering and DiffServ-TE)
MPLS used by US government today
Infrastructure Work Group 39
Network Cost Efficiencies and Simplification Realized in MPLS Network
Network Cost Efficiencies and Simplification
MPLS Network
Any-to-Any IP Connectivity (MPLS)
Host #1 Host #2
Traditional Frame Relay, ATM or Private Line Networks
Host #1 Host #2
Infrastructure Work Group 40
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?
Infrastructure Work Group 41
Why QoS?
Controls Latency sensitive data such as Video and Voice Admission control – bandwidth control and policy control Resource Allocation – Queuing and scheduling – Traffic
flows and traffic classes Gatekeepers – Network administer – manages the pool of
available bandwidth Types:
IP Precedence Differentiated services (Diffserv) Integrated services (IntservRSVP)
QoS must be available all the way to the end equipment
Infrastructure Work Group 42
Optimized Queuing Using QoS
11VideoTraffic
22LAN
Traffic
33 3InternetTraffic
23 2 11
Transmitring
Infrastructure Work Group 43
HIPAA
Code of Federal Regulations – 21 CFR-11 21 CFR-11 took effect on 08/20/1997 and
was intended to permit the widest possible use of electronic technology
Part 11 requirements for electronic records Section 11.10 and 11.30 define controls
for closed and open systems