Home Medical Teleconferencing: Conversation with a Sceptic
We had a candid conversation with an IT person who supports telemedicine applications at a major research university. I thought it might be useful to post a de-identified version of the discussion, as it brought out a number of points, both positive and negative about our DocBox units that we developed and deployed to deliver a 12 week 3x per week Tai Chi session for elders who had fallen or had a fear of falling. The conversation addresses several questions regarding installation, support, and the differences between the DocBox vs. Tandberg and Polycom gear. I’ve changed my interlocutor’s name to “Tom”. His questions and responses were copied to clinical staff at the university, when the staff asked about the feasibility of using the DocBox, and about videoconferencing in general.
LK: Tom, I’ve left a phone message if you want to chat…. feel free to call or eMail at any point. Here are some answers questions you have raised. I’ve have your questions enclosed in chevrons, and my comments below.
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Q. Videoconferencing has come a long way in recent years and the video quality is impressive provided all the network issues can be resolved. In recent months, I have worked with pediatrics and family medicine on installing videoconferencing equipment at several off-site locations and in some cases it has taken months to get some of the network firewall issues resolved at these locations.
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LK: No miracles here. With all of our DocBox home installations, we’re either dealing with
a.) a direct connection to a cable modem or DSL modem, or
b.) connecting to a home (Linksys, Netgear, etc.) type router.
In the first instance, a.) we attach a laptop to the cable or dsl modem to assure it is functioning as expected, figure out what the IP address is from DHCP, and/or whether we can or should assign a fixed IP address to the DocBox. Then we attach the DocBox. We’ll use the firewall on the DocBox for fire walling.
In the second instance, a home router, then we have to accommodate a possible firewall…. Usually we’ve installed the unit in the router’s DMZ, and then activated the Windows firewall on the DocBox for firewall protection. (If there is a firewall on the DSL or cable modem, then that has to be dealt with as well.)
You can also go the port-forwarding route, but that tends to be less reliable on consumer-grade routers, and the DMZ method is set up quickly.
We prefer to have our “own” internet connection, just so we don’t end up fiddling with a patient’s existing connection if they have one. In one or two instances we’ve installed a second cable modem, or even a whole second internet connection within a home to accommodate the DocBox.
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Q. In recent months, I have worked with pediatrics and family medicine on installing videoconferencing equipment at several off-site locations and in some cases it has taken months to get some of the network firewall issues resolved at these locations. While videoconferencing technology has many benefits, it is not simple to deploy at clinics or at a private residence. There are many technical issues that often prevent videoconferencing from working correctly including: the lack of bandwidth, unreliable network connections, network firewall at residence, and no service level agreement with the Internet service provider.
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LK:This is more likely to be problematic where you are dealing with physicians practices a opposed to home consumer-grade internet connections. In our own work with physician practices, we do indeed have to deal with their IT service providers who manage the firewall for the practice. We’ve found it essential to establish a good working relationships. In a couple instances (hospitals), we have installed our own cable modem connection to the hospital, and the internal hospital cabling folks ran a Cat 5 pair from the modem site in the wiring closet or basement, to the site where we installed our unit.
With home systems, we have them set up the day we bring the equipment; it hasn’t been a big problem as long as the internet connection is active. You have to bring a laptop on the installation to figure out what is happening, and to access the management screens of their modem and/or router.
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Q. There are many technical issues that often prevent videoconferencing from working correctly including: the lack of bandwidth, unreliable network connections, network firewall at residence, and no service level agreement with the Internet service provider.
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LK: Regarding bandwidth…. we need 384Kb in each direction for a solid connection. We’ve managed with 256Kb. We have had issues when the IP provider is DSL “at the end of the line”, for example, when line quality was not what it should be. We are working in rural Vermont, and a solid home internet connection is not a given, and many places have none whatsoever, (or cell phone service for that matter..) Some DSL connections at the end of the line have been problematic. Cable is most reliable (or fiber, of course, if you can get it.) Haven’t tried 3G. 4G is a pipe dream up here.
That said, the quality is not designed to be identical to commercial -grade Tandberg/Polycom business systems using HD. In all cases we’re attaching to the person’s TV set, and in many cases people still have their older sets.
Wireless service (via satellite) does not work. Internal wireless within a person’s home can be unreliable, and finicky to set up. We preferred a wired connection if at all possible, although we have successfully used Wireless G in a couple homes.
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Q. Skype often does better at videoconferencing from a residence simply because it was designed for low-quality, low bandwidth environments such as home use.
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LK: We have a version of our unit that uses Skype. It is not H.323 compatible, so for our telemedicine application wasn’t going to work. We’ve never used it in a production situation, but it looks promising, and the cost of our unit can be considerably lower, if Skype is an option. Skype will also now do at least 4 connection multipoint. Skype looks really interesting for point-to-point connections, but it does require you to go through the Skype servers to make the connections. There has been a lot of discussion in the literature of using Skype for psychiatric counseling, and the security implications of using Skype to set up the conferences. (jury is still out.)
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Q. I have asked our Cisco product team to put together some other videoconferencing options that could work in this application.
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We use a Tandberg/Codian (now Cisco) MCU 4205 for our multi-point connections. We would love to be able to afford some of their clients units, but developed our unit to serve as both a lower-cost alternative, and to allow for “no interface”….i.e. the patient just needs to turn it on and tune it to their TV.. everything else happens on the back end. Their Umi product is interesting, and we have a long history with it, including beta testing a couple earlier versions but we never got it to work for us. The main issue for us was that we needed to be able to control the interface. We couldn’t present the patient with a multi-windowed interface that had directories, and buttons, etc. (Not least because they had no way to manipulate the interface…no mouse or keyboard).
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Q. There are two main “protocols/technologies” to hold video conferences online. First would be with something like Skype with a low cost camera and a computer and high speed Internet access. The pros are it is cheap and fairly easy and straight forward. The cons are you can only do one on one, but there might be other software out there which would possibly allow up to 3-4 connections at the same time. This might cause some performance issues, it would just have to be tested.
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LK: See above. Our point-to-point tests for Skype were favorable. Multipoint with four connections were also good (by our standards, anyway….again it isn’t as “perfect” as standard H.323). Our unit does use a PTZ web-cam and is based on a mini-ITX form-factor PC running Windows Embedded.
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Q. The next technology is the H.323 video teleconferencing. This is the protocol Polycom uses, and it also works over existing high speed lines. It is just dedicated to be a video teleconference system, and needs to be setup at each location. The nice thing about this system, is as long as you have the equipment, you can include multiple parties on a video call. You don’t want to do too many, or it will look like a Brady bunch theme. You might choose to see yourself on the screen and a few people, but many people can see you IF they have the equipment.
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LK: This describes our unit. We use the Polycom PVX client software which is H.323 compatible, allows AES encryption, and integrates with whatever H.323 infrastructure may already be in place, such as MCUs and session border controllers for firewall traversal. We aggregated up to 12 people for our classes, so the comment about the Brady Bunch, really depends on the application. We found that our instructor was able to observe and supervise about 10-12 class participants. Indeed, one of the advantages of such supervision is the ability to react if anything untoward happens, for example, if a participant falls. As a point of safety and manageability 12 was about the maximum that the instructor could handle, (displayed on a large (64?) plasma monitor and still give individual attention to each person.
In our case the Codian 4305 MCU which we used to aggregate our calls, was limited to 12 connections. We had a session manager actively viewing the MCU who would turn microphones on and off, change the view to whom was speaking, and allow occasional views of all the participants.
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Q. Each patient would have to have high speed Internet, a router such as a Linksys, D-Link, Net gear, etc. which would have to be properly configured. They would have to purchase a webcam such as a Logitech 9000 Pro, and have a computer/laptop. On the computer, they would have to have the Polycom license and software setup to answer or call us.
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LK: We use Logitec Orbit web cams attached to a mini-ITX form-factor PC running the Windows Embedded OS. We don’t use laptops as in our applications, we want to make things as transparent as possible for the patient, so there is no keyboard or mouse provided. (We worked through other iterations of remote hand-held controls, etc, and found those presented problems for the patients).
Patients do not require a router, if they have no other computers in their home. In such cases we would connect the DocBox directly to the cable modem or DSL modem.
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Q. The challenge would be setting up the patients. IE: who would install/configure/pay for their Internet access etc. Perhaps we would need to contract someone?
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LK: A few comments above about the patient’s internet connection. We provide detailed installation instructions. We found that a successful approach is to have an IT-capable person, who knows about dealing with routers and firewalls do the installation. We’re happy to provide telephone help during the installation and make test calls to the unit once it is installed. Both we, and you (or either combination), can do remote access into the unit to help configure. In once case, when a patient moved 400 miles away, we had the Geek Squad from Best Buy set up her unit in her new home.
On the other hand, the DocBox has been successfully installed by a range of “lay” persons, usually family members, from a ten-year-old to persons with a PhD. degree.
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Q. As far as outputting to a television set, they will need to have a TV that is capable of accepting the video input from a PC, such as a LCD or plasma high definition TV.
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LK: We can actually work with pretty much anything, and one attraction from the patient’s perspective is we work with their existing TV, so there aren’t a lot of extra (new) electronics around. Our unit has a S-Video output and DVI . In most cases we convert the S-Video to a standard TV input. If they had a fancy plasma TV with S-Video input, we could go direct. New versions have HDI outputs, suitable for newer televisions. In several cases on really older TVs we used a scan converter to provide a coax connection(!) which sounds horrible, but actually worked fine. In one case we loaned them a flat computer screen, and mini-speakers.
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Q. The MXDesign website does not provide much information either. http://www.mxdesign.net/mxdesign/Telemedicine%20Summary%20with%20FAQ.PDF Why is there no technical information on their website? I don’t think this is an oversight. I’m not interested in marketing and sales information. I’m interested in seeing a real spec sheet on the how the unit is built, its capabilities, dimensions, weight, etc.
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LK. Tom, I hope you’ll forgive the lack of a “real” spec sheet; as I think most of the relevant technical specs are included in our narrative, and pictures, but let me summarize:
Video Client = Polycom PVX v. 8.04
AES Encryption
H.323 compatible
SIP compatible
Mini-ITX form factor.
Weight: I estimate it is about 1.5 pounds. (never weighed the unit..)
Size: 8″ x 8″
Camera: Logitech Orbit PTZ with built-in microphone and echo cancellation
Outputs: DVI, S-Video, RCA audio
Inputs: USB 4
OS = Windows XP Embedded
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Q. have many, many concerns about this product and would not recommend it for any telemedicine project. There is a Telemedicine advisory board that reviews telemedicine technology for its validity, methodology, reliability, etc and I think those folks need to be involved with this project.
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LK: I hope the above comments address some of these concerns. I’d like to respond to each of them that were not addressed. I would be more than happy to:
1. Discuss these on the phone or via video (see for yourself what the connections look like…)
2. Send you a unit to try; (but it sounds like you need some additional reassurances before that would be helpful. )
3. Address your Telemedicine advisory board in any fashion convenient.
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Q. The videoconference market is dominated by two very large international companies. These two companies are Polycom and Tandberg. Tandberg was acquired two years ago by Cisco. These two companies both provide very high quality videoconference systems designed for telemedicine applications such as this one. Both Polycom and Tandberg also provide videoconferencing technology to the United States government (DOE, DOD, NIH, CDC, etc.), universities, colleges, banks, corporations, and many other organizations. Polycom and Tandberg are the industry leaders in videoconferencing technologies. Most of the 17 University of (an eastern state in the U.S.) campuses use Polycom products. The Veterans’ Administration, including all VA hospitals in (an east coast-state) use Tandberg products. In our Telemedicine program here, we have used both Tandberg and Polycom products over the years to provide psychiatry and pediatric services to patients. Smaller companies like Vtel have not survived in this market. Cisco could not compete so they bought Tandberg just to get market share. The MXDesign website mentions the Polycom PVX, VSX-7000, and the Tandberg/Codian 4500 MCU in the sales brochure but provides few specifics.
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LK: For the record we LOVE our Cisco and Tandberg and Polycom products and the enhancements they provide
We use the VSX 7000 to originate our classes to the DocBoxes installed in the patient homes. I’d be happy to discuss that set-up at some point. (the VSX7000 itself can host up to four connections, which might prove to be useful for small multi-point sessions).
We manage the 12 connection multi-point using a Codian 4203 MCU. Codian was acquired by Tandberg which was acquired by Cisco.
One of our strengths is that the DocBox is not a “closed” system (like Skype, or many other cloud-based video systems) which rely on a third-party relationship, ongoing monthly fees, and the necessity of going to the hosts’ directory to make connections and establish end-points. We *want* to be able to interface with the standard systems used at all sites you describe. What we found was that the standard offerings from Polycom and Cisco did *not* address needs for patients in homes. We have no illusions about “competing” with Cisco and Tandberg but we did find that we add significant value for particular purposes.
Hope this helps!
— Larry
Lawrence Keyes
Microdesign Consulting Inc.
www.mxdesign.net
www.techforhomehealthcare.com
