Http:// 1 Copyright © 2007 BF Technologies, Inc. All Rights Reserved. Telemedicine Technology Summit October 30, 2007 UC Davis Medical

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Copyright © 2007 BF Technologies, Inc. All Rights Reserved.

Telemedicine Telemedicine Technology Technology

SummitSummitOctober 30, 2007 October 30, 2007

UC Davis Medical CenterUC Davis Medical Center



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Requirement for Requirement for fixedfixed communication lines: communication lines: For high-speed transmissionFor high-speed transmission For error-free transportFor error-free transport Uses triplex, or triple ISDN linesUses triplex, or triple ISDN lines

System requires System requires fixedfixed stations on both ends: stations on both ends: Fixed video camera sending stationFixed video camera sending station Fixed, expensive base stationFixed, expensive base station

→ → Consulting MD must travel to base station.Consulting MD must travel to base station.

Typical Video Conferencing Typical Video Conferencing TechnologyTechnology

ER MD

High-quality Video}



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ER MD

Requirement for Requirement for fixedfixed communication lines: communication lines: For high-speed transmissionFor high-speed transmission For error-free transportFor error-free transport Uses triplex, or triple ISDN linesUses triplex, or triple ISDN lines

System requires System requires fixedfixed stations on both ends: stations on both ends: Fixed video camera sending stationFixed video camera sending station Fixed, expensive base stationFixed, expensive base station

→ → Consulting MD must travel to base station.Consulting MD must travel to base station.

Typical Video Conferencing Typical Video Conferencing TechnologyTechnology

High-quality Video}



4AccessVideoAccessVideo Site-IndependentSite-Independent TechnologiesTechnologies

Eliminates requirement for fixed linesEliminates requirement for fixed lines Physician Access ANYTIME, ANYWHEREPhysician Access ANYTIME, ANYWHERE Utilizes:Utilizes:

Internet Internet Wireless BroadbandWireless Broadband Advanced SMPTE VC1 Video (Broadcast Advanced SMPTE VC1 Video (Broadcast

Quality)Quality) Advanced IP Video Error Correction & QoS Advanced IP Video Error Correction & QoS

Technologies provide highest quality video Technologies provide highest quality video transporttransport

AccessVideo Telemedicine Systems Deployed AccessVideo Telemedicine Systems Deployed since 2003since 2003

MD

ER

MDMD

MD

Partnering:Partnering: UCSD Cal-(IT)²UCSD Cal-(IT)²

Clinical TrialsClinical Trials QualcommQualcomm

Early EVDO Alpha Early EVDO Alpha TesterTester

Verizon WirelessVerizon Wireless Broadband Wireless Broadband Wireless

Beta TesterBeta Tester



5AccessVideo Telemedicine System AccessVideo Telemedicine System Deployments by StateDeployments by State

New York Wisconsin Montana Arizona California

Nevada Florida Colorado Minnesot

a Texas



6Key Requirements for Key Requirements for TelemedicineTelemedicine

Site IndependenceSite Independence Full HIPAA Compliance (Full HIPAA Compliance (NOTNOT just encryption) just encryption) Precision Video & AudioPrecision Video & Audio

Smooth, Full 30 fps: NO JITTERSmooth, Full 30 fps: NO JITTER Cannot Guess or Interpolate Lost FramesCannot Guess or Interpolate Lost Frames Video Quality IndicatorsVideo Quality Indicators

Remote Control of CameraRemote Control of Camera Adheres to FDA Requirements: 510K Adheres to FDA Requirements: 510K

CertificationCertification Integrated PACS Server, DICOM ViewerIntegrated PACS Server, DICOM Viewer

Telemedicine is NOT Video ConferencingTelemedicine is NOT Video Conferencing



7Common Misconceptions Common Misconceptions About TelemedicineAbout Telemedicine

Telemedicine is NOT the same as Video ConferencingTelemedicine is NOT the same as Video Conferencing Video Conferencing does not require precise videoVideo Conferencing does not require precise video Low-Latency not as important in telemedicineLow-Latency not as important in telemedicine Video Conferencing sacrifices video accuracy for lower Video Conferencing sacrifices video accuracy for lower

latencylatency HIPAA Compliance is NOT ONLY Video EncryptionHIPAA Compliance is NOT ONLY Video Encryption

Requires Audio TrailsRequires Audio Trails Intruder AlertsIntruder Alerts Password Protection: both for access and to protect Password Protection: both for access and to protect

passwordspasswords FDA Certification MAY BE REQUIREDFDA Certification MAY BE REQUIRED

Required when “used to diagnose a patient”Required when “used to diagnose a patient” Physicians may not be near a terminalPhysicians may not be near a terminal

Site Independence is a REQUIREMENTSite Independence is a REQUIREMENT The Internet was NOT DESIGNED for VIDEOThe Internet was NOT DESIGNED for VIDEO

Best Effort, NO PRIORITIES for Telemedicine: Packet LossBest Effort, NO PRIORITIES for Telemedicine: Packet Loss Requires special video transport technology Requires special video transport technology



8HIPAA RULES: SummaryHIPAA RULES: Summary HIPAA Administrative Simplification Regulation Text, HIPAA Administrative Simplification Regulation Text,

March 2006March 200645 CFR Parts 160, 162, and 16445 CFR Parts 160, 162, and 164

§ 164.308 Administrative safeguards§ 164.308 Administrative safeguards (5)(ii)(c) Log-in monitoring(5)(ii)(c) Log-in monitoring (5)(ii)(d) Password management (Password (5)(ii)(d) Password management (Password

Encryption)Encryption)

§ 164.312 Technical safeguards§ 164.312 Technical safeguards (a) Access Control(a) Access Control

Access Authorization (SSL Conditional Access)Access Authorization (SSL Conditional Access) Encryption & Decryption (Video & Audio)Encryption & Decryption (Video & Audio)

(b) Audit Controls(b) Audit Controls Report logsReport logs Log-in MonitoringLog-in Monitoring Intruder AlertsIntruder Alerts

(c) Integrity(c) Integrity Method to authenticate dateMethod to authenticate date Insure that data is correctInsure that data is correct

(d) Person or Entity Authentication(d) Person or Entity Authentication SSL Conditional Access (128-bit keys)SSL Conditional Access (128-bit keys) Password Protection (Encryption)Password Protection (Encryption)

(e) Transmission Security(e) Transmission Security Integrity (Insure data is correct: ClearQoS™)Integrity (Insure data is correct: ClearQoS™) Security (Video, Audio & DICOM Encryption & Security (Video, Audio & DICOM Encryption &

Decryption)Decryption)



9HIPAA RULES (con’t)HIPAA RULES (con’t) HIPAA Administrative Simplification Regulation Text, March HIPAA Administrative Simplification Regulation Text, March

20062006 § 164.308 Administrative safeguards. § 164.308 Administrative safeguards. (a) (a)

A covered entity must, in accordance with A covered entity must, in accordance with §164.306:§164.306:““(5)(ii) Implementation specifications. (5)(ii) Implementation specifications.

Implement:Implement:(C) (C) Log-in monitoringLog-in monitoring (Addressable). (Addressable).

Procedures for monitoring log-in Procedures for monitoring log-in attempts and reporting discrepancies.”attempts and reporting discrepancies.”

§ 164.312 Technical safeguards. § 164.312 Technical safeguards. A A covered entity must, in accordance with covered entity must, in accordance with §164.306:§164.306:

““(b) (b) Standard: Audit controls.Standard: Audit controls. Implement hardware, software, and/or Implement hardware, software, and/or procedural mechanisms that record and procedural mechanisms that record and examine activity in information systems examine activity in information systems that contain or use electronic protected that contain or use electronic protected health information.”health information.”



10Telemedicine Vs. Video Telemedicine Vs. Video ConferencingConferencing

Must OptimizeMust Optimize Lower Lower PriorityPriority

TelemedicinTelemedicinee

Video Accuracy:Video Accuracy: - Full, Constant 30 - Full, Constant 30 frames/secframes/sec

- Minimize Jitter- Minimize Jitter

- Minimize transmission - Minimize transmission lossloss

- Loss Indicators- Loss Indicators

Latency not Latency not critical: critical: Audio Audio primarily primarily unidirectionunidirectionalal

Video Video ConferencinConferencingg

Low LatencyLow Latency Can Can Interpolate Interpolate VideoVideo



11Quality & CompatibilityQuality & CompatibilityTechnology TradeoffsTechnology Tradeoffs

Telemedicine System: AccessVideoTelemedicine System: AccessVideo Video quality & accuracy are highest prioritiesVideo quality & accuracy are highest priorities Site independence w/ robust transport is criticalSite independence w/ robust transport is critical

Windows Media Encoding (SMPTE VC1) instead of H.264Windows Media Encoding (SMPTE VC1) instead of H.264 Used by broadcasters (NBC) Used by broadcasters (NBC) →→ high quality at low bit rate high quality at low bit rate Fixed frame rate, 29.97 fps, for smooth accurate motionFixed frame rate, 29.97 fps, for smooth accurate motion 30 to 40% MORE efficient than Baseline H.264 30 to 40% MORE efficient than Baseline H.264 → → Lower Bit rate, Lower Bit rate,

Better VideoBetter Video Encryption Protocol Encryption Protocol →→ HIPAA Security for Site Independence HIPAA Security for Site Independence Error Correction Error Correction →→ Accuracy for Site Independence Accuracy for Site Independence

Video Conferencing SystemVideo Conferencing System Low delay & interoperability trumps video quality & Low delay & interoperability trumps video quality &

accuracyaccuracy Audio quality & low bit rate more important than videoAudio quality & low bit rate more important than video

H.264 allows variable frame rate for low bit rate H.264 allows variable frame rate for low bit rate →→ jerky video jerky video SIP for broader interoperability SIP for broader interoperability →→ no link calibration support no link calibration support No error correction No error correction →→ broadens interoperability, reduces delay broadens interoperability, reduces delay Error concealment hides loss w/ low delay Error concealment hides loss w/ low delay →→ corrupts video corrupts video

AccessVideo offers H.264 & SIP as compatibility AccessVideo offers H.264 & SIP as compatibility optionoption



12System Layers & System Layers & InteroperabilityInteroperability

Error Correction: FEC vs. ARQ vs. None

No General Compatibility or Interoperability

Remote Camera Control

Not well standardized (many standards)

Secure Access Control

Not generally interoperable

Error Correction Not generally interoperable (ARQ, FEC, ProMEG)

Encryption Many standards: AES, DES, RC4, etc.

Generally Agreed-upon Standards

Video Encoding Format

H.264 (MPEG4-AVC Baseline Profile) vs. SMPTE VC1 (High Profile, Broadcast & PC)

Connection Protocol

SIP (vs. H.323)

Networking Layer

Internet (vs. Pt-Pt Links, ISDN, Frame-Relay)

Interoperability for Telemedicine (HIPAA & Diagnostic):→ Compatibility Requirement Across ALL 7 System Layers

Level of Telemedicine Standards



13AccessVideoAccessVideoVideo Transport TechnologiesVideo Transport Technologies

6 Pending US Video Technology Patents6 Pending US Video Technology Patents Advanced Video QoS TechnologiesAdvanced Video QoS Technologies

High resilience to network losses & congestionHigh resilience to network losses & congestion Feedback & Feed-forward Error CorrectionFeedback & Feed-forward Error Correction

Eliminates nearly all Internet & Wireless packet lossEliminates nearly all Internet & Wireless packet loss Provides Best Possible Video AccuracyProvides Best Possible Video Accuracy

Automatic & Dynamic Calibration and AdjustmentsAutomatic & Dynamic Calibration and Adjustments Optimizes Video Quality, Resolution, BitrateOptimizes Video Quality, Resolution, Bitrate Minimizes DelayMinimizes Delay

Video Loss IndicatorVideo Loss Indicator Broadband Wireless Access TechnologiesBroadband Wireless Access Technologies

Promotes Site IndependencePromotes Site Independence Link AggregationLink Aggregation

Patent-pending technology binds together multiple Patent-pending technology binds together multiple low-cost linkslow-cost links

Better video resolution at low costBetter video resolution at low cost



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SummarySummary Telemedicine Systems have Unique Telemedicine Systems have Unique

Requirements from Video Conference SystemsRequirements from Video Conference Systems Site IndependenceSite Independence PACS & DICOM CapabilityPACS & DICOM Capability HIPAA ComplianceHIPAA Compliance FDA ComplianceFDA Compliance

AccessVideo Telemedicine SystemsAccessVideo Telemedicine Systems Designed from ground up for telemedicineDesigned from ground up for telemedicine Site IndependenceSite Independence Smooth, Accurate Diagnostic-quality Video & AudioSmooth, Accurate Diagnostic-quality Video & Audio Telemedicine-specific features (Battery Backup, Telemedicine-specific features (Battery Backup,

etc.)etc.) Full HIPAA & FDA ComplianceFull HIPAA & FDA Compliance



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Extra SlidesExtra Slides



17STRokE DOC / AccessVideo STRokE DOC / AccessVideo

Related Publications & Clinical Related Publications & Clinical TrialsTrialsPoster Presentation:Poster Presentation:

Meyer BC, Chacon MR, Jensen M, Werner J, Haase G: Prospective Reliability of the STRokE DOC Meyer BC, Chacon MR, Jensen M, Werner J, Haase G: Prospective Reliability of the STRokE DOC Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Abstract. Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Abstract. StrokeStroke 2007; 38: 496. 2007; 38: 496.

Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Fellman R, Beer J, Henthorn T, Zivin JA, Raman R: Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Fellman R, Beer J, Henthorn T, Zivin JA, Raman R: Prospective Reliability & Validity of the “Stroke Team Remote Evaluation using a Digital Prospective Reliability & Validity of the “Stroke Team Remote Evaluation using a Digital Observation Camera (STRokE DOC)” Wireless/ Site Independent Telemedicine Consultation Observation Camera (STRokE DOC)” Wireless/ Site Independent Telemedicine Consultation System Using the NIHSS and mNIHSS. Abstract. System Using the NIHSS and mNIHSS. Abstract. Stroke Stroke 2004; 35: 294. 2004; 35: 294.

Meyer BC, Lyden PD, Rao R, Raman R: Reliability of the Interpretation of Head CT images via a Meyer BC, Lyden PD, Rao R, Raman R: Reliability of the Interpretation of Head CT images via a Prototype Wireless Telemedicine System. Abstract. Prototype Wireless Telemedicine System. Abstract. StrokeStroke 2004; 35:261. 2004; 35:261.

Meyer BC, Lyden PD, Werner JD, Fellman R, Beer J, Rao R, Raman R, Zivin JA: Stroke Team Meyer BC, Lyden PD, Werner JD, Fellman R, Beer J, Rao R, Raman R, Zivin JA: Stroke Team Remote Evaluation using a Digital Observation Camera (STRokE DOC) Telemedicine System: Remote Evaluation using a Digital Observation Camera (STRokE DOC) Telemedicine System: Methods. Abstract. Methods. Abstract. StrokeStroke 2005; 36:494. 2005; 36:494.

Papers:Papers: Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Raman R, Fellman R, Rao R, Zivin JA. “Prospective Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Raman R, Fellman R, Rao R, Zivin JA. “Prospective

Reliability of the STRokE DOC Wireless/ Site Independent Telemedicine System. Reliability of the STRokE DOC Wireless/ Site Independent Telemedicine System. NeurologyNeurology. . 2005;64:1058-1060.2005;64:1058-1060.

Meyer BC, Raman R, Rao R, Fellman RD, Beer J, Werner J, Zivin JA, Lyden PD: The “Stroke Team Meyer BC, Raman R, Rao R, Fellman RD, Beer J, Werner J, Zivin JA, Lyden PD: The “Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC)” Telemedicine Clinical Remote Evaluation Using a Digital Observation Camera (STRokE DOC)” Telemedicine Clinical Trial Technique: “Video Clip, Drip and/ or Ship”. In Press. Trial Technique: “Video Clip, Drip and/ or Ship”. In Press. Int Journal Stroke.Int Journal Stroke. November 2007. November 2007.

Meyer BC, Raman R, Chacon MR, Jensen M, Werner J: Prospective Reliability of the STRokE DOC Meyer BC, Raman R, Chacon MR, Jensen M, Werner J: Prospective Reliability of the STRokE DOC Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Submitted for Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Submitted for Publication to Publication to Stroke.Stroke. October 2007. October 2007.

Scott PA, Starkman S, Choi JY, et al. Provider support systems for acute stroke. National Institute Scott PA, Starkman S, Choi JY, et al. Provider support systems for acute stroke. National Institute of Neurological Disorders and Stroke, proceedings of a national symposium on improving the chain of Neurological Disorders and Stroke, proceedings of a national symposium on improving the chain of recovery for acute stroke in your community. Task Force Reports. NIH Publication No. 03-5348. of recovery for acute stroke in your community. Task Force Reports. NIH Publication No. 03-5348. Bethesda, MD: National Institutes of Health Department of Health and Human Services, Office of Bethesda, MD: National Institutes of Health Department of Health and Human Services, Office of Communications and Public Liaison; 2003: 83-95. Available at: Communications and Public Liaison; 2003: 83-95. Available at: http://www.ninds.nih.gov/news_and_events/proceedings/strokeworkshop.htmhttp://www.ninds.nih.gov/news_and_events/proceedings/strokeworkshop.htm



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Federal RegulationsFederal Regulations Health Insurance Portability and Health Insurance Portability and

Accountability Act of 1996 (HIPAA)Accountability Act of 1996 (HIPAA) Specific technical requirementsSpecific technical requirements Protection of data integrity and securityProtection of data integrity and security

Food and Drug Administration Regulations Food and Drug Administration Regulations (FDA)(FDA) Medical Devices REQUIRE 510K CertificationMedical Devices REQUIRE 510K Certification Medical Device Definition (excerpt):Medical Device Definition (excerpt):

"an instrument, apparatus, implement, machine, "an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other contrivance, implant, in vitro reagent, or other similar or related article, including a similar or related article, including a component part, or accessory which is:component part, or accessory which is:

intended for use in the intended for use in the diagnosisdiagnosis of disease or other of disease or other conditions, or in the cure, mitigation, treatment, or conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or …”prevention of disease, in man or other animals, or …”



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Quality & CompatibilityQuality & CompatibilityTechnology TradeoffsTechnology Tradeoffs

Video Encoding: Video Encoding: MPEG4-VC1 (Windows Media Encoding)MPEG4-VC1 (Windows Media Encoding)

Used by broadcasters (NBC)Used by broadcasters (NBC) MPEG4-AVC (H.264)MPEG4-AVC (H.264)

Primarily for video conferencing & security camerasPrimarily for video conferencing & security cameras Session Protocol:Session Protocol:

ClearQoS™ Auto-adaptive Link ProtocolClearQoS™ Auto-adaptive Link Protocol SIP (Session Initiation Protocol)SIP (Session Initiation Protocol)

Error HandlingError Handling ClearQoS™ Error Correction & QoS FeaturesClearQoS™ Error Correction & QoS Features Error ConcealmentError Concealment NoneNone

AccessVideo offers H.264/SIP compatibility AccessVideo offers H.264/SIP compatibility optionoption



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Video EncodingVideo Encoding

MPEG4-VC1 (Windows Media Encoding)MPEG4-VC1 (Windows Media Encoding) Used by professional broadcasters (NBC)Used by professional broadcasters (NBC) Used in DVDs (eg, Terminator in HD)Used in DVDs (eg, Terminator in HD) Standard feature w/ AccessVideoStandard feature w/ AccessVideo

MPEG4-AVC (H.264)MPEG4-AVC (H.264) Video conferencing & security camerasVideo conferencing & security cameras Used where bitrate is limitedUsed where bitrate is limited

Automatically variable frame-rateAutomatically variable frame-rate Used where choppy video is OKUsed where choppy video is OK

Available as an option for interoperabilityAvailable as an option for interoperability



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Session ProtocolsSession Protocols ClearQoS™ Auto-adaptive Link ProtocolClearQoS™ Auto-adaptive Link Protocol

Automatic Link Measurement & CalibrationAutomatic Link Measurement & Calibration Optimizes Session ParametersOptimizes Session Parameters

Best video resolution per Internet connectionBest video resolution per Internet connection Lowest delay with optimal loss resilienceLowest delay with optimal loss resilience

Standard feature w/ AccessVideoStandard feature w/ AccessVideo SIP (Session Initiation Protocol)SIP (Session Initiation Protocol)

Industry StandardIndustry Standard Available as a compatibility optionAvailable as a compatibility option



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Error HandlingError Handling ClearQoS™ Patent-Pending TechnologiesClearQoS™ Patent-Pending Technologies

ClearQoS ARQ: dynamic error CorrectionClearQoS ARQ: dynamic error Correction ClearQoS FEC: robust forward error correctionClearQoS FEC: robust forward error correction Other ClearQoS featuresOther ClearQoS features

Internet clock synchronization for delay minimizationInternet clock synchronization for delay minimization Jitter removalJitter removal Packet shaping for congestion avoidancePacket shaping for congestion avoidance Dynamic Out-of-Order packet resequencingDynamic Out-of-Order packet resequencing

Standard feature with AccessVideoStandard feature with AccessVideo Error ConcealmentError Concealment

May be inappropriate for TelemedicineMay be inappropriate for Telemedicine Not available with AccessVideo Not available with AccessVideo

Documents

Http:// 1 Copyright © 2007 BF Technologies, Inc. All Rights Reserved. Telemedicine Technology Summit October 30, 2007 UC Davis Medical