1. Virginia Telehealth Network Infrastructure Work Group White Paper Consensus Conference: "Developing a Vision and Strategic Plan for Telehealth in Virginia” May 26, 2005

2. Infrastructure Work Group2 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

3. Infrastructure Work Group3 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

4. Infrastructure Work Group4 Site Survey Responding 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

5. Infrastructure Work Group5 Site Survey Findings

6. Infrastructure Work Group6 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.

7. Infrastructure Work Group7 Sites Pound Norfolk Wise Cedar Bluffs Abington Wytheville Coving- ton Blacksburg Martinsville South Boston Lynchburg Farmville Williamsburg Newport News Portsmouth Petersburg Richmond Fredericksburg Alexandria Culpepper Leesburg Winchester Fairfax Harrisonburg Charlottesville Staunton Pennington Gap Big Stone Gap Norton Clintwood Gate City Grundy Vansant Tazewell Saltville Dungannon Konnarock St. Paul Marion Bland Bastion Pulaski (2) Salem Pearsburg Blacksville Lebannon Radford Christianburg Floyd Stuart Galax Hillsville Clifton Forge Hot Springs Monterey Low Moor New Castle Laurel Fork Craigsville Danville Troy Madison Heights Goochland Powhatan Dillwyn Blackstone Boydton Catawba Warrenton Manassas Mitchells Burkeville Bowling Green Colonial Beach Jarratt Dahlgren Arlington Falls Church Warsaw Aylett Glen Allen Ashland Tappanahanock St Stephens Church Chesapeake Heathsville Suffolk Callao Hayes Cheriton Accomac Franktown Hampton Virginia Beach Kilmarnock Saluda Charles City Vinton Chesterfield Montross Olney Hartfield Lancaster Nassawadox (17) (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) X X

8. Infrastructure Work Group8 VCUVDHUVA Dept. of Corrections Networks are Isolated VT/VCOMVDMHMRSAS/CSBOthers

9. Infrastructure Work Group9 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) * Chesterfield VDH site survey

10. Infrastructure Work Group10 Issues Service quality Cost Scheduling of remote consultations Training Needs of remote location not always met New services implemented too slowly

11. Infrastructure Work Group11 Example: Current Process to Establish Video Conference

12. Infrastructure Work Group12 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) *s ee technical annex for information on QoS

13. Infrastructure Work Group13 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

14. Infrastructure Work Group14 Optimal Virginia Telehealth Network VCU VDHUVA Dept. of Corrections Virginia Telehealth Network Provider offices Hospitals Home patients Other Networks VT/VCOM VDMHMRSAS/CSB EMS- Satellite Geriatric facilities

15. Infrastructure Work Group15 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

16. Infrastructure Work Group16 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

17. Infrastructure Work Group17 Options Status Quo Integrate existing networks Build a new network

18. Infrastructure Work Group18 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

19. Infrastructure Work Group19 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

20. Infrastructure Work Group20 For an Integrated Network to Succeed All participating network administrators/IT departments MUST: Open their networks to all potential public and private users!!!

21. Infrastructure Work Group21 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

22. Infrastructure Work Group22 Next Step Detailed requirements analysis to support network envisioned by strategic plan.  Define revenue streams, cost savings and sustainability.

23. Infrastructure Work Group23 Questions? Steve Gillis (703) 869-3085 steve@telehealthsolution.com Technical Annex: David Heise (703) 477-5456 david@telehealthsolution.com

24. Infrastructure Work Group24 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

25. Infrastructure Work Group25 TeleHealth/Telemedicine Network Technical 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

26. Infrastructure Work Group26 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)

27. Infrastructure Work Group27 Equipment and Capacity Requirements

28. Infrastructure Work Group28 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)

29. Infrastructure Work Group29 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

30. Infrastructure Work Group30 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

31. Infrastructure Work Group31 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

32. Infrastructure Work Group32 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

33. Infrastructure Work Group33 Network Design

34. Infrastructure Work Group34 Currently Sites in Virginia Connect Using IP over ATM Gatekeeper proxy DATA Switch PSTN ISDN Video Infrastructure Gateway M C U Gatekeeper proxy MCU Gatekeeper proxy Regional Site Headquarters Site Gatekeeper proxy Regional Site

35. Infrastructure Work Group35 Customer Edge Access: Type 1, 2 3 Private IP Edge Router Private IP Core Access: Type 1, 2, 3 Customer Edge Private IP Edge Router MPLS (IPv6) IP Core Provider Edge FR, ISDN or ATM T1, NxT1, T3, OC3 Provider Edge Video MCU/Gateway Gatekeeper Other MPLS networks (Internet 2) T1, NxT1, T3, OC3 IPv6 with MPLS is becoming Industry Standard

36. Infrastructure Work Group36 Technology Review and Comparison

37. Infrastructure Work Group37 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.

38. Infrastructure Work Group38 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

39. Infrastructure Work Group39 Network Cost Efficiencies and Simplification Realized in MPLS Network Network Cost Efficiencies and Simplification MPLS Network Any-to-Any IP Connectivity (MPLS) Host #1Host #2 Traditional Frame Relay, ATM or Private Line Networks Host #1Host #2

40. Infrastructure Work Group40 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?

41. Infrastructure Work Group41 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

42. Infrastructure Work Group42 Optimized Queuing Using QoS 11 Video Traffic 22 LAN Traffic 3 3 3 Internet Traffic 2 3 211 Transmit ring

43. Infrastructure Work Group43 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