© 2013 SBR Health, Inc.
Healthcare without
Boundaries
Video Communications - From room to desktop to
cloud and how it’s enabling a new wave of
video-enabled healthcare applications
Healthcare without Boundaries
Video Communications - From room to desktop to cloud and how it’s
enabling a new wave of video- enabled healthcare applications
By Peter Eggleston, Chief Marketing Officer, SBR Health, Inc.
Introduction
Once a complex expensive technology, video communications have gone from being a scarce resource that needs to be scheduled to one that is inexpensive, pervasive and available to all through the cloud. Advances in soft CODEC technologies, adaptive compression schemes, and out-of-the box support for video on a wide variety of computing and communication devices are allowing the virtual delivery of health services inexpensively with a minimal of dedicated equipment. The net effect is that now the scarce resources are the clinicians themselves, and the next driver for adoption and growth will not be video technologies, but rather technologies that seamlessly integrate video communications into existing clinical workflows to enhance quality and efficiency.
For medical device manufactures, advances in video communication technologies are providing market opportunities that go far beyond simply providing devices that exist only to serve as imaging endpoints. The evolution of cloud-based video communication is enabling manufacturers to provide video-enabled services as part of their product, as well as opportunities to provide video applications. The later are applications built around video devices and platforms that provide a new frontier of interactive enablement.
Video Applications
To understand the concept of “video applications” and their potential implications, we can look to cell phones and mobile applications as an illustrative example. The cell phone is an endpoint and initially a high-value component that the end consumer had to pay a lot of money for and had limited choices in what device to purchase. The cellular networks dictated which devices you could purchase and use on their networks. As these devices were not cross-network compatible, the value they provided was letting you access the cellular network to make an audio connection. Fast forward to today and cell phones are a commodity. Consumers can purchase handsets of choice from a variety of sources, and if you have a GSM device, you can now utilize that device with a variety of carriers. Now the distinguishing value of these devices is not so much the handset itself, but in the applications the device can run. Android and iOS-based devices have given cellular users an almost unlimited marketplace of applications and services, and are, to many users, the real value they derive from their mobile devices.
Now think video applications – applications built around video devices and platforms providing a new frontier of application enablement. Until now, this was not practical due to the cost and complexity of capturing, encoding, routing, transmitting, decoding and displaying a moving image of high quality, the need for dedicated networks for carrying this data, the lack of unifying standards for cross network/device interoperability, and the need for dedicated IT staff to set up, operate, support and maintain these systems. But now video has entered the cloud, and Video-as-a-Service (VaaS) promises to be the next wave of what’s new and trending in cloud technologies.
Video as a Service (VaaS)
The notion of cloud-based applications is as old as the computer itself (think timeshare). The basic premise is that instead of purchasing a software application and the hardware required to run it, you purchase the right to use this application from an entity that has purchased the hardware and software, and maintains and supports that installation “in the cloud.” However what is new is how all the right forces have finally come together: inexpensive HD capable cameras, scalable and adaptable CODECs that can run efficiently on even modestly powered PCs and handheld devices, open standards and services that allow cross-platform interoperability, cheap bandwidth, and new ways to map video routing and switching in the cloud itself. We are now at the precipice where video communications has evolved from the dedicated room-based hardware systems of yesterday, to the software-based desktop and handheld devices of today, to the cloud-based systems of tomorrow.
To learn more about what’s making VaaS a reality, especially as it relates to its use in healthcare, it’s useful to understand what’s driving companies who are the forefront of enabling this. Not surprisingly, it isn’t the companies that are deriving huge revenues from traditional room-based video conferencing systems. These companies and their reseller networks have huge residual revenue streams to protect from maintaining, upgrading and running traditional on-site hardware based systems.
In that respect, a company that is creating the biggest buzz in healthcare video communications technology and paving the way into the cloud, is Vidyo (www.vidyo.com). Vidyo believes that video conferencing has always been limited in its capacity mainly due to the fact that every endpoint is expensive, dedicated/managed networks are required to maintain quality, and the user experience in using these systems is simply not good enough. Therefore, the company has created a video communications platform that addresses all these categories and has introduced several technology drivers supporting the move
VidyoWay, a free cloud-based inter-connectivity service from Vidyo, is as easy to set up as a telephone call and frees organizations from network, location, and device constraints to enable true “any device, any network, any time” video communications.
towards cloud-based video. First, their video communications call quality supports TelePresence, defined as low-latency and high-definition video, which is perhaps the most important characteristic needed to enable a natural quality interaction. In healthcare, high quality imagery quality is crucial to build patient trust and ensure a meaningful interaction, and low latency (delay) is essential to allow participants to carry on a natural conversation. The second direction where Vidyo is driving change is from hardware to software, which cuts the cost of endpoints, switches and routers by many orders of magnitude. A traditional Tele-room may cost several tens of thousands of dollars, but with Vidyo, the costs are down to tens of dollars or less for every software endpoint, achieved by enabling the use of desktop computers, laptops, tablets and mobile devices. This means existing hardware can be utilized as endpoints and that opens doors for very large-scale deployments. This is essential for health delivery organizations that want to scale up virtual visit programs to their entire patient populations, which can extend to thousands of clinicians and millions of patients. Another change this technology driving is more conceptual but very important. In the past, to utilize visual communities, one had to go to rooms, which connected to other places, not people. With low-cost software turning any computing device into a video endpoint, this has been reversed - now people connect to people, and you do not have to be in an expensive room to have a TelePresence experience.
Another technology enabler Vidyo is exploiting is the ability to overlay video networks onto existing data networks. Video communication used to require dedicated networks with quality of service mechanisms. However, these are not scalable. You cannot provide a T1 connection to each patient at home so you need to overlay the video network with any connection a patient has. And, since these are highly variable networks in terms of quality, you need a way to maintain quality over public networks if you are going to maintain TelePresence quality across existing platforms and networks. If you can do this, you have the advantage of being able to host video communications in the cloud. Vidyo has accomplished this through the use of scalable video coding technology that optimizes the available network quality and bandwidth, as well as factors hardware capabilities of the sending and receiving devices.
Furthermore, to utilize the existing internet for video transmission and enable VaaS, there is additional “infrastructure” that needs to be put into the cloud. The video CODEC, the device that compresses and encodes a video signal, needs to be physically adjacent to the camera itself. Once captured, compressed and encoded, the video signal needs to be routed to the receiving party. So, just as a browser’s commands have to be routed to the right web server someplace, video signals likewise need to be routed. A device called a portal acts as a manager, allowing a user to log into the network, look up users to communicate with, and finally to instruct another device called a router how to connect endpoints. Here is where the new magic is. Previously, organizations had to purchase, install and maintain portals and routers on their local networks, even lay dedicated cables to connect them. This required large cash outlays, dedicated IT teams, a lot of operating expense, and closed networks. Now, portals and routers can be entirely software based and run on general-purpose servers in the cloud, thereby making the infrastructure much leaner with the net effect of reducing deployment costs by a factor of 100. With these changes, cloud-based services can now be constructed to provide a virtual video infrastructure for any organization, thus enabling low-cost video communications for any person, any device, any network, at any time.
But what if you and I want to video chat but we are using different CODECs? In that case you need video transcoding to convert the transmitting format into the format used by the receiver, and vice-versa. This gets especially complex for multi-way calls (more than two participants). Transcoding is often provided by devices called bridges, which are often part of a multipoint control unit (MCU). The bridge receives the streams from all the endpoints from whatever protocol they were sent in, decomposes them, put them in a common format and/or re-encodes them, and finally sends them on their way in the proper encoding to
the endpoints. These devices have also migrated to the cloud, and one such company providing a cloud--based bridging service is Blue Jeans Network (www.bluejeans.com). By applying concepts pioneered by companies like Google, Akamai, and Amazon, Blue Jeans has architected a scalable, multipoint bridging solution that leverages off-the-shelf hardware and proprietary software to deliver a single global high performance virtual MCU. In fact, many healthcare organizations are starting to experiment with the Blue Jeans Network to connect patients using consumer grade video communications platforms like Skype to traditional hardware-based room and cart-based systems in which they have significant capital investments.
The move towards private virtual clouds as well as public (e.g., Amazon) cloud services makes it easy to put software instances of video routers anywhere and gives you the ultimate flexibility in terms of IT management – you can move your infrastructure at the click of a keyboard. In fact, Vidyo is running on Amazon now and working with IBM and VMware to run in their cloud. This allows users to implement video in the cloud with minimal effort and flexibility without compromising privacy or security. In the next few years, watch for some big network providers to move into the space, which will provide organizations with even more options and cost efficiencies in setting up their own cloud-based systems, or contracting with third-party VaaS providers.
But it isn’t entirely that utopian. Moving to the cloud brings up issues of security, manageability, and privacy, especially important issues for healthcare institutions. As they are not operating on networks with secure connectivity and access, VaaS providers need to provide mechanisms for each institution to have its own siloed access to the system, so there is no communication between the virtual video communication networks unless it is intended for them to communicate. This is why healthcare organizations are hesitant to utilize Skype with their patient populations. What encryption is being utilized? How are the calls being routed? How do you authenticate an end user? How to you prevent an unwanted communication link? In contrast, some companies such as Vidyo provide tools that allow the construction and management of completely secure virtual video networks, and thus many healthcare organizations are starting to develop large-scale telehealth programs on their technology platform.
However, once institutions go beyond their walls, it does not matter if you are in the cloud or have your own hardware – either you are the cloud or you are using someone else’s cloud, and both ways rely on an
No stranger to stringent requirements around data security in healthcare, Quest Systems is growing their network of Service Delivery Centers allowing healthcare organizations to rapidly provision HIPAA secure video communications on any device, anywhere with cloud-based video servers.
external data transport layer that comes with some potential availability caveats that need to be planned for. Unless everyone is in the same building, it is a cloud. So, you don’t want to seriously depend on it and not have it be there anymore. While many of the cloud providers have backup systems for failures, the systems aren’t foolproof as users aren’t able to get to other entities if the intermediate network is compromised. Therefore, if institutions can keep their entire infrastructure close to them, this is helpful, but when healthcare institutions start video conferencing with remote hospitals, clinics and patients in their homes, they are by definition, connecting with people that are not on their network.
So in general, with video conferencing, there is no option; you have to be aware of the risks and plan accordingly. This could include selecting a VaaS provider that is entirely software based, rather than simply hosting hardware-based routers and gateways at a hosting facility. This provides the option of deploying across large, geo-physically dispersed hosting networks such as the Amazon cloud. Even then, Amazon, Yahoo and everyone in this space has experienced problems with their cloud computing services. These are companies that have spent very large sums of money on getting their act together, and they have experienced major problems even in the last year. If the Internet goes down in the customer’s location or the host location, it is an inconvenience, people do not die. In healthcare, there could be situations where the situation is life threatening. As an example, if DNS is down, a company can be in a very difficult situation. There are a lot of DNS attacks, and this could affect video connectivity. Therefore, some VaaS providers such as Connexus Inc. (www.connexusvideo.com), have their own DNS servers, and do not rely on the major providers, as the major providers are often the very providers being targeted and attacked. However, there are some distinct operational advantages the cloud adds to ensure failsafe operation. While system hardware and software upgrades need to be cautiously managed in on-site deployments of a video communications platform to maintain compatibility across sites, cloud-based systems upgrades happen simultaneously across the network, and compatibility is always maintained. And cloud deployments make it easy to ensure everything is up and running by allowing constant monitoring of endpoint readiness status and connectivity to the network, thus ensuring resources are online and reachable when needed. Furthermore, it also provides greater connectivity across devices, allowing users to engage in video communications on whatever device they are carrying, rather than mandating that they have to be at a specific, pre-provisioned endpoint. In healthcare where clinicians are especially mobile and needed 24x7, this means clinical resources can be reachable and convertible into a workflow when and wherever needed. This is what is meant by ‘any device, any network, anytime’ connectivity.
In fact, the implications for healthcare are enormous once video communications can be integrated into the care delivery workflow. Traditional hardware-based systems are very inflexible in terms of workflow integration but once you move into software-based endpoints, you open the door to embedding the video into the workflow you are trying to enhance. And therein lays the opportunity for medical device manufacturers who can now leverage the power of VaaS to deliver innovative new products or video-enable existing devices utilizing Video Web Services APIs (Application Programming Interfaces). These APIs utilize standards such as SOAP over HTTP and can be easily integrated by developers to create a customized video communication experiences that are interoperable with any type of video portals or endpoint applications. [Note: Simple Object Access Protocol is a protocol specification based on XML for exchanging structured information in the implementation of Web Services in computer networks.]
One health IT company creating these customized experiences is SBR Health, Inc., a developer of clinical and consumer applications that enable video communications to be utilized seamlessly in the delivery of existing or new care delivery models. SBR Health is leveraging the significant opportunities VaaS is creating
and believes video conferencing offers great potential in medicine. However, they realize that despite decreasing equipment costs and advanced in cloud-based deployments, it still remains difficult to integrate video communication into health care workflows. This is creating new opportunities for companies like SBR Health to create applications that support the dynamic nature of healthcare delivery organizations and solve the problem of how to utilize VaaS technologies seamlessly in existing IT and clinical processes so as to facilitate the delivery of care in a more efficient and effective manner. The company’s first product, ResourceManager, is a true enterprise client-server application that intelligently matches patients to care providers to achieve optimal relationship pairing and real-time resource-based workforce scheduling and optimization. This SBR technology when combined with video communications infrastructures enables healthcare organizations to deploy more efficient care models that improve patient satisfaction, increase access to specialists, raise the overall levels of patient care, and improve delivery of treatment. The ResourceManager also allows care providers to work virtually anywhere at any time they choose, and gives companies and organizations access to an on-demand global workforce to address staff shortages, serve hard to reach patients, control costs and ultimately increase the level of patient care.
Another manufacturer leveraging the cloud is InTouch Technologies, Inc. (www.intouchhealth.com), a provider of remote presence medical devices. InTouch believes cloud-based video communication will profoundly restructure healthcare delivery, as when healthcare providers have high quality and greater access at a lower cost, then organizations can deliver care when and where it’s needed at greater efficiencies. While current systems require patients and providers to be at locations that have been pre-provisioned and connected at specific times, remote presence, cloud-based video communications can instantly connect disparate entities without requiring two IT departments to collaborate in advance. In some instances such as stroke, providing the right therapy within a 3-hour window can mean life or death – it is that significant. In many rural and community hospitals, a stroke neurologist is not accessible that quickly, which may be one of the contributing factors that make stroke the highest reason for disability in the US.
Video- as-a-Service (VaaS) is enabling a new category of software termed Video Applications such as this video call and skills routing
management solution from SBR Health, Inc., shown here running on the ubiquitous iPhone as well as the new Google Nexus7. Now healthcare resources can be brought into video calls on-the-go for less than $200!
As hospital IT staff have an overabundance of tasks and objectives such as getting electronic medical records systems up and running, many do not have the expertise for video and where to find it, which allows cloud-based systems such as VaaS to have a significant impact on healthcare workflow. People who understand how to configure and deploy video communications networks may not always be part of the hospital’s IT staff, but this expertise can be quickly and cost effectively ‘sourced’ from the cloud. In fact some organizations such as Quest Systems (www.questsys.com) have provided hosted data and computing solutions to numerous large hospitals for the better part of a decade, and now offer video-hosted services as well. This benefits hospitals who have the expertise of what they are trying to do with virtual care models from a clinical standpoint, but are challenged to design and support this from a user perspective. With VaaS, IT departments can be focused on their clinical end user requirements and deliver support for virtual care much more quickly, and VaaS options also allow health delivery organizations to not have to make large commitments to video communication technologies. If they want to try it out first, they can secure and try virtual visit solutions such as SBR Health’s e-Visit platform from the cloud with one department or a limited number of doctors with minimal investment – they do not need to capitalize equipment and hire people in-house to manage and support such an endeavor.
Summary
In closing, medical device and HIT solution developers need to think beyond video communication as a fixed offering. The cloud exists as a shared environment, and the deliverable is fairly static, much like the iTunes experience. It’s similar to all users, and the experience is fixed. Unlike embedding static video communications hardware, VaaS does not have to be a canned, hope it works, experience. By utilizing today’s cloud-based, video communications platforms, manufacturers of medical devices can deliver truly unique and flexible experiences, and can therefore offer value comparable to an internal, custom-developed solution.
InTouch Technologies, Inc., leverages cloud-based video conferencing to create FDA-cleared remote presence products allowing physicians to be available on demand whenever and wherever their expertise is needed.
