Once the telemedicine concept has been properly documented for the telemedicine department to review internally, a separate meeting should take place with the physician or administrative leader who is requesting the telemedicine program to review the concept and to figure out what is the most appropriate type of service to embark upon since a “one-size-fits-all” technology is rarely appropriate for every concept .

The delivery of remote health services is used for a variety of purposes:

Most programs may involve a specialist referral service or direct patient care service; there could be a combination of one, two, or even three services depending upon the concept and end result that has been presented by the physician or administrative leader .

The biggest concern around technology and telemedicine has been the lack of knowledge if the physical equipment is onsite and installed in a particular location or for public clinical use. It is the “you don’t know what you don’t know” type of mentality. A technology audit should be conducted on the entire campus or healthcare setting to see what types of equipment are in use as well as what can be utilized for a telemedicine program. The audit should be documented in a spreadsheet so that it lists all manufacturers, model numbers, current firmware version, current Internet Protocol (IP) addresses, main point of contact to book the room or equipment, and any other details about the equipment or conference room. Figure 9.2 is an example of what a typical audit spreadsheet should catalog during the inventory process. This process limits the challenge of multivendor complexity seen with disconnected purchasing and deployment of various vendors.

If the conference room is used for standard audio meetings including content sharing and slide presentations but does not have any videoconferencing capabilities, this room should not be used for any potential telemedicine consults unless the budget will fund the necessary technology for the room. If the room has the necessary video technology, it should be reviewed for setup, configuration, and ease of use with a particular focus on microphone placement and audio challenges. All equipment, no matter if in a conference room or mobile equipment, should be easy for nontechnical people to use [3]. This is where the simplistic approach comes in because if the equipment is too difficult to use, it will not be used for anything including telemedicine.

Conference room design impacts the quality of the telemedicine services and it should not be overlooked during the development of a telemedicine program. Good telemedicine room design will accomplish two major functions: it will create the visual and audio clarity and accuracy that is necessary to support clinical examination and diagnosis from a distance and a connection between the patient and the remote provider sites where the patient–clinician interaction, not the technology, is the focal point. The patient and provider’s location should ensure privacy to prevent any unauthorized access or distractions to take away from the virtual consultation—in particular, windows with bright light and loud noises from hallways or mechanical doors .

The challenge in creating a telemedicine room is to integrate the technology into the regular flow of an examination and to reproduce the images at the consulting clinician site with clarity and accuracy. There are a number of aspects to consider when designing a telemedicine examination room. The most important design considerations are room location, room size, placement of equipment/furniture, electrical and telecommunications connections, lighting, acoustics, and wall color. Since most patient sites will be adapting an existing room for telemedicine, it is important to select the best possible fit and to budget, if necessary, for room modifications [4]. A well-created telemedicine room assessment guide should be developed, including all of the necessary design considerations, and should be utilized during any type of construction reviews with all of the necessary impacted parties.

Once a telemedicine audit has been performed, the telemedicine department should be able to get a sense of what type of technology is currently being deployed and utilized across the network. If a telemedicine audit renders a long list of consult or conference rooms that have been enabled with videoconferencing , the telemedicine department should work with the physicians providing the teleconsult service to see if this approach would be the best for the program along with adding in desktop videoconferencing for the physicians and a model solution for patients. Patients should be given a clear hardware and software solution that requires little to no investment or a bring your own device (BYOD) strategy. If the patients have a device that is capable of using the software for a teleconsult, this will be a much desired solution since there will not be a large expense. The complexity of the telemedicine infrastructure is one of the factors that either grows the adoption of a telemedicine program or fundamentally challenges it [5].

Traditional videoconferencing solutions are equipped with a type of video codec for compression and transmission of video. The following are a few of the more popular video protocols that are being used today over the Internet:

For more information on the telemedicine and telehealth standards along with definitions of some of the common terms, see Appendix 10.1 and 10.2 at the end of the chapter [7].

During the telemedicine audit, if a very old, archaic technology is no longer under support warranty or cannot be placed under any type of support contract, a short-cycle telemedicine strategy session is imperative. A roadmap of how to put a cohesive solution in place and who is going to be funding this initiative will need to be decided upon during program development. If an entire videoconferencing solution needs to be purchased and will be available for clinicians and administrators, a telemedicine executive planning committee should be formed with the top leaders in the organization driving telemedicine adoption to put the standards in place. If the remote specialist does not want to wait for a larger initiative to be funded and installed by the telemedicine and IT departments, they may want to purchase or lease a cloud-based videoconferencing solution that is rapidly becoming commoditized.

Cloud-based solutions typically come in two different models: hosted within customer’s location for security and privacy sake, or at the vendor’s site for a better scalabilty and less expense. The second model is called a “software as a service” model or SaaS. Most cloud-based vendors operating as a truly virtual model will price their solutions based on the number of participants in a telemedicine consult as well as if the remote specialist needs audio and video as well as interoperability to H.323 or SIP endpoints, mobile/tablet solution, as well as far-end camera control (FECC). A cloud-based solution can be a much more reasonable investment for a provider or even a smaller remote specialist group. It can be expanded as the telemedicine program grows with more remote specialists and patients, as well as the exchange of collaborative efforts between customer and vendor to expand the cloud-based platforms, electronic medical record interface, and other possibilities.

The most important aspects to remember when selecting the proper technology to use for your telemedicine consult solution are:

Most of the original plain old telephone service (POTS) and integrated services digital network (ISDN) videoconferencing systems were originally built to communicate among other videoconferencing systems on the same network. This is an example of a closed-network program that relied on a great deal of security and privacy, which is a topic that will be discussed later in this chapter. For the government and military, this solution works and everyone else who wants to communicate with them needs to have interoperable solutions that scale down to these levels. This level of scalability is also known as interoperability. While most federal government and military videoconferencing infrastructure solutions are not always used for telemedicine purposes, the same level of security and privacy for the patient should be kept to the same standard as well as being able to provide interoperable infrastructure video solutions that are flexible and cost-effective. This issue goes back to the building of a telemedicine infrastructure that can be scaled for one or multiple programs by a tiered approach .

Most videoconferencing systems or even off-the-shelf components are adequate for their intended function, but being able to add new features tends to be costly and time-consuming. The closed-network designs from one vendor may not be able to communicate or talk the same video language to another vendor [8]. In order to provide an interoperable video solution for remote specialists, patients, and many of the telemedicine programs, the telemedicine infrastructure must be designed and built with virtual bridges to handle the necessary video protocols from one system to another. These virtual bridges can be very expensive to purchase after the original video infrastructure has been implemented; so it is very important to consider interoperable codecs when making the initial purchase. If the virtual bridge must be purchased after the telemedicine design, a proper technology requirements document should be presented to the finance team for consideration of this capital investment.

Another possible solution to the interoperability problems of a telemedicine program is adding a middleware solution (possible software and network engineering) to act as the glue that enables incompatible systems to talk among each other [9]. This can be accomplished by purchasing a middleware software solution to be added to the current environment. Another possibility is leasing a solution from a third-party vendor who has already built this into their cohosted environment. A final optional solution would be to find a third-party vendor who can host an entire interoperable solution in the cloud for a per month fee .

Interoperability among the most recognizable videoconferencing infrastructures is one of the main factors that has limited the early adoption and expansion of telemedicine. Remote specialists experience frustration when they try to perform a telemedicine consult with a patient who does not have either the proper software or hardware. Patients experience frustration when the remote specialist’s office does not relay the proper information about the telemedicine software/hardware or cannot complete the consultation without having a technical person guide them through the controls of the system. In order to grow telemedicine programs and their popularity, a telemedicine department must be able to provide an interoperable solution that is cost-effective, not time-consuming, and can work on any technical platform without any problems .

The connection between remote specialist and patient should appear as if everyone was in the same room together. In order to provide this type of appearance, the telemedicine equipment should be connected at the highest, acceptable network speed as well as to the most reliable connection—wired at all times if possible and wireless when needed using mobile carts, tablets, and smartphones. Reliability of the networks and the telemedicine connections must be kept at the highest regard since the remote specialists and patients will be surveyed on their telemedicine experience. The most common delivery mechanisms for remote healthcare and data delivery are dependent on the reliability of the network. The list below is the most common delivery mechanisms:

Most health systems and hospitals have preferred to outfit an examination room or conference room with the necessary equipment and to use a wired data connection for the remote specialists to communicate with their patients. Examination and conference rooms can be designed with standard-based videoconferencing systems or off-the-shelf high-definition webcams and headsets just as long as the wired data connection has been set up on the local area network (LAN) with the proper network speed. The elimination of audio feedback or video jitter is among what is typically seen via pixelated images or the sound from a person not matching their mouth movements. The networks of most health systems and hospitals are also set up with quality of services (QOS) network protocol to provide the most reliable network experience without sacrificing network speed.

As technology has advanced over the years, many people have set up their own home personal wireless networks to provide portability and accessibility of their laptops and tablets. These wireless networks, while acceptable but not the most preferred connection type, must be robust enough to allow the video and audio traffic from a telemedicine consultation to be communicated to the remote specialists in an acceptable manner. If the patient is utilizing a smartphone or cellular-enabled tablet and using their data plan for connectivity, a mock telemedicine event using this technology should be tested prior to the actual telemedicine consult to verify that remote specialist acceptance of the network connection. If the remote specialist requires a more reliable connection, the patient may need to find a wireless access point in their area or direct the patient to reschedule the telemedicine service when they have a more reliable and robust network. In turn, if the remote specialist is on call and is in the midst of traveling, they need to provide a reliable network connection and a secure location to the patient so that they are seen and heard over their mobile device. Being able to provide the most reliable and trusted network connection will enhance the telemedicine experience for both the remote specialist and the patient. Reliability in network connectivity will also help increase the use and adoption of telemedicine for remote specialists and patients, which will hopefully be reflected in telemedicine survey results.

When a patient’s survey is returned and they state that the best part about the telemedicine consult was that they felt like they were in the same room as the remote specialist, a large amount of this is credited to the network bandwidth that is supplied to the network. The video hardware that is being used for the telemedicine experience should be isolated from the rest of the traffic on the network. In a small office with little to no IT staff, this might be very difficult, but in a hospital environment this is very feasible. With the amount of equipment on a hospital network, the networking team should be able to build a video network to isolate the traffic off so that it does not collide with all of the other computers, wireless phones, and even the mobile carts that are deployed throughout the hospital.

The higher the transmission speed is, the better performance on the network will be seen on the telemedicine consult. For optimal evaluations, a minimum of 768 Kbps transmission speed is needed for the video system; however, many telemedicine consults have functioned at 384 Kbps [11]. Many telemedicine programs base their network bandwidth speeds on preexisting practice standards as described by the governing body of telemedicine, that is, the American Telemedicine Association (ATA). Per the ATA, the minimum bandwidth for adequate bandwidth, resolution, and speed for a clinical consultation is 384 Kbps in both downlink and uplink directions. They also state in their practice guidelines that the resolution should be set at a minimum of 640 × 360 and have a speed at 30 frame per second [16]. When possible to troubleshoot network issues found during a previous telemedicine consult, network test tools should be utilized for troubleshooting. These network test tools will run any number of bandwidth algorithms to test dropped packets, network jitter, audio issues, or to detect any issues that might be compromising the network.

In the event of any network deactivations or emergency management protocols, there should be a downtime procedure set in place for both the remote specialist and the patient. This downtime procedure should be documented for the remote specialist and their care team as well as provided to the patient in paper and electronic form and provided to all prior to telemedicine consultation. For remote specialists and care team troubleshooting, an audio line can be utilized to walk through troubleshooting steps or possibly implementing a remote desktop software to take control of the needed equipment. The downtime procedure should have the necessary phone numbers and support staff identified for normal business hours and after-hours support. [12].

Privacy and confidentiality, much like in the banking industry, has always been a concern in healthcare where patient health information (PHI) has been and will continue to be a concern for health systems, their clinicians, and the patients. With the advancements in technology over the years, the use of encryption software has been able to protect information from unauthorized access. The encryption software is located at both ends of the telemedicine communication and effectively encodes the video, sound, and data during transmission and reconstitutes the information at the other end. Even if someone were able to intercept the transmission, the software would prohibit anyone but an authorized user from reconstructing the encrypted video, sound, and data [13].

The privacy and confidentiality requirements for clinical and healthcare organizations to follow are properly outlined by the Health Insurance Portability and Accountability Act (HIPAA) as well as other applicable state and local laws. As with an in-person office visit, a provider must document in the patient’s medical record either on paper or electronically the visit. Accessing the patient’s medical record should follow standard HIPAA privacy provisions. For those providers or telemedicine departments utilizing a third-party vendor for an electronic medical record (EMR) or videoconferencing solution, a business associate agreement (BAA) should be executed as stipulated under the HIPAA Act of 1996 and the HITECH Act of 2009. When it comes to security and privacy , the encryption standard should include FIPS 140-2, known as the Federal Information Processing Standard (FIPS) as well as the American Encryption Standard (AES) [14].

Most healthcare organizations have a department(s) specializing in network connectivity and security. These departments should be included during the telemedicine program development so that the necessary precautions are put in place to protect all parties. Videoconferencing systems, computers, and mobile devices should also be encrypted by either software running locally on the device to secure the connection or by logging into a virtual private network (VPN) with the proper credentials to use the telemedicine software and hardware. The authentication process of entering a unique username and password should be a requirement to the technical architecture as well as setting up timeout thresholds when the software programs lay in an idle state. Devices should be configured to utilize an inactivity timeout function that requires a passphrase to access the device after timeout threshold has been exceeded. This timeout should not exceed 15 min mode [15]. The use of generic usernames and passwords should not be allowed nor endorsed by the telemedicine department for ease of use by the providers.

Patients should be educated about the technologies available to use regarding computer and mobile device security, as well as be informed about the privacy and security options. Videoconferencing privacy features should be available to both the provider and the patient. Privacy features should include audio muting, video muting, and the ability to easily change from public to private audio mode [16]. If a provider is sending out a “click to join” e-mail to the patient, the provider should have the ability to assign a passcode for the patient as well as the “lock” or secure the teleconsult to only those required to participate in the session. This will ensure that the proper patient has entered the teleconsult as well as to prevent previous or future teleconsults happening without the provider’s knowledge. At the end of a teleconsult, the provider should have the ability to disconnect all parties from the session.

Providers, using mobile devices to perform the teleconsult visit with their patient, should keep devices in their possession when traveling or in an uncontrolled environment. Providers should have the capability to remotely disable or wipe their mobile device in the event it is lost or stolen [17]. The organization’s mobile device governing body should educate and deploy a mobile device management (MDM) solution. A MDM solution provides the loading of appropriate and warranted applications to the user’s job description as well as deactivating or remotely wiping the device for security purposes. While this might deter some providers of receiving a free device from an organization and using their own device, the MDM solution should provide peace of mind to the provider and information technology group who must support and upkeep these devices.

As stated earlier in this chapter, a provider must document the teleconsult visit as if the patient participated in an in-person visit. Most healthcare organizations are planning or have already transitioned to an EMR and are even allowing patients to view their records online, modify their own demographic data, upload radiology images, and even communicate electronically over a secure e-mail system via a patient portal. The patient portal provides further involvement of the patient in their own healthcare as well as the ability to review the provider’s notes and the exact treatment plan. Patients should be advised of security risks of attempting to upload information from mobile devices. As described above in the Security and Privacy section, patients are also required to authenticate their user credentials and must accept the same timeout thresholds.

During a telemedicine consult, the telemedicine physician should work off a checklist to assure that the collection of all needed information from the patient has been received and recorded within the patient’s EMR. In a typical hub and spoke telemedicine program, a remote site uses a provided patient documentation checklist to capture and record all of the patient’s information prior to the telemedicine consult start so that the remote specialist has all required information prior to evaluating the patient. This will assure the most informative package of information is provided to the remote specialist so that the best diagnosis can be offered to the patient. As telemedicine systems and health information systems continue to merge, it will become easier to integrate these checklists and required patient demographic fields into the software interfaces for the telemedicine system as well as a referring provider will be able to assemble all the necessary information and transmit it to the consulting provider instantly [18].

While telemedicine has its own barriers with technology and risk, there is an even larger barrier with providers and healthcare systems allowing patients to access their own information. The patient has the right to see their EMR and now these patient portals are providing the necessary gateway regardless of provider acceptance. Many organizations have to provide this patient portal access because of meaningful use (MU). At the current time, while the Veterans Administration nationwide is on a single EMR platform, VistA, many hospitals and healthcare systems are running different EMRs; some interoperate or communicate with each other and some are silo solutions. For more information on patient documentation, patient portals, and MU, it would be best for those providers and clinicians to connect with their information technology departments that support these areas.