Communications and Telemedicine Workshop MHCA Tenth Annual Forum Savannah Georgia September 20-20, 2014

Transcription

1 Communications and Telemedicine Workshop MHCA Tenth Annual Forum Savannah Georgia September 20-20, 2014 Part I: Communications Connectivity: Jerry McLarty, PhD, LSU/Feist-Weiller Cancer Center (LA) Part II: Tele-health/medicine: Lisa Gwynn, DO, MBA, FAAP, CPE, University of Miami (FL)

2 Agenda Part I Getting Connected McLarty Part II TeleMedicine/TeleHealth Applications - Gwynn 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

3 This is a workshop Be interactive interrupt with questions or comments at any time There will be a short Q/A period after each speaker After the presentations we want to discuss your particular problems and questions The speakers will be available for one-on-one interactions after the program 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

4 Disclosures I have no financial conflicts or commercial interests in anything discussed in this workshop. The conclusions and recommendations are my own. During the presentation there may be certain commercially available products mentioned by name. This is done for illustrative purposes only. Neither MHCA nor the speaker endorses the products discussed over any competing products in the industry 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

5 Who I Am I am a mobile health provider. We have two mobile mammography vehicles and teams in place. We provide free cancer screening services to persons who are uninsured or underinsured in Louisiana I am not a communications engineer. I am a cancer epidemiologist. I will do my best to minimize the geek factor in this presentation 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

6 Exclusions Satellite systems necessary in extreme situations but generally more expensive, slower and more prone to dropped connections with VPN encryption. Land-based Microwave communications I am not experienced with these systems but there are MHCA Sponsors who are. 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

7 Our Mobile Clinic (one of two) Slide-out exam room Mammography suite With Tomosynthesis (3-D) Interview/Waiting area Small office Ethernet cable throughout Two laptop computers Two scanner/printers Two VOIP telephones e-fax Cellular Router With 4 cell devices 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

8 Mobile Screening Sites Louisiana 2014 T B A O S C P Q D J R N 5 E M 7 F G H I 3 8 K L A. Shreveport-Bossier (home site) B. Mansfield C. Coushatta D. Natchitoches E. Winnfield F. Colfax G. Jena H. Jonesville I. Alexandria J. Leesville K. Marksville L. Bunkie M. Oakdale N. Kinder O. Springhill P. Homer Q. Arcadia R. Jonesboro S. Many T. Vivien 1. St. Joseph 2. Bastrop 3. West Monroe 4. Sicely Island 5. Ruston 6. Tallulah 7. Farmerville 8. Monroe 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

9 Take Home Lession #1: Mobile Communications Can be Difficult 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

10 Here is the heart of the issue: Mobile communications can require expertise in Information Technology typically found in a medical institution (firewalls, servers, s, web browsers, image storage). But it can also require expertise in radio equipment (cellular, satellite, microwave). It can also require highly technical knowledge of medical equipment (mammogram, dental, optical machines, etc) Typically your vehicle must be designed to accommodate this complex equipment. (onboard networking, generators, power conditioners, antenna access) It is practically impossible to find someone who knows all four pieces of the puzzle. But the technologies have to all work together seamlessly! 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

11 Digital Switch Computer Ethernet Ethernet Cell Tower Radio Waves COAX Cable Vehicle Antenna Cellular Router Cellular Provider Internet Connection Fiberoptic Cable 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

12 If something goes wrong, These guys Digital Switch Computer Ethernet Ethernet Cell Tower Radio Waves COAX Cable Will blame these guys Vehicle Antenna Cellular Router Cellular Provider Internet Connection Fiberoptic Cable Will blame these guys, And vice versa 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

13 What is to be done? Have your own expert? If you buy a new vehicle, the manufacturers are pretty good at setting up the on-board network and even installing specialized medical equipment, routers and antennas. But they won t program the routers for you! If you are retrofitting an existing vehicle, local companies who install police and emergency radio equipment are good at installing antennas, and cables But they won t program the routers for you Buy your communications equipment from a third party supplier who will guarantee setup: The major equipment manufacturers won t set things up for you a difficult task requiring specialized training. 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

14 Not Everyone Needs Such a Complex System Some of the same issues apply But lets start with a simple system 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

15 We may need to have just one or a combination of the following: Voice Communications , Fax Internet Communications Complete forms online, Register patients, order tests Connect to databases, other resources Image transmissions 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

16 USB Wireless Modem Sometimes called an Aircard Plugs into your computer USB slot. Connects to the internet via cellular carrier Requires account with a cellular carrier e.g. Sprint, Verizon, AT&T, etc 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

17 Connect Each Onboard Device to the Internet via USB Modems Speed is limited to the speed of a single Cellular carrier Limited by availability of a single carrier Usually too slow for transmission of large Images Limited to cell phones devices that work with a USB Modem Cell phone provider Connects to internet Dropped calls may be an issue with secure Communications. 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

18 Example: laptop, tablet, cell phone You could connect each device via Wi-Fi to a Hotspot Tablet/iPad Cell Phone Local Wireless Hotspot (Starbucks? Hospital, Clinic) DSL, Fiber-optic or other broadband Internet connection Requires a Wi-Fi hotspot at each remote site. Speed is O.K. for voice, and low-speed computer connections for devices with wireless capability. Typically too slow for uploading Images. Security may be an issue on a public hotspot. Dropped Calls may be an issue with VPN (secure communications). 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

19 MiFi 3 ¾ long Supports 5-10 devices Optional antenna (shown not to scale) 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

20 Connect all onboard devices via wireless to a mobile hotspot or Mi-Fi Onboard MiFi or Mobile Hotspot Cellular Provider Internet Cell Phone 9/20/2014 Bandwidth is shared by all devices. May be sufficient for low-speed applications but upload speed is limited. Restricted to a single cellular provider, different remote locations may have different carriers. Dropped calls may be an issue with secure communications. Devices can be easily hacked! MHCA Annual Meeting 2014 Savannah Ga.

21 Use a Wi-Fi Hotspot Device That Can Use Multiple Cellular Carriers Onboard Wi-Fi Hotspot /Router Cellular Company Cellular Company Cellular Company Broadband Internet Onboard Network and/or Wireless Devices Cellular Company Chooses best cell signal and can balance the load among the devices. Can combine multiple carriers to get a high upload bandwidth. Depending upon availability and quality of cellular signals, works well for all applications including sending images. MHCA Annual Meeting 2012 Charlotte NC

22 Cellular Router. Like a souped-up Mi-Fi This should be the heart of almost every mobile communications system, simple or complex. 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

23 Advantages of a Cellular Router Multiple Cellular carriers (I use 2 Verizon, 2 AT&T) Can serve as an onboard Hotspot Can plug the onboard Ethernet network into it Can link to a close-by Wi-Fi Hotspot Can use internal or external Antennas Encrypts all data (military spec)* Signals can be load-balanced or bonded* (Always use external antennas. Your vehicle may be fiberglass but chances are the roof is aluminum, attenuates cellular signals) * more on this later 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

24 My Earlier Setup External Antennas Ethernet Switch MHCA Annual Meeting 2012 Charlotte NC Router with 4 USB Modems

25 Disadvantage Antenna connection to the USB modems is unreliable 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

26 Router with 3G or 4G LTE Embedded Supports up to 20 Wireless Devices Rugged design. Doesn t require USB Connections All the advantages of the previous USB modem device. Modem These are now available with one, Two or 4 embedded modems. Can be chained to get more Cellular connections. In my opinion, this is the way to go. It relatively simple to install, its rugged, and reliable. My two units use these and have been running for over a year with no problem. MHCA Annual Meeting 2012 Charlotte NC

27 My Current Setup External Antennas Ethernet Switch MHCA Annual Meeting 2012 Charlotte NC Router with 4 embedded USB Modems

28 Medical Data has Special Needs HIPAA rules demand patient privacy. Transmission of medical date must be secure and encrypted. This is typically done with VPN 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

29 What is VPN? (Virtual Private Network) VPN is a means of secure data transmission Encrypts the data Requires more coordination between sender and receiver equipment VPN adds to the overhead of sending information and can significantly reduce bit rates Can be accomplished by software or hardware MHCA Annual Meeting 2012 Charlotte NC

30 VPN Continued Most of the newer cellular modem devices have hardware VPN built in. Anything plugged into the device is encrypted. This hardware encryption requires a box on the receiving end (homebase) to de-encrypt the signal. This is the most secure and the fastest VPN. Software VPN is sensitive to delays in (latency). 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

31 Latency - an enemy of effective Network news example communications This same delay of signal (latency) happens with virtually all communications devices, including satellite and cellular systems. Geosynchronous satellites have the highest latency. VPN is especially sensitive to latency: if one end of the conversation doesn t hear back from the other end of the conversation within a certain period of time, VPN will break the connection as part of its intruder protection algorithm. This causes wasted time re-establishing connections, logging back into data systems and often starting over and entering the same data again. Especially with software based systems. MHCA Annual Meeting 2012 Charlotte NC

32 Communications Primer Bits, Bytes, data transfer speeds, image sizes, uploads, downloads, latency MHCA Annual Meeting 2012 Charlotte NC

33 Terminology 101 Download Upload For most systems downloading (receiving data) is faster than Uploading (sending data) MHCA Annual Meeting 2012 Charlotte NC

34 Device speeds and services are often described in terms of bits, kilobits (Kb), megabits (Mb), But data file sizes on your computer are described in bytes, megabytes (MB) or gigabytes (GB). MHCA Annual Meeting 2012 Charlotte NC

35 Bits and Bytes A bit is a single binary number, with possible values of 0,1. All digital systems work with bits. To make characters, symbols and decimal numbers out of bits takes a collection of 8 bits. This is called a byte. For example, the letter A is represented digitally by the 8-bit byte Bits are designated with lowercase b, bytes with an upper case B. MHCA Annual Meeting 2012 Charlotte NC

36 Typical Satellite Transfer Speed $600/month service plan Download speed 1500 Kbps (receiving) Upload speed 512 Kbps (sending) 512,000 bits per second How long would it take, theoretically, to upload a typical set of mammogram images, say 100MB? 100,000,000 Bytes MHCA Annual Meeting 2012 Charlotte NC

37 How long would it take to upload? 100 MB = 100 Mega Bytes = 100,000,000 Bytes 512 Kbps = 512 Kilo bits per second = 512,000 bits per second = 512,000/8 = 64,000 bytes per second 100,000,000 Bytes = 1,562.5 seconds 64,000 Bytes per second = minutes to send one patient set of mammograms! MHCA Annual Meeting 2012 Charlotte NC

38 For most of us, 26 minutes per patient images would not be practical. This is a theoretical maximum upload speed, in practice you cannot even do this well, there are delays in the system due to distances, routing, encryption, firewalls, security checks, etc. One solution: a more expensive, higher speed satellite service. Typical costs for higher speed run $5,000 per month and can send 100MB images in approximately 5 minutes. MHCA Annual Meeting 2012 Charlotte NC

39 Note: This doesn t mean satellite systems are impractical for mobile health operators. Satellite speeds are satisfactory for voice, patient registrations, determination of insurance coverage and other non-image based applications. Many mobile operators use it just for these kind of applications, and pay $500-$600 per month for this service. MHCA Annual Meeting 2012 Charlotte NC

40 Another image time example: AT&T claims its average 3G cellular user gets 0.71 Mbps upload speed..71 Mbps /8 =.089 MBps 100MB image/.089mbps = 1124 seconds =18 minutes So you probably wouldn t want to send large images over a single 3G cellular carrier either. Much higher speeds are possible with 4G MHCA Annual Meeting 2012 Charlotte NC

41 Increasing bandwidth by Bonding Cellular Company Onboard Wi-Fi Hotspot /Router Cellular Company Cellular Company Broadband Internet Onboard Network and/or Wireless Devices Cellular Company The router device can break the signal into packets and divide them among the various carriers, getting a higher upload speed than is possible with only one cellular connection. MHCA Annual Meeting 2012 Charlotte NC

42 Combining Multiple Cellular Carriers From the AT&T example, with 4 cell devices combining bandwidth 0.71 Mbps X 4 = 2.84 Mbps. This could upload the 100MByte image in 4.5 minutes, a much more manageable time*. Actual uploads of 100MB images in 2 minutes or less are possible with cellular technology. This depends upon having good cellular connections; rural areas often don t have this fast service available. *Ignoring speed loss due to processing overhead MHCA Annual Meeting 2012 Charlotte NC

43 VOIP (Voice over Internet Protocol) Special considerations are required to make telephone calls from a mobile unit via the internet Can be done with software or hardware, via a special phone that converts voice into an internet compatible signal. Requires an account with a third party, e.g. Skype, Vonage to make the phone connection MHCA Annual Meeting 2012 Charlotte NC

44 End of Primer MHCA Annual Meeting 2012 Charlotte NC

45 Summary Use more than one cellular carrier to assure more reliable connectivity Always use external antennas if possible Use routers with embedded cellular modems for more rugged and reliable communications. Always use 4G LTE devices. If 4G is not available in an area they will automatically fall back to 3G. Always use VPN encryption from remote site to the home base. Buy your equipment from someone who will assist in proper setup. 9/20/2014 MHCA Annual Meeting 2014 Savannah Ga.

46 Questions? Comments? Handout My contact information: Jerry McLarty, Ph.D /20/2014 MHCA Annual Meeting 2014 Savannah Ga.