Australian Association of Consultant Physicians

Glossary of Term

A

auto-tracking

Feature of a Pan/Tilt/Zoom camera that enables it to follow a speaker either by voice detection (usual), by a colour pattern recognition or by Radio signals (rare). Helps to allow the speaker to move freely during a videoconference.

B

bandwidth

A measure of the amount of data that can fit on a network. Measured in Hertz or bits per second. For example, a regular Ethernet line has a bandwidth of 1000Mbps (1000 million bits per second.) Note that bandwidth is sometimes measured as the bandwidth in one direction, and sometimes as the total in both directions. Be sure you understand which it is for the system you are looking at.

bit rate

The number of data bits per second that can flow in a communications circuit.

Some common speeds are 56K (for dial up modems), 384K (for most entry level video conferencing) and 10 Megabits (for a low-speed Ethernet).

buffering

The process by which a codec stores temporarily captured video frames before encoding or decoding them in order to ensure regular and timely transmission or reception. In video conferencing, buffering is very limited, since communications must take place in almost real-time, which allows for delays of only a fraction of a second.

C

CODEC

Stands for Coder/Decoder (a telecommunications term) or Compressor/Decompressor (a computer term). A codec is a piece of hardware or software that compresses and decompresses digital audio and/or video. CODEC's reduce the amount of bandwidth needed for video conferencing.

D

decoder

A piece of hardware or software that is used to convert video or audio (typically) from the digital form used in transmission or storage into a form that can be viewed.

digital audio

Audio that has been encoded in a digital form for processing, storage or transmission.

E

echo suppression

Echo suppression is a crucial portion of all video conferencing systems. If echo is not suppressed, the speaker hears his own audio coming back from the other end of the circuit, after a small time delay. The fault always lies with the far end, although they do not perceive any problem.

F

firewall

A hardware or software based system that filters network traffic based on a set of rules. Simple firewalls normally block access to specific ports and are one of the main cause of VC equipment not communicating. Firewall configuration is a major consideration when deciding on VC equipment technologies.

firewall traversal

Firewall traversal technology creates a secure path through the firewall barrier safely and seamlessly

G

gatekeeper

In the H.323 world, the gatekeeper provides several important functions. First, it controls access to the network, allowing or denying calls and controlling the bandwidth of a call. Second, it helps with address resolution, making possible email type names for end users, and converting those into the appropriate network addresses. They also handle call tracking and billing, call signalling, and the management of gateways.

gateway

A network device that allows an H.323 (Internet-based) videoconference device to connect to an H.320 (ISDN) videoconference device. It is essentially an adapter to allow dissimilar network devices to exchange information.

H

I

IP

The Internet Protocol. IP is the basic language of the Internet. It was developed by the government for use in internetworking multiple computer networks together.

ISDN

Integrated Services Digital Network. This set of standards allows multiple digital channels at 64Kbps to be used on top of the standard Public Switched Telephone Network (PSTN) infrastructure. BRI and PRI are common configurations of ISDN connections.

J

jitter

The change in latency with time. This is a network problem that is very important to video quality. Significant jitter destroys video.

K

L

latency

The length of time it takes a packet to move from source to destination; delay.

loopback test

A testing often found in the menus of videoconference systems. It creates a virtual connection with itself, and allows the user to see the video and hear the audio signals they are transmitting.

lossless compression

Refers to data compression techniques in which no data is lost. For most types of data, lossless compression techniques can reduce the space needed by only about half. Only certain types of data can tolerate lossy compression. Lossless compression technique when compressing data and programs.

lossy compression

Refers to data compression techniques in which some amount of data is lost. Lossy compression technologies attempt to eliminate redundant or unnecessary information. Most video compression technologies, such as MPEG, use a lossy technique.

M

MPEG

MPEG (Moving Picture Experts Group) is a series of ISO standards for digital video and audio, designed for different uses and data rates.

N

O

P

packet

A unit of information sent across a (packet-switched) network. A packet generally contains the destination address as well as the data to be sent.

port

Logical endpoints used by TCP and UDP networking protocols to distinguish specific data channels on a network interface.

Q

QuickTime

A file-format and architecture developed by Apple for use with digital audio and video. Available on most computing platforms.

R

real time

A transmission that occurs right away, without any perceptible delay. Very important in video conferencing, as much delay will make the system very unusable.

S

streaming media

Sending video or audio over a network as needed, instead of forcing the user to download the entire file before viewing it. Typically a few seconds of data is sent ahead and buffered in case of network transmission delays. (Although some data is buffered to the hard drive, it is written to temporary storage and is gone once viewing is complete).

T

T.120

T.120 is an ITU-T standard (International Telecommunications Union) for document conferencing. Document conferencing allows two or more people to concurrently view and edit a document across a network. T.120 is the commonly used name to refer to a family of distinct standards.

TCP/IP

Transmission Control Protocol over Internet Protocol. It is the combined Ethernet protocol standard that covers both network and transport layers.

teleconferencing

Two or more people who are geographically distant having a meeting of some sort across a telecommunications link. Includes audio, video, and/or data conferencing.

U

V

VC

Acronym for Video conferencing

voice activated switching

Automatically switching the video feed to whoever is speaking in a multipoint videoconference. Usually a function of the MCU (multipoint conferencing unit)

W

X

Y

Z

Broadband

Some help with the technical terms ...

To successfully undertake videoconferencing, you will need a broadband connection; while it may be technically possible to undertake some form of videoconferencing (e.g. Skype) via dial up, the quality of the connection would be so poor as to make it unusable for a consultation with a patient.

The other important point to remember is that the connection is only ever as good as the slower "end" – even if your broadband or ADSL speed is very good – if your referring doctor's internet speed is relatively poor, that is the speed at which the signal will be transmitted, and this may not be adequate for the type of videoconsultation you need to perform.  Trying to conduct a consultation with a patient with pixelated images and audio and video out of sync does not bode well for a successful consultation (excepting of course in emergency situations, when this may be the best option).

ADSL (Asymmetric Digital Subscriber Line) remains one of the most common broadband products in Australia and has the benefit of operating over existing telephone lines.  Theoretically ADSL has download speeds of up 1.5mbps and up to 20Mbps for ADSL2+ services; so-called "naked" DSL plans that are frequently on offer from internet service providers (ISPs) are also subject to the same technology and speeds as ADSL and ADSL2+.

If you are not sure of your broadband speed, see the section on speed test page on our website, or you can test your broadband speed here:

www.broadbandguide.com.au/broadband-speed-test

Cable broadband is another product that has become increasingly popular because it can provide subscribers with pay TV, telephone and broadband internet bundles.  Both Optus and Telstra BigPond and in some areas other major ISPs, e.g. iiNet, offer these packages.  Cable broadband can have download speeds of up to 20 mbps, although this is very dependent on the location and line condition.  Also remember that available download and upload speeds are usually different. Some parts of Sydney, Melbourne and Brisbane now have theoretical cable broadband speeds of 20mbps to 100mbps using a new DOCSIS 3.0 technology.  Again, if you need to check your broadband speed, use the link above.

Mobile broadband networks now provide wireless internet access to nearly 99 per cent of Australians through 3G (third generation) technology which offers connection to the internet almost anywhere at fixed line broadband speeds.  The mobile broadband networks are not as robust or consistent as ADSL2+ or cable fixed line but offer significant convenience (for example, if you need to do an emergency videoconsultation via
your smart phone or tablet).  The connection speeds are lower than ADSL and cable, but the expanding 4G wireless technology is expected to have a significant impact on speeds.

National Broadband Network

The Australian Government's National Broadband Network (NBN) is integral to wide uptake of videoconsultation.  The NBN aims to connect 93 per cent of homes, schools and workplaces with a minimum peak speed of 12 megabits per second via high-speed optical fibre technology.  The NBN's promotional material indicates that services delivered via optical fibre technology will initially provide high download speeds of up to 100 megabits per second and will also have the capacity to be upgraded to 1gb per second.  The actual speeds achieved ultimately will vary depending on factors such as your broadband plan, your equipment and the connections in your consulting rooms.

The remaining seven per cent of Australia's population will be connected to the NBN by fixed wireless and satellite broadband services.  A particular type of wireless technology ("Long Term Evolution" [LTE] wireless technology) has been identified by the NBN Co as the preferred technology type to service the rural or remote areas that will not have access to the NBN connection. Some ISPs are currently offering 4G Mobile Broadband plans using this LTE technology and are providing subscribers with typical download speeds from 2mbps to 40mbps and upload speeds from 1mbps to 10mbps.

As noted above however, the speed of your connection and therefore the quality of the images and data, will be dependent on the slowest connection on the line so that needs to be considered in any decision about whether to undertake a videoconsultation.

Given the overall objective of the telehealth / videoconsultation program is to connect rural and remote patients to regional or metropolitan CPPs and specialists, the future development of internet technologies in rural and remote areas will have a significant impact on the longer term take up and maintenance of the telehealth program.

Factors that might affect your broadband speed

Some of the factors that affect broadband speeds are:

• proximity to the exchange
• the quality of your internal wiring / cabling
• the speed of connection between your computer and your modem or router (i.e. wireless is slower than Ethernet)
• whether your broadband "microfilters" have been correctly installed (i.e. if your broadband shares a phone or fax line and the "microfilters" are not installed correctly, you could get a lot of line "drop outs" or poor quality sound
• the processing speed of your computer, router or modem (although with continuing improvement of equipment, this issue is becoming less important).

Cable internet speed is more predictable and faster that DSL media, but it is usually only available in larger metropolitan areas and the location is determined by the telecommunication companies.  If you have cable connection, once it is set your maximum broadband speed should remain relatively stable. The main factors governing the speed of cable connections are:

• how busy the network and the internet are at any given time (e.g. 6.00pm-9.00pm is generally the busiest time for the internet)
• the speed of individual videoconferencing systems with which you are communicating
• whether you are sharing your connection (e.g. with smartphones being used for internet browsing or other videoconferencing equipment)
• whether you are running other software in the background that is taking desktop processor power
• the quality of your modem or router connection
• external factors (extreme weather, third party provider issues)

What are the options for videoconferencing

Your choice of both equipment and connection will depend on the type of videoconferencing you need to do.  For example, you may only do videoconsultations with one patient (accompanied by the referring doctor or other health professional) – that is, one on one videoconferencing.  However, you may also be involved in videoconferencing with multiple participants, e.g. if you are a geriatrician or consultant physician conducting a family conference with a patient, family members and a number of that patient's health professionals.  While these conferences often involve the participants all meeting at a single place, there will be times when this is not feasible.  It is also worth considering that for some older patients this technology may be very challenging and it will be especially important to ensure your set up is technically capable of providing a high quality service.

For example, using your mobile phone for videoconferencing may sound feasible at the outset, and may be useful for emergency situations, however the quality (including the size of the image) and speed tends to be inappropriate for routine, high quality videoconferencing, although for one-off or emergency situations, or follow up the mobile phone may be appropriate. Similarly, using a tablet (e.g. an iPad) provides opportunities for mobility, however the optimum quality will be via a desk or laptop based videoconferencing arrangement with a good quality high definition camera (with back up provided by smaller equipment options). In setting up your office-based system, at the very least it is recommended that you ensure you have a high definition camera – they can be purchased for around $100 from major suppliers and will give you a good image. The AACP is
trialling a number of hardware and software options for videoconferencing and will continue to provide further updates on these options.

ISDN (Integrated Services Digital Network)

ISDN-based videoconferencing provides guaranteed picture and audio quality at a known price and is particularly suitable for group conferences and videoconsultations where high-quality audio and reasonable-to-good quality picture is necessary.

ISDN provides reasonably high data transmission rates; ISDN videoconferencing between more than two sites requires the use of a Multipoint Control Unit (MCU) (i.e. each participating site calls the MCU site, and its location determines the cost of the call).

It is unlikely that any practice-based videoconferencing would be using ISDN and in any event, to achieve high quality video signals, there is a need for multiple channels of ISDN to support the high bandwidth needed. There are also issues with stability (line drops, different delays between channels), the high cost of the call, and the need to install new individual ISDN lines into every location where video communication is required.  Overall, this type of set up is more likely to be available through a health service, rather than a CPP practice.

Internet Protocol (IP) videoconferencing

IP videoconferencing (or VoIP – Voice Over Internet Protocol) is more widely used to communicate between individuals (e.g. Skype used between family members). This technology is currently free to the user since it uses the internet, but does not provide a guaranteed picture and audio quality, as it is dependent on internet traffic, which can vary.  The AACP currently does not recommend VOIP for videoconsultations due to the relatively poor quality of the signal for consulting with patients who have been referred for specialist care.

Videoconference Systems

Tips for Choosing a Video Conferencing (VC) system

Like any technology that integrates with your existing network, whatever you choose for video conferencing should be based on your current network capacity, your anticipated use for the technology and your budget.

Network capabilities

Can your current network support in-house VC; i.e. do you have adequate bandwidth for VC or do need to upgrade.

Consider the features you may need

If you expect to participate in only the occasional VC with only one or two other participants, you do not need capacity for up to 20 video attendees – nor do you need to pay for it! For an infrequent user, consider a subscription like Cirtix GotoMeeting or one of the other "small" solutions.  Similarly, if you are unsure whether VC will be a consultation mode that will suit your type of practice, it would also be wise to consider a basic "entry level" VC set up until you determine the role of VC in the longer term.

However, if you know you want to hold regular videoconferences and/or have the ability to attach peripherals such as Otoscopes and ECGs, you need to consider a VC solution that accommodates these capabilities.  Noting down all the likely uses and the additional capabilities you think you will need should help to determine the type of software and/or hardware you might need and this is also likely to be dependent on your sub-specialty.

Your budget and your VC requirements

Again, the cost of a VC set up will be driven by the range of functions you need; for many, entry level software-based (and usually free) solutions will suffice.  However, if you
require additional on-screen capability, it is likely these basic solutions will not be adequate.

There is a wide range of VC systems – hardware and software based; there is software for tablets and smart phones.  This range of options means you can have a high quality desk based system in your consulting room (e.g. with a large high definition monitor, stereo sound and voice locating camera), and also have a tablet or smart phone option for urgent calls, or as a back up if something goes wrong with your main system.

Security Issues

It is important to remember that there are security requirements associated with video conferencing: data sent needs to be encrypted in order to maintain appropriate patient confidentiality.

Please refer to our Technology Directory for guidance, as they all meet the required level of encryption you need when conducting a telehealth consultation. The encryption protocols you are most likely to find are 128-bit AES and 256 AES, with the 256-bit AES encryption being the most secure of all. For a more detailed explanation of telehealth security requirements please refer to the Telehealth standards document.

Will you always be able to connect with other VC participants?

While there is now a range of VC options, unfortunately they are not always interoperable – however, it is expected that interoperability will improve as more clinicians are involved in VC as vendors are, theoretically, developing their products on a common platform – that is, they should be able to "talk to each other".  One approach is to encourage those clinicians with whom you will VC to have the same VC set up as yours, however this does limit your capacity to expand your VC reach if that is what you want to do.

Where possible find a solution that is compatible to your participants or choose multiple manufactures of VC equipment that will allow a more diverse audience, eg. Polycom Hardware CODEC's (more expensive) and several software solutions that your partners may use, eg. Cisco's Jabba (Free) and Citrix GoToMeeting (subscription).

Several vendors now offer gateway services or equipment that allows communication with competing products, but usually at an additional cost.

The other option is to join a regional VC service (e.g. some Medicare Locals are setting up regionally-based VC services which allow participants to purchase a "licence" (at a relatively low cost).  This offers regionally-based CPPs a cost effective VC option.

However, metropolitan based CPPs could also consider participation in such arrangements since they will allow each of access to a VC network with their potential referring GPs and their patients and, while they will not guarantee such access in all cases, this would provide useful VC contacts for a significant number of patients who may be suitable for VC consultations. AACP is working with some Medicare Locals with a view to setting up such arrangements.

Firewalls

One of the most common problems with connecting a VC is reportedly the difficulty of traversing a public hospital firewall and for many CPPs, participating in a VC will involve one or other participant being in a public sector facility.  Most software based VC systems allow firewall traversal, meaning that it will be much easier for participants behind firewalls to connect to your videoconference. However, connections are not assured where there is a significant firewall in place and if connections with a particular location are difficult it may be necessary to request the participant at that site to seek IT support.

Hardware, Software and Bandwidth

Hardware assisted VC solutions (that is, proprietary VC equipment with its own software – such as those offered by companies like Polycom, which is used in many public sector facilities) currently use considerably less bandwidth than software alone solutions.  The hardware-assisted equipment (CODEC) has the ability to compress the data being sent and therefore this equipment uses less bandwidth (although it should be noted this is usually limited to communication with the same proprietary equipment).

IT support

Do you have IT expertise locally?  Depending on your computer purchasing arrangements, there may be maintenance agreements available that will include technical support, warranty and software upgrades.

Security

Videoconferencing systems security

There are a number of ways to increase the security of your IT system if you wish to participate in videoconferencing / telehealth and, given you will be discussing patient information and consulting with patients, it is important to address the relevant security issues.

 

Fortunately, with the amount of attention that has been paid to videoconferencing / videoconsultation since the Government launched its telehealth program, most of the VC (videoconferencing) vendors in Australia who are interested in selling their products for use in videoconsultations have paid attention to securing their systems from intentional and unintentional infiltration from unwanted visitors and, at the same time, have addressed the security requirements that have been outlined by the Government in relation to its telehealth program. For the most part these systems use encrypted data transmission and call logging.

 

Nevertheless, it is equally important for the medical profession to take an interest in ensuring that whatever system is used is secure and that basic precautions be taken to enhance security, in the same way that your paper-based medical records are secured within your practice offices.

 

Similarly, you should have password-protection on the system, just as you would have on your desktop or laptop computer, tablet or mobile phone.

 

Encryption

One of the early security requirements instigated was for encryption of transmission for all VC systems used to conduct a telehealth consultation and, while at the introduction of the telehealth program there were significant concerns about the encryption security of common videoconferencing methods (such as Skype), most companies have improved this element of security and it now tends to be offered by default. Nevertheless, it is important to check against the current (?NEHTA Standards) to ensure the system you want to use complies with the required encryption standard.
 

Firewalls and Virus Protection Software

Firewalls are designed to prevent unauthorized access to or from a private network and can be implemented in both hardware and software forms, or a combination of both. The firewall enables all data entering or leaving the system to be examined and data that do not meet the specified security criteria will be blocked.

 

In the AACP’s experience public hospital system firewalls can be a significant issue in seeking to set up videoconsultations between hospital based specialists and community based GPs and patients. The main issue is they often need to be configured to allow videoconference systems to interconnect and are usually the main cause of videoconference calls failing to connect or function properly. Examples of incorrectly configured firewalls could be: there is video but no audio (and vice versa) or the user is unable to dial out or the other party dial in.

 

Most software based videoconferencing systems can go through firewalls because they follow similar rules to web pages that are usually already accepted by firewalls.

 

If you cannot get your videoconference system to connect, particularly if one of your parties is using a public hospital IT system, then the firewall is the most obvious target as the problem.

 

If you have problems in this regard and are unable to get the hospital IT staff to assist, the AACP’s Technical Resources Officer may be able to assist you with advice on how to tackle this (details below).

 

The other important factor is keeping your practice software (not just programs like “Medical Director”) up to date because the vendors are constantly updating the features of the program. As with the security standards, the software vendors (including the suppliers of anti-virus programs) recognise the importance of complying with the Government’s requirements for security and will be continually upgrading software to ensure compliance.  It is important to ensure your office upgrades software whenever there is a new “patch” available to address security issues identified by the software provider.

Auto Answer and Direct Calling

It is important to remember that unless you disable functions on your computer or videoconferencing system, such as “auto answer”, it may be possible for someone to call you when they wish – and at a time that may be completely inappropriate for you.

 

If you plan to do only a relatively small number of videoconsultations, this may simply involve disabling these automated functions on your computer.

 

However, if you can see that your involvement in videoconsultations may grow because many of your referrals are from rural and remote areas, then you may need to consider whether a dedicated videoconferencing room will suit you, or whether you set up a “virtual room” which works as a form of intermediate “meeting room”, where participants dial in and wait for other participants to join. This form of virtual room does not connect directly to the end user and allows you to control the videoconference call or for your staff members to accept the calls and hold them for you. Many current videoconferencing systems can be configured to direct all incoming calls to a “virtual room”.

 

Physical lens covers for your camera and auto mute for maintaining privacy

There are also physical solutions that allow you to take control of videoconference calls, including using the lens cap that comes with many videoconferencing cameras and the automatic mute function. If you have a separate videoconference camera or system, keep the lens cap on when the camera is not in use; in the event of an inadvertent connection, at least the caller is prevented from seeing anything and if the system is set to mute on connection (which is recommended) inadvertent callers see and hear nothing.

 

If your videoconference camera does not have a lens cap, face the camera towards a wall. If your camera has “pan-tilt-zoom” capacity, i.e. it is remotely movable it would be more secure to disable these controls. These can be useful at the “patient end” when you need to direct a physical examination remotely with the assistance of the referring doctor, however it is unlikely you would require this function at your end of the videoconference.

 

Inclusion of your contact details in a telehealth directory

The AACP is encouraging CPPs who are interested in participating in videoconsultations to include their names on one of the telehealth directors (e.g. the directory being developed by the Australian College of Rural and Remote Medicine, with which the AACP is working closely on telehealth matters, is recommended) it is not recommended to publish your VC number in such directories. Publishing a contact telephone and/or email address is preferable as it maintains the referral process as it would normally exist were the patient to attend physically at your rooms.

 

Separating video and audio

This method of videoconferencing involves transmitting only the video via the videoconferencing system and calling the participant via a separate phone call for the audio component. This method may be helpful in low bandwidth situations to improve video quality although there is the major drawback that it causes the picture to be out of sync with the audio (video takes longer to transmit than audio) and this is unlikely to comply with Medicare’s requirements for videoconsultations. However, in an emergency situation, such an arrangement may prove useful.

 

Assessment of your videoconferencing system for vulnerability

It is possible to have a professional vulnerability assessment of your system and this is something you may wish to consider. Many videoconferencing vendors and IT professionals can assist you with these services. The AACP’s Technical Resources Officer can provide advice on this assessment process.