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.