1. TECHNOLOGY
WITH
INTEGRITY
Technology Needed to Support
Telemedicine and Telehealth
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4. Your Network
A network is a collection of
computers and other hardware
components interconnected by
communication channels that allow
sharing of resources and
information, where at least one
process in one device is able to
send/receive data to/from at least
one process residing in a remote
device then, the two devices are
said to be in a network.
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5. Your Network
Local Area network – The network portion that you or your Network
Administrator controls. (Switches, Router, Firewall, physical
connections, cabling in your building, etc.)
WAN – Wide area network, or maybe just to keep it simple, a
telecommunications Circuit – Controlled by a Telco service provider
and/or Network Provider.
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6. Basic Rules – Network for
Voice and Video
• Dedicated Bandwidth
• Quality of Service (QOS)
• Low Latency
• Managed Switched Network
• Cabling meets minimum standards
• Expert Support
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8. Dedicated Bandwidth
Congestion can occur in shared
circuits provided through standard
commercial internet.
This creates many problems with
voice and video; such as
latency, jitter, and packet loss.
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9. Quality of Service (QOS)
A method of giving some packets
higher priority than others – Fast
Lane. Priority is given to voice and
video
QOS is useful on over-utilized
intranet/WAN links, as well as LANs.
QOS is not available across the
public internet.
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10. Low Latency
Latency - The time required for a packet to
traverse a network from source to destination.
Jitter – A variation in latency over time.
Packet Loss - If a packet arrives too late, it is
discarded without being used.
You see an example of packet loss, which could
be caused by excessive latency.
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11. Managed Switched
Network (vs. Hubs)
Hubs (repeaters) are old technology.
A hub sends (repeats) packets that are coming
in on one port to all other ports.
Collisions can occur, so devices must listen for
them, and so can only operate in half-duplex
mode.
Bandwidth is shared among all devices and
collisions force re-transmissions causing jitter
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12. Cabling Standard
Voice and video are very sensitive to
florescent lighting, high voltage.
Ensure proper installation.
Test to ensure that the cable can
meet or exceed transmission speeds
and are error free.
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13. Expert Network Support
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14. THANK YOU
FOR YOUR TIME
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Editor's Notes
I need a show of Hands from:Network Engineers/Network AdministratorsTelecommunication ExpertsOK – Just to let you know that this presentation is not for you and is NOT going to impress you a lot, I just needed to know who NOT to take questions from later. The intent of this brief presentation is to better your understanding of the technology needed to support Telemedicine and Telehealth
Well, this is just a way we have at let all of you, as Health Care Providers, that we have a few books too. I have seen my Doctor’s bookshelves and they resemble these books. Very Thick Books, lots of acoryonms, very few pictures,Here is one of mine, over 40,000 entries on telecommunication. Please do not ask me to explain them without the book in front of me.
I feel pretty good that my Doctor knows a pretty good bit about what is in his books, and he also can condense it to provide me with some good advice without taking up a lot of time to explain it. He has made it clear that if I follow these basic rules, I have a good chance to live longer and healthier. Not a guarantee, but chances are in my favor. (FADE IN)As network providers and technology experts, we can essentially do the same thing. We can give you some basic do’s and don’ts that will “in most cases” make it pretty simple to have a reliable and pleasureable experience provided by the technical aspect of Telehealth and Telemedicine. This will not make you better looking on video or improve my speaking ability, however.
As users to a Telehealth or Telemediciene Session, we only want to think about the simple network in this first diagram
For Networking professionals, we think about it more in terms of the large diagram on the left. Today we will try and simplify the discussion to the condensed version on the right, consisting of the Local Area Networks (LAN) and the Wide Area Networks (WAN)The “Network” can be easily divided into two distinct components too. Local Area network – What you or your Network Administrator controls. (Switches, Router, Firewall, physical connections, cabling in your building, etc.) WAN – Wide area network or maybe just to keep it simple, a telecommunications Circuit. – What is controlled by a Telco service provider and/or Network Provider? Separated by some type of Demarcation (Demark) equipment, so the SP can say that the problem is on your end. In some cases, the LAN will be the very least of our problems. Say you decide just to bring in a dedicated circuit from the service provider and connect it directly to your endpoint, similar to the first network slide. The LAN then basically consists of a Router with the correct components, and the cables that connect the Video Endpoint, Router, and the Service Provider’s demarcation equipment. Not a lot to configure, not a lot to support. In other cases, the LAN could be comprised of hundreds of switches, miles of cable, both copper and fiber, and very complex routing and security. A team of network engineers most likely supporting the LAN, specializing in different parts like security, routing, switching, Voice and Video, and more. The WAN is very simular to the more complex LAN on the left, with the Cloud representing many devices and sometimes large amounts of infastructure.
I promised to keep this pretty simple and here we go. Just like the basics to a healthy life, we have some basics to a reliable Telehealth network. Define the terms later in presentation
Now you can purchase as much bandwidth as you can afford, but we are not promoting spending money for unused bandwidth. It is important that you have the ability to send the data, however. These two are examples of plenty of bandwidth. I can go a lot faster on the highway, but I can still get there on the dirt road. But guess what. These are public highways and we all know what happens from time to time.
When you depend on shared bandwidth, you will always take the chance that your voice and video will be delayed. What are examples of Shared bandwidth? The public internet, provided by Cable Modems, and DSL are examples. Certainly, the public internet has improved in its ability to provide a more Video friendly medium and will continue to improve. I believe over the next couple of life cycles of the network equipment, that you will not be able to tell much difference in video. We are not there yet, however.
Not currently feasible on commercial Internet and Internet2 networks for production, regular use. Internet2 is working on QoS plans, but the current over-provisioned Internet2 network doesn’t dictate need
LatencyLatency is the time required for a packet to traverse a network from source to destination.Components of latency include:Propagation delay: the time it takes to traverse the distance of the transmission line; controlled by the speed of light in the media; rule-of-thumb: 20ms San Francisco to New York.Transmission delay: the time it takes for the source to put a packet on the network. Rule-of-thumb for general network devices: < 1ms.For H.323 this includes time to encode/decode the videoStore-and-forward delay: the cumulative length of time it takes the internetworking devices along the path to receive, process, and resend the packets. Rule-of-thumb: variable, and depends upon network load. Rule of thumb:A one-way delay of:0 – 150 ms provides excellent interactivity150 – 300 ms is OK300 – 400 ms is bad400+ ms is unacceptableSatellite delay in the “unacceptable” range, but you will find that you get used to the delay JitterJitter is variation in latency over time.If the endpoints are on switched LANs, then the primary source of jitter is variation in the store-and-forward time, resulting from network load.Network media are adversely affected by high levels of jitter. If a packet arrives too late, it is discarded without being used. Videoconference devices can put packets in a buffer and read them out with precise timing, but a buffer adds latency to the conference.As an example, Polycom VSX devices can correct up to about 75 ms of jitter. Above that, the packets will arrive to late too be used. Packet LossPacket loss is typically due to congested links and routers. 1% is noticeable 5% becomes intolerable
Still very common to find hubs or unmanaged switches in healthcare. Basically shares the bandwidth pipe and creates collision. Do not honor QOS, hard to troubleshoot. Ethernet LANBandwidths are 10 / 100 / 1000 MbpsFull- and Half-DuplexHalf-duplex: since sending and receiving are on the same pairs of wires or fibers, equipment can only send or receive at one time, and must listen for collisions with packets from other devices.Full-duplex: since sending and receiving are on different pairs of wires or different fibers, equipment can send and receive simultaneously and do not need to listen for collision.full-duplex is not consistently implemented on old 10 Mbps Ethernet equipment – test before your conference to be sure it works.100 Mbps supports half- and full-duplex.Modern devicescan auto-sense speed and duplex.LAN- Switches vs HubsHubs (repeaters) are old technology.A repeater sends (repeats) packets that are coming in on one port toall other ports. Collisions can occur, so devices must listen for them, and so can only operate in half-duplex mode.Bandwidth is shared among all devices and collisions force re-transmissions causing jitter
Very basic but cause of many issues blamed on more expensive componants
Just as we listen and take advice from experts in other fields, it is vital that you have someone that supports your Telemedine and Telehealth Initiatives from a technology standpoint; someone that you can trust and that will provide timely support; someone you on which you can rely with expert advice for networking advice for Voice and Video. This could be your internal staff, Lloyd and his staff, outsourced professionals, or a combination of all of these, review existing and proposed network circuits and configuration.
