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AV In Medicine

NightHawk, firewall traversal, FDA 501(k), and ?time is tissue? might sound like plots from a cheesy techno-thriller, but they're all terms that AV professionals must know when selling to the health care market.

Jennifer Spagna of Office Environments of New England.

Jennifer Spagna of Office Environments of New England.

NightHawk, firewall traversal, FDA 501(k), and “time is tissue” might sound like plots from a cheesy techno-thriller, but they're all terms that AV professionals must know when selling to the health care market.

Case in point: NightHawk of Coeur d'Alene, Idaho, furnishes radiological services, such as reading X-rays. Its name comes from its selling point: A hospital doesn't have to maintain a full radiological staff overnight; an emergency room can send an X-ray at 2 a.m. to NightHawk's staff in Sydney, Australia, and Zurich, Switzerland. Other companies offer similar telehealth services, such as foreign language translation.

To enable those applications, AV pros need to understand the concerns of health care IT departments, such as allowing sensitive information, be it an X-ray or a videoconference, to traverse firewalls. They also need to know guidelines, such as the Food and Drug Administration's 501(k) rules for medical devices. And everything has to work flawlessly, because glitches can lead to delays that can have serious consequences; for example, part of a stroke victim's brain could die because a clot-busting drug wasn't administered in time. As ER nurses often put it, “Time is tissue.”

Vendors wanting to work with hospital customers must know of regulations and requirements that don't happen elsewhere, says Doug Young, media network specialist at the Charleston Area Medical Center in West Virginia.

Time for Homework

One of those requirements is resolution. “The AV pro should be armed with resolution-related facts,” says Jennifer Spagna, who handles technology sales in the AV division at Boston-based Office Environments of New England. “Some medical facilities have specific computer applications, which require a specific native resolution. It's imperative to know what that native resolution is, as well as what type of operating system the client plans to display.”

Some vendors and integrators say health care professionals often have done their homework, too. Their research sets their expectations. “They will have a laundry list,” says Spagna. “Be prepared to separate fact from fiction, as they'll have gathered so much information, they'll need some help to sort it out.” For example, she says, sometimes their research comes from studying consumer models of big box retailers, such as Circuit City. The challenge is to help them understand that they get what they pay for.

Clients often do their research online “in an effort to design the AV system on their own,” says Spagna. “This is challenging, because it creates a situation where the client knows enough to be dangerous, but not enough to build a quality system.”

To make the sales process even more challenging, several departments usually are involved in specifying and approving AV solutions. “The AV dealer should be working with all departments, [including] hospital management for budgeting and finance, [and the] IT department to work with technical and existing network considerations/integration,” says Dan Woodward, product manager at ViewSonic in Walnut, Calif.

Bandwidth Bottlenecks

Health care AV is a growth market, partly because just about any specialty can have a “tele” prefix on its name. One example is teledermatology. A patient at a rural health clinic can have a video conference with a dermatologist at a hospital a hundred miles away. For the examination, the patient would put the affected area under a video camera, or a nurse would take a high-resolution photo and send it over the same link.

“I've been seeing dermatology patients in rural, underserved areas of Missouri for more than 10 years,” says Karen Edison, chairwoman of the University of Missouri Department of Dermatology and medical director of the Missouri Telehealth Network. “Just because people in rural areas have cars and roads doesn't mean they can travel to get the health care they need.” Teledermatology is a “patient-centric way to deliver care, because you're taking the care to the patient.”

But taking care to patients can be a challenge. For example, in rural areas, broadband technologies such as cable, digital subscriber lines and fiber optics often aren't available. That is a hurdle for AV integrators because, depending on the application, you need a certain amount of bandwidth for a good user experience.

In a telepsychiatry video conference, for instance, jerky video and audio drops can frustrate the patient and keep the psychiatrist from picking up on nuances, such as facial tics and changes in tone of voice.

With the H.264 video codec, “256 kb/s seems to be the point where people are happy and don't notice any degradation,” says Ron Emerson, director of health care markets at Polycom in Pleasanton, Calif. He also ran a Maine non-profit that specialized in health care AV before joining Polycom. He said the prison system in Maine is doing telepsychiatry at 256 kb/s, “and they feel very comfortable with it.”

Others recommend aiming a bit higher. “384 kb/s is a minimum requirement in my mind” for video conferencing, says David Stadler, director of telemedicine at Wexford Health Source, a Pittsburgh company that specializes in prison health care.

Some states have created broadband networks that serve schools, libraries, and health care facilities in rural areas. One example is Missouri's MOREnet. “Where I connect is all broadband,” even in remote areas, says Edison of the University of Missouri.

Government-funded broadband networks could become more common, setting the stage for more AV applications such as telemedicine. That's because in September 2006, the Federal Communications Commission created a pilot program to fund up to 85 percent of the cost of state and regional broadband networks for health care applications.

“That's going to be huge; it will pay for video endpoints and beef up infrastructure,” says Emerson of Polycom.

Reimbursement Runaround

Success in health care AV often means being aware of government funding sources that clients can tap into defray the cost of telemedicine and equipment, such as video walls in surgical suites. Two examples are the Agriculture Department's Rural Utilities Service and the U.S. Health Resources and Services Administration's Office for the Advancement of Telehealth.

AV pros also need to be mindful of Medicare, Medicaid, and private insurance reimbursement guidelines. These rules often vary by state and by application. For example, patient-physician videoconferences generally are reimbursable, while sending high-res photos of a skin lesion for later review generally is not., Potential clients, particularly those on a tight budget, may become discouraged if the integrator has them on hold while checking on reimbursement qualifications.

Edison says that as of Sept. 1, 2001, Medicare pays the provider the same, as if it sees the patient in person, if the patient is in what's called an approved originating site, such as a hospital, a community health center, or a rural health clinic. IT will not pay for store-and-forward telemedicine except in Alaska and Hawaii, she says.

Playing Up Productivity

Reimbursement issues won't necessarily scuttle a health care AV project. In fact, some vendors and integrators maintain that AV equipment often can improve productivity to the point that it outweighs being reimbursed only partly or not at all.

“Has it been a limiting factor for the industry? Certainly a concern, but many programs find so much value in other aspects of this delivery model that outweigh pure billing issues,” says Joe D'Iorio, manager of telehealth for Oslo, Norway-based Tandberg.

One way to get over the reimbursement hurdle is to educate potential clients about the return on investment. One example is the time-is-tissue maxim: Using the stroke patient example, blood thinners can reverse a stroke's effects, but only if they're administered within three hours. A neurologist decides whether to administer the drug, but such specialists aren't always at the hospital.

“It's generally recognized that it usually takes a patient 90 minutes to realize they're having a stroke and get to the emergency room,” says D'Iorio. “Most doctors figure that from the time the patient hits the ER, they've got about 90 minutes.”

In that situation, a hospital might be able to make a business case for a video conferencing system that lets neurologists read a brain scan from a home or office. Besides saving brain cells, that setup could reduce costs, because the neurologist doesn't have to drive to the hospital to make the decision.

The business case also can get a boost from the fact that physicians and nurses are well paid, so increasing their productivity just 15 minutes per day can add up to a lot of money over the course of a year. For example, Fletcher Allen Health Care in Burlington, Vt., installed 45-inch Sharp LCD monitors in its operating rooms and radiology department.

“A typical everyday benefit to me as a vascular surgeon is when I need to refer to a pre-op angiogram,” says Dr. Michael Ricci, vice president of clinical services. “Before, I had to leave the patient and walk over to the wall with the films. Now, I can continue to be at the patient's side and glance up from across the room — a small but obvious benefit which we couldn't live without.”

Fletcher Allen Health Care is an example of how AV can let a physician teach more students at once, reducing the need for — and cost of — hiring more instructors. “Teaching is easier,” says Ricci. “Having a resident or two and a student crowd around those old, two-foot CT films always left someone out. We have used a few [displays] in the surgeon areas, where they can review studies while outside the actual operating room.”

Learn the Lingo

In one respect, health care is similar to the general enterprise market. Both increasingly require AV pros to understand at least the basics of IT.

All AV vendors should have someone on staff who is very IT savvy, says Young of the Charleston Area Medical Center. “Because of the convergence of AV and all things computer, it is no longer just a case of bringing in a device in a box and installing it,” he says.

But like other vertical markets, such as financial services, health care has another layer of IT requirements. The AV system must comply with laws that protect patient privacy, such as the Health Insurance Portability and Accountability Act (HIPAA). Although HIPAA is detailed, it's essentially about procedures and due diligence rather than specific technical requirements such as using a virtual private network for video conferences.

One way to identify HIPAA issues is to use the experience in general enterprise environments. For example, any type of wireless, such as 802.11 Wi-Fi data or UHF mics, can create vulnerabilities.

“Inadvertent outside access, such as an unencrypted wireless access point on a control system, or conventional wireless mics used in a teaching hospital auditorium” are concerns, says Jim Smith, CTS, CVE, consulting systems engineer for AV channels at Polycom.

Keep It Clean

Another difference between health care and most other vertical markets can be summed up in a line from the Hippocratic oath: Do no harm. In this case, harm can be divided into two types: interference and germs.

“Equipment near patient access must have ‘medical isolation' for the electrical system,” says Smith. “That usually means isolation transformers with special grounding circuitry in between the AV and the wall outlets. One couldn't just put generic AV gear into an operating or emergency room without extra care taken in the power distribution.”

Shielding AV equipment or using fiber rather than copper are other ways to ensure there is no interference with medical gear, or vice-versa. Physical space also may be a requirement under FDA and Underwriters Laboratories guidelines, such as FDA 501(k) and UL-60601.

“The product needs to be approved if it is within about a 10-foot area around the operating table,” says Bruce Goldstein, senior business development manager for the professional display division at Sharp.

However, it may be possible to avoid some guidelines and their costs by installing the AV equipment a certain way.

“[Our display] goes on the walls and is mounted out of the scope of that certification requirement,” says Goldstein. “Because it is a large screen with such a high resolution, it is still effective, and all doctors and surgeons can see the monitor at once.”

In the case of germs, sanitary requirements vary by application. For example, in some environments, unfiltered forced-air vents and nonairtight connectors might be unacceptable. In other environments, AV products may need to meet liquid-resistant standards for cleaning and disinfecting.

All those variables raise an important question: How does an AV pro identify potential issues before making a bid? Part of the answer is to be sure all key parties are involved, including the IT department, from the start. This could save last-minute, must-have surprises.

“IT recommends, and the medical staff decides,” says George Pontiakos, founding partner of MedEfficient Healthcare Solutions in San Clemente, Calif.

Like physicians and nurses, AV pros should be ready to ask probing questions to sift out underlying problems.

“Vendors need to ask questions about the actual application a potential health care client might have,” says Young of the Charleston Area Medical Center. “Many times, clients don't know what they really need, and the vendor needs to educate them as to what's available and how the various devices might be used to fill the need.”

Tim Kridel is a Kansas City, Kan., freelance writer and analyst who covers telecom and technology. He can be reached at tkridel@kc.rr.com.



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