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Telemedicine: Life, Death and AV?

AV professionals can't often say that their work involves life-or-death issues, but in the growing health care niche known as telemedicine, they can. In fact, ensuring high-quality, reliable video signals is a non-negotiable objective of every telemedicine project.

AV professionals can't often say that their work involves life-or-death issues, but in the growing health care niche known as telemedicine, they can. In fact, ensuring high-quality, reliable video signals is a non-negotiable objective of every telemedicine project.

Broadly defined as the use of telecommunications to deliver medical information and services, the sort of telemedicine that concerns AV integration almost always involves distance conferencing. Other segments of this broad field, such as home monitoring, electronic health records, and subspecialties like teleradiology, don't directly touch AV technology. But even that's changing, as telemedicine users ask to integrate conferencing with all other electronic information normally at their disposal.

As the most visible form of telemedicine, videoconferencing usually manifests in one of three typical scenarios. The hallmark configuration involves a doctor viewing, diagnosing, and recommending treatment to a patient he doesn't see in person, but instead interacts with over live video. Another common application allows a doctor or nurse to bring in a specialist for a remote consultation, sometimes during a live procedure, such as open-heart surgery or triage on a trauma patient.

In a third common scenario, patient exams and certain medical procedures are transmitted to distance-learning facilities at hospitals and universities, providing students with real-world, practical instruction–even the chance to question the surgeon. Or, students can join "grand rounds," a long-standing practice in teaching hospitals, in which medical students visit a series of patients in their rooms. But thanks to videoconferencing, they never leave the auditorium.

This last scenario was what the University of Arizona had in mind when it upgraded AV systems and conferencing equipment in an amphitheater at its Institute for Advanced Telemedicine and Telehealth, or T-Health Institute. The institute is basically a teleconferencing hub that allows students, professors, and working professionals to participate in live meetings from various locations. Plus it lets them switch among discussion groups almost instantly, says Jim Mauger, director of engineering at integrator Audio Video Resources, which worked on the project.

The institute standardized on Tandberg videconferencing systems, including six in the amphitheater alone, Mauger says. Virtual meetings take place in the amphitheater, which sports a videowall comprising 12 50-inch Toshiba P503DL DLP Datawall RPU video cubes controlled by a Jupiter Fusion 960 processor. Digital signal processors control audio from 17 student desks, each equipped with a microphone and headphones. Visitors to a rear gallery can don headphones and listen in on the conferences while they watch through a window.

An instructor uses a Crestron control system to choose how up to 16 conference participants are grouped on the wall, with Extron hardware switching the feeds.

In fact, controlling the participants' audio and video feeds so they could be quickly grouped and regrouped according to instructional needs was the biggest challenge. Attendees can participate in a single large meeting, or they can be broken into groups. One group of screens might be outlined in blue and the other in red to distinguish between the two meetings. "We developed a pretty elaborate request-to-speak queuing system," Mauger says, including a Crestron HTML page that displays the names in the queue.

When the Doctor Is In–Or Out

Of course, telemedicine as education and telemedicine as actual health care can be two different things. By some estimates, only 10 percent of operating rooms are currently outfitted for telemedicine, representing a significant business opportunity, provided AV professionals do their homework.

"AV integrators need to understand the workflow of the operating room," says Ron Emerson, Polycom's director of global health care markets.

Which is to say nothing about the physical dynamics of actual operating rooms. For example, where video isn't as high a priority, audio conferencing, integrated correctly, can be an important enabler of telemedicine.

"There are some real challenges in an operating room from an audio standpoint," says Scott Woolley, director of product marketing at ClearOne, a maker of audio digital signal processors ( "The walls are tiled. There's no acoustical absorption in them at all. You have to be careful that the microphone placement is done well. There's other equipment that's fairly noisy."

Line and microphone level inputs and noise cancellation in DSPs like ClearOne's ConvergePro 880TA help ensure each participant's voice is intelligible above the din of an OR.

Experts says health care facilities lag other industries in adopting AV and information technologies. "For example, they're just now getting into HD," says Paul White president and founder of Beaverton, Ore.-based CompView Medical, a market-specific spinoff of AV integrator CompView ( But now that hospitals are incorporating high-definition imagery, they're moving quickly to establish the video infrastructure to meet their needs. HD's high-resolution images have begun driving telemedicine investment because of its ability to show very fine detail and color–key for visualizing those hard-to-reach places in the human body.

The challenge comes in getting those HD signals where they need to be. Woolley says some hospitals ensure the quality of OR video by piping the signal uncompressed, without running it through codecs (though they still use codecs for conferencing away from the OR). Coax or fiber-optic cabling are typical, though as in other markets, more hospitals are considering transmission over Cat-5 cables to save money and retrofit existing rooms.

Still, not all telemedicine applications need high-definition video. "You may have a high-definition camera but the platform that you're using is not high-definition," says Neal Schoenbach, telemedicine design manager for GlobalMedia (, a solution provider in Scottsdale, Ariz.

"More than resolution, we really focus on how much bandwidth is being used," says Polycom's Emerson, a registered nurse and former American Telemedicine Association (ATA) board member. According to Emerson, the typical bandwidth for clinical applications is only 384Kbps.

In any case, video signal distribution is playing a greater role in hospitals, in part because many want fewer codecs to serve more rooms. Rivulet Communications, a Herndon, Va.-based vendor that tailors solutions to telemedicine, utilizes video over IP ( Its Dynamic Synchronization Technology carries video over the Cat-5 already running a hospital's data network, and without the extra boxes to convert from analog. Rivulet ensures quality-of-service (QoS), in part by piggybacking on the QoS features in Cisco routers. Another product, its IP Expansion Gateway, extends the benefits outside the hospital. "It will allow someone at home on a low-bandwidth connection to log in securely and watch video of an operation," says Jeff Schmitz, Rivulet's senior vice president of sales and marketing.

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