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Angels in the Outskirts: Telemedicine in Action

Known as the Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), the program employs conferencing technology to virtually transport a medical specialist to wherever the mother and child live and allow the doctor to perform many of the same examinations they would in person.

CHALLENGE: Extend neonatal care and education to people and hospitals throughout the state of Arkansas.

SOLUTION: Employ IP-based videoconferencing and telemedicine, integrated into the unique workflow of a health care system.

Last thing first: in 2007 the american Telemedicine Association bestowed an award on a program run by the University of Arkansas for Medical Sciences (UAMS), in association with the state government and medical society, that contributed to a drop in infant mortality rates in that state's rural areas and helped lead to increased treatment of low-birth-weight babies and mothers with high-risk conditions.

Known as the Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), the program employs conferencing technology to virtually transport a medical specialist to wherever the mother and child live and allow the doctor to perform many of the same examinations they would in person.

"Telemedicine is one of the more challenging verticals for AV, but it's one of the most rewarding," says Michael Sanders, regional sales manager for telemedicine at Interactive Solutions (ISI), which worked on the project. "It has a large impact that's measurable."

In fact, getting ANGELS to the point where it's impact could actually be measured took considerable work.

"Our biggest hurdle in this state has always been that we don't have a single service provider that serves the entire state," says Eric McKenney, UAMS's IT manager for video. As a result, the ANGELS program has to tie in each new videconferencing site individually, working with local service providers. Internet protocol can help.

UAMS has been gradually migrating its videoconferencing systems from the older H.320 standard to H.323, which brings with it the ability to transmit over IP networks. Classrooms at affiliated campuses have also been moving to H.323.

In addition to delivering care to rural areas, ANGELS employs custom videoconferencing carts to train specialists.

In addition to delivering care to rural areas, ANGELS employs custom videoconferencing carts to train specialists.

Credit: Courtesy UAMS

The university started with Polycom multipoint conferencing units (MCUs), but now has several Tandberg 4520 MCUs. The Border Controller and Gateway from Codian, a company Tandberg later acquired, provides firewall traversal so participants outside the UAMS network aren't stymied by its network protection.

McKenney says the group is testing another Tandberg appliance, the Video Communication Server (VCS), which supports a newer standard called Session Initiation Protocol (SIP) that is more interoperable with other standards and has more features than H.323. "The VCS will give us registration redundancy," McKenney says, adding that some conferencing participants connect from legacy equipment that won't register their user information with UAMS' Codian hardware.

Cartography

In the hospitals, as is the case with many telemedicine systems, ANGELS is built around mobile carts that hold AV, conferencing, and medical hardware. UAMS started out with standard vendor carts, but commissioned ISI, a Memphis integrator, to make custom carts.

"Doctors are used to specialized instruments for each specialty, and they like the telemedicine carts to reflect that," says ISI's Sanders, who has helped develop carts for pediatrics, OB/GYN, genetics, and geriatrics. He says the challenge was to build units that were both generic and capable of easily accommodating specialized equipment. The risk of coming into contact with bodily fluids also requires cart equipment to be waterproof. Connectivity is not a problem thanks to wide use of standards such as DVI. "Rarely do you run into something that's proprietary," Sanders says.

The carts were also designed for easy integration into auditoriums and other teaching spaces. Sanders says each one has a distribution amplifier that allows the VGA output on the cart's laptop computer to be split. "It's a way to quickly get videoconferencing to a room," he says.

ANGELS also extends beyond one-to-one conferencing between doctors and patients. It encompasses ongoing learning and collaboration–all the way into operating rooms, which are hostile environments for AV. Perhaps the biggest issue can be calculating camera and display angles in close quarters, accommodating the needs of both in-room and remote participants. "The line of sight is usually very difficult," Sanders says. "You have to get really creative." So ISI uses another vendor's telescoping arm to position the cameras.

Audio is another problem, with doctors having side conversations and machines beeping. Sanders says each room requires its own solution–perhaps lip microphones for surgeons, lapel mics for others, or a ceiling mic attached to a light.

With human factors such as these playing such a large role in design, ISI spent much of its time on the front end asking users about their needs and analyzing their workflows. "Instead of changing the day-to-day operations, you're just supplementing it or enhancing it," Sanders says.



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