Video pays off twice at VA

What do you do when your field offices are scattered across the country, but the experts they rely on for the tough cases are back at headquarters? When expert consultation is needed, the norm has been that someone has to travel to another locale, usually far away. That practice is expensive, time-consuming and not particularly flexible to evolving needs.

The Veterans Affairs Midwest Healthcare Network is testing how videoconferencing could help end that travel. And it has plenty of travel to eliminate. The network serves retired service personnel spread across the Midwest, covering Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota, Wisconsin and Wyoming.

Known as the Veterans Integrated Service Network 23 (VISN 23), the videoconferencing system serves veterans in those states, and allows them to visit a local field office rather than traveling to headquarters in Fargo, N.D.

'Every psychiatrist has video access in his office and every emergency room has video systems that are set up for intake after-hours,' said Jeffrey Day, VISN 23's senior telecom engineer.

'A patient walks in and he needs to speak to his doctor right away. He can do it visually instead of making the doctor come in.'

There now

First deployed in 2003, VISN 23 has grown fourfold in the past four years and now supports about 23,000 patients who can live independently while receiving services. VISN 23 now delivers videoconferencing services over IP-based networks to eight medical centers, 35 outpatient clinics, seven nursing home-care units and four homes.

VISN 23 uses Tandberg equipment, employing 151 video systems tied together with Tandberg's Media Processing System and protected by the company's Gatekeeper and Gateway firewall services.

Video is stored on a Tandberg Content Server.

Depending on the version employed, that MPS can support as many as 160 video feeds and up as many as 48 audio feeds in one or multiple conferences, support widescreen high-definition display (1,280x720 resolution), and can handle bandwidth as fast as 2 megabits/sec.

The system also supports remote users of laptop PCs and video cameras. The remote devices are connected to the network via a Tandberg MOVI unit, and the company's Border Controller manages firewall traversal and provides dialing services.

Thanks to the full-duplex communications offered by the system, the performance is much the same as with a phone conversation, Day said. 'There's no pause, there's no delay.'

One of the VA doctors who sees patients in Minnesota resides in Tennessee. 'There are no physical limitations any longer,' Day said.

VISN 23 is being used to deliver a variety of services, but perhaps its greatest impact has been through the Telepsych initiative, which allows veterans to consult with psychiatrists or counselors.

'We found that patients prefer being in a room with a video screen and nobody else around, because it provides anonymity,' Day said. 'You're not confronted face-to-face and having to look somebody in the eye or feel like you're trapped in a room with another individual.'

Videoconferencing offers other benefits to patients as well. 'This was an obvious tool to reduce wait time' Day said, 'reduce travel, and reduce the level of anxiety for these younger vets who don't want to have to announce to the world and to their families that they're seeing a psychiatrist or psychologist.'

VISN 23 also supports VA's Tele-Ortho and MOVE programs. The former provides post-operative consultations for surgery patients by allowing physicians to consult with specialists in other locations and inspect a patient's incisions or wounds remotely. The MOVE program offers consultations for overweight veterans, particularly those considering gastric- bypass surgery.

'They just go into one of our rural clinics, and they sit in front of the video, and the doctor can look at the incision very closeup,' Day said of the Tele-Ortho program.

'They have their X-rays done there by their local hospital, and they put them on a projector, and the doctor looks at the X-rays and, he can see the range of motion over the video. He'll say: 'Looks good, we'll see you again in three months.' It saves them a 16- or 18-hour trip, having to travel in possibly bad weather.'

The system even allows the physician to control the camera on the patient's end. 'The doctor can zoom in on the patient's hands or feet, and the patient doesn't know what the doctor is doing,' he said. 'The doctor can zoom in on the patient's motions or tics, any type of nervous habit.'

Time and money

VISN 23 also delivers benefits to VA staff. For starters, the Tandberg Management System software relieves information technology staff members of having to manage videoconferencing schedules, Day said.

'We put in a scheduling package that allowed the users to schedule their own calls instead of having to call somebody to schedule the system, which made it very user-friendly,' he said.

Centralized administration is another benefit.

'I'm able to manage the entire video network from my desktop,' Day said.

It's difficult to estimate the total cost savings from VISN 23, but VA officials point to an obvious area of savings: travel expenses for both patients and staff.

When veterans travel for appointments, they are typically reimbursed for expenses, including meals and accommodations. However, they also have to take a day or more off from work and make arrangements for day care for children or other dependents.

Using videoconferencing saves dollars spent on travel for patients, and in some cases, it can make physicians more efficient. According to VA, the director of rehabilitation in Fargo uses her video system to see as many as five orthopedic or surgical post-operative patients in only 30 minutes.

Overall, VA estimates that it is getting a 54:1 ratio on its return on investment in the videoconferencing system.

Patients have been quick to take to the videoconferencing system. 'The veterans have embraced it,' Day said. 'I've often asked the vets how they enjoy being on TV, and they love it.

I've never heard one negative response about using videoconferencing for telehealth.'

Physicians have been a tougher sell. For all the benefits of the VISN 23 system, Day said, it has taken coaxing and education to get them to make greater use of it.

'Often, people want to slowly adapt to technology, but we're going to put it in their face,' Day said. 'That's the best way we can introduce them to it. You make it available, you put it in their office, then it's awfully hard to say, 'I can't see patients.' '

Catching on

VA is not alone in deploying videoconferencing.

Other federal agencies and departments have begun expanding their use of IP-based videoconferencing too.

For example, the Social Security Administration has created, in partnership with the University of North Dakota, a videoconferencing service to help process applications in rural areas, particularly for American Indians in North Dakota, South Dakota, Montana and Wyoming.

'The reason it's caught on so quickly is that you have a couple of barriers to adoption that have been eliminated,' said Joel Brunson, president at Tandberg Federal.

'With the availability of IP, whether it's your home or office, it has cut the cost by about 40 percent in installation and operating costs, Lee said. 'So that's a huge reason why people have readily adopted it.'

Higher-definition video has also boosted interest.

'The video quality makes it almost a natural experience,' he said. And the migration of high-quality equipment to the desktop has been yet another factor spurring adoption. 'Instead of getting up and wasting time going to a remote site in your building where that one conference room is that is used for videoconferencing, now you can do it at your desktop,' Brunson said.

'We haven't even scratched the surface,' Brunson said of videoconferencing implementations in the federal sector.
Many seasoned systems administrators know the power and pain of the reboot.

Many, if not most, user problems can be solved by a simple reboot, and most systems require a power cycle after a major update of the software. But when you have hardware scattered around an office, or across the country. it can be a pain to go to each location just to punch the restart button.

Dataprobe has come up with a power strip that can be rebooted over a network.

And that can be a time saver for administrators whose equipment is scattered hither and yon.

For example, audiovisual technical consultant K2 Audio has found the strips to be handy in supporting the Senate Hearing Room Audio Network.

The Senate's hearing rooms are wired to record meetings. Microphones in the rooms connect to an audio interface box that converts analog inputs from the microphone into digital form, so it can be relayed back through the system for storage and real-time listening.

Each room has about six of these boxes. Each room also has an uninterruptible power supply to ensure any temporary power outages don't lead to long reboot times of the cameras and other equipment, said Rodrigo Ordonez, K2 design consultant.

A two-second lapse in power can result in a three-minute wait for the equipment to come back online.

Occasionally, the boxes ' which are on an Ethernet network ' need firmware upgrades, which can be done remotely. But after the firmware is installed, the equipment must be rebooted.

And it is impossible to reboot the equipment without being in the room.

'It's a kind of a problem to go to every room for anything that happens,' Ordonez said.

So K2 invested in iBootBar power strips from Dataprobe. The iBootBar is a simple power strip with an Ethernet port. A more expensive model also comes with an optional telephone jack for modem use, too. The port lets administrators log in to the power strip, via a Web page and shut off and restart power for each outlet on that strip.

Instead of going from room to room to reboot equipment after a firmware upgrade, administrators can reboot the equipment from the maintenance shop.

Although somewhat expensive for a power strip ' prices start at $485 ' the iBootBar can be handy in many circumstances, said Dataprobe President David Weiss. Equipment that isn't being used can be shut off remotely for security and energy savings.

The power strips have a command line interface, with support for Telnet and Simple Network Management Protocol, so administrators could write scripts to automate when the units shut down, start up or reboot.

The modem unit supports dual-tone multifrequency, so administrators could work with the power strip using only a telephone.