Telemedicine Technology Summit

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 2 Requirement for fixed communication lines: For high-speed transmission For error-free transport Uses triplex, or triple ISDN lines System requires fixed stations on both ends: Fixed video camera sending station Fixed, expensive base station ? Consulting MD must travel to base station. Typical Video Conferencing Technology ER MD High-quality Video }

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 3 ER MD Requirement for fixed communication lines: For high-speed transmission For error-free transport Uses triplex, or triple ISDN lines System requires fixed stations on both ends: Fixed video camera sending station Fixed, expensive base station ? Consulting MD must travel to base station. Typical Video Conferencing Technology High-quality Video }

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 4 AccessVideo Site-Independent Technologies Eliminates requirement for fixed lines Physician Access ANYTIME, ANYWHERE Utilizes: Internet Wireless Broadband Advanced SMPTE VC1 Video (Broadcast Quality) Advanced IP Video Error Correction & QoS Technologies provide highest quality video transport AccessVideo Telemedicine Systems Deployed since 2003 MD ER MD MD MD Partnering: UCSD Cal-(IT)² Clinical Trials Qualcomm Early EVDO Alpha Tester Verizon Wireless Broadband Wireless Beta Tester

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 5 AccessVideo Telemedicine System Deployments by State New York Wisconsin Montana Arizona California Nevada Florida Colorado Minnesota Texas

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 6 Key Requirements for Telemedicine Site Independence Full HIPAA Compliance (NOT just encryption) Precision Video & Audio Smooth, Full 30 fps: NO JITTER Cannot Guess or Interpolate Lost Frames Video Quality Indicators Remote Control of Camera Adheres to FDA Requirements: 510K Certification Integrated PACS Server, DICOM Viewer Telemedicine is NOT Video Conferencing

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 7 Common Misconceptions About Telemedicine Telemedicine is NOT the same as Video Conferencing Video Conferencing does not require precise video Low-Latency not as important in telemedicine Video Conferencing sacrifices video accuracy for lower latency HIPAA Compliance is NOT ONLY Video Encryption Requires Audio Trails Intruder Alerts Password Protection: both for access and to protect passwords FDA Certification MAY BE REQUIRED Required when “used to diagnose a patient” Physicians may not be near a terminal Site Independence is a REQUIREMENT The Internet was NOT DESIGNED for VIDEO Best Effort, NO PRIORITIES for Telemedicine: Packet Loss Requires special video transport technology

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 8 HIPAA RULES: Summary HIPAA Administrative Simplification Regulation Text, March 2006 45 CFR Parts 160, 162, and 164 § 164.308 Administrative safeguards (5)(ii)(c) Log-in monitoring (5)(ii)(d) Password management (Password Encryption) § 164.312 Technical safeguards (a) Access Control Access Authorization (SSL Conditional Access) Encryption & Decryption (Video & Audio) (b) Audit Controls Report logs Log-in Monitoring Intruder Alerts (c) Integrity Method to authenticate date Insure that data is correct (d) Person or Entity Authentication SSL Conditional Access (128-bit keys) Password Protection (Encryption) (e) Transmission Security Integrity (Insure data is correct: ClearQoS™) Security (Video, Audio & DICOM Encryption & Decryption)

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 9 HIPAA RULES (con’t) HIPAA Administrative Simplification Regulation Text, March 2006 § 164.308 Administrative safeguards. (a) A covered entity must, in accordance with §164.306: “(5)(ii) Implementation specifications. Implement: (C) Log-in monitoring (Addressable). Procedures for monitoring log-in attempts and reporting discrepancies.” § 164.312 Technical safeguards. A covered entity must, in accordance with §164.306: “(b) Standard: Audit controls. Implement hardware, software, and/or procedural mechanisms that record and examine activity in information systems that contain or use electronic protected health information.”

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 11 Quality & Compatibility Technology Tradeoffs Telemedicine System: AccessVideo Video quality & accuracy are highest priorities Site independence w/ robust transport is critical Windows Media Encoding (SMPTE VC1) instead of H.264 Used by broadcasters (NBC) ? high quality at low bit rate Fixed frame rate, 29.97 fps, for smooth accurate motion 30 to 40% MORE efficient than Baseline H.264 ? Lower Bit rate, Better Video Encryption Protocol ? HIPAA Security for Site Independence Error Correction ? Accuracy for Site Independence Video Conferencing System Low delay & interoperability trumps video quality & accuracy Audio quality & low bit rate more important than video H.264 allows variable frame rate for low bit rate ? jerky video SIP for broader interoperability ? no link calibration support No error correction ? broadens interoperability, reduces delay Error concealment hides loss w/ low delay ? corrupts video AccessVideo offers H.264 & SIP as compatibility option

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 12 System Layers & Interoperability Error Correction: FEC vs. ARQ vs. None Interoperability for Telemedicine (HIPAA & Diagnostic): ? Compatibility Requirement Across ALL 7 System Layers Level of Telemedicine Standards

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 13 AccessVideo Video Transport Technologies 6 Pending US Video Technology Patents Advanced Video QoS Technologies High resilience to network losses & congestion Feedback & Feed-forward Error Correction Eliminates nearly all Internet & Wireless packet loss Provides Best Possible Video Accuracy Automatic & Dynamic Calibration and Adjustments Optimizes Video Quality, Resolution, Bitrate Minimizes Delay Video Loss Indicator Broadband Wireless Access Technologies Promotes Site Independence Link Aggregation Patent-pending technology binds together multiple low-cost links Better video resolution at low cost

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 15 Summary Telemedicine Systems have Unique Requirements from Video Conference Systems Site Independence PACS & DICOM Capability HIPAA Compliance FDA Compliance AccessVideo Telemedicine Systems Designed from ground up for telemedicine Site Independence Smooth, Accurate Diagnostic-quality Video & Audio Telemedicine-specific features (Battery Backup, etc.) Full HIPAA & FDA Compliance

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 17 STRokE DOC / AccessVideo Related Publications & Clinical Trials Poster Presentation: Meyer BC, Chacon MR, Jensen M, Werner J, Haase G: Prospective Reliability of the STRokE DOC Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Abstract. Stroke 2007; 38: 496. Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Fellman R, Beer J, Henthorn T, Zivin JA, Raman R: Prospective Reliability & Validity of the “Stroke Team Remote Evaluation using a Digital Observation Camera (STRokE DOC)” Wireless/ Site Independent Telemedicine Consultation System Using the NIHSS and mNIHSS. Abstract. Stroke 2004; 35: 294. Meyer BC, Lyden PD, Rao R, Raman R: Reliability of the Interpretation of Head CT images via a Prototype Wireless Telemedicine System. Abstract. Stroke 2004; 35:261. Meyer BC, Lyden PD, Werner JD, Fellman R, Beer J, Rao R, Raman R, Zivin JA: Stroke Team Remote Evaluation using a Digital Observation Camera (STRokE DOC) Telemedicine System: Methods. Abstract. Stroke 2005; 36:494. Papers: Meyer BC, Lyden PD, Al-Khoury L, Cheng Y, Raman R, Fellman R, Rao R, Zivin JA. “Prospective Reliability of the STRokE DOC Wireless/ Site Independent Telemedicine System. Neurology. 2005;64:1058-1060. Meyer BC, Raman R, Rao R, Fellman RD, Beer J, Werner J, Zivin JA, Lyden PD: The “Stroke Team Remote Evaluation Using a Digital Observation Camera (STRokE DOC)” Telemedicine Clinical Trial Technique: “Video Clip, Drip and/ or Ship”. In Press. Int Journal Stroke. November 2007. Meyer BC, Raman R, Chacon MR, Jensen M, Werner J: Prospective Reliability of the STRokE DOC Telemedicine System When assessed by Telemedicine- Naïve Stroke Practitioners. Submitted for Publication to Stroke. October 2007. Scott PA, Starkman S, Choi JY, et al. Provider support systems for acute stroke. National Institute of Neurological Disorders and Stroke, proceedings of a national symposium on improving the chain of recovery for acute stroke in your community. Task Force Reports. NIH Publication No. 03-5348. Bethesda, MD: National Institutes of Health Department of Health and Human Services, Office of Communications and Public Liaison; 2003: 83-95. Available at: http://www.ninds.nih.gov/news_and_events/proceedings/strokeworkshop.htm

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 18 Federal Regulations Health Insurance Portability and Accountability Act of 1996 (HIPAA) Specific technical requirements Protection of data integrity and security Food and Drug Administration Regulations (FDA) Medical Devices REQUIRE 510K Certification Medical Device Definition (excerpt): "an instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article, including a component part, or accessory which is: intended for use in the diagnosis of disease or other conditions, or in the cure, mitigation, treatment, or prevention of disease, in man or other animals, or …”

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 19 Quality & Compatibility Technology Tradeoffs Video Encoding: MPEG4-VC1 (Windows Media Encoding) Used by broadcasters (NBC) MPEG4-AVC (H.264) Primarily for video conferencing & security cameras Session Protocol: ClearQoS™ Auto-adaptive Link Protocol SIP (Session Initiation Protocol) Error Handling ClearQoS™ Error Correction & QoS Features Error Concealment None AccessVideo offers H.264/SIP compatibility option

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 20 Video Encoding MPEG4-VC1 (Windows Media Encoding) Used by professional broadcasters (NBC) Used in DVDs (eg, Terminator in HD) Standard feature w/ AccessVideo MPEG4-AVC (H.264) Video conferencing & security cameras Used where bitrate is limited Automatically variable frame-rate Used where choppy video is OK Available as an option for interoperability

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 21 Session Protocols ClearQoS™ Auto-adaptive Link Protocol Automatic Link Measurement & Calibration Optimizes Session Parameters Best video resolution per Internet connection Lowest delay with optimal loss resilience Standard feature w/ AccessVideo SIP (Session Initiation Protocol) Industry Standard Available as a compatibility option

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http://www.bf-technologies.com Copyright © 2007 BF Technologies, Inc. All Rights Reserved. 22 Error Handling ClearQoS™ Patent-Pending Technologies ClearQoS ARQ: dynamic error Correction ClearQoS FEC: robust forward error correction Other ClearQoS features Internet clock synchronization for delay minimization Jitter removal Packet shaping for congestion avoidance Dynamic Out-of-Order packet resequencing Standard feature with AccessVideo Error Concealment May be inappropriate for Telemedicine Not available with AccessVideo

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Telemedicine Technology Summit. October 30, 2007. UC Davis Medical Center. http://www.bf-technologi more Telemedicine Technology Summit. October 30, 2007. UC Davis Medical Center. http://www.bf-technologies.com. Copyright © 2007 BF Technologies, Inc. All Rights ... less
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