1 From Teletraining to Telehomecare – Design of Mobile and Multi-Stream Telehealth Systems Pierre Lepage, Dominic Letourneau,´ Mathieu Hamel, Simon Briere,` Michel Tousignant and Franc¸ois Michaud

Abstract—Telehealth success relies on the ability of information and emergency room visits [17]. AT&T, Qualcomm, Sprint and communication technologies (ICT) to maximize the quality of and Verizon [21], along with Telus Health [18], are actively care provided remotely, i.e., providing diagnostics and treatments exploring opportunities in this area. The compound annual of the same quality compared to face-to-face or conventional means, and maximize the benefits for the patients, the clinicians growth rate of this market is evaluated at 26.9% between 2011 and the system of care. Because of the specific nature of and 2017 [25]. health-related processes, successful development of telehealth To conduct more lively and interactive consultations, virtual technologies must be driven by clinical and application needs visits involve the use of video and audio for live and remote that are not addressed by currently available ICT. In this paper, consultations between clinicians and with patients [6], [10]. we present two telehealth systems developed in two different contexts, one for teletraining of surgical procedures, and one for This modality tries to emulate face-to-face assessments usually telerehabilitation, and from which common requirements can done by having either the patient go to the clinic or the be identified for the development of a more generic platform. clinician going to see the patient at home. Representing the This paper also situates where these systems are in relation to telemedicine hype cycle into five phases (i. technology trigger; their stage of development and their assessment as telehealth ii. peak of inflated expectations; iii. trough of disillusionment; technologies. iv. slope of enlightenment; v. plateau of productivity), real- Index Terms—Teletraining, Telehomecare. time video visits (which we refer in this paper as tele- treatment) entered phase iii as of June 2010 [6], and is starting I.INTRODUCTION to show value. Many software video or web conferencing ELEHEALTH is defined as the use of information and platforms are now available on the market, using computers T communication technologies (ICT) to extend health care and mobile computing devices. As real-time, high-bandwidth service delivery across distance [6]. Recent advances in tech- videoconferencing becomes pervasive in consumer technology nology (e.g., digital imaging, mobile communications, wireless and behaviour, it is expected that telehealth growth will vital signs instrumentation) are enabling accelerated develop- accelerate and become a well-established channel for health ment of the field [6]. Telehealth revenues increased by 18% service delivery and education [6]. from 2011 to 2012, and are expected to grow rapidly and To implement a tele-consultation system, the common strat- reach 1.8 million patients worldwide by 2017 [19]. Emerging egy is to use a general-purpose telecommunication platform, evidence demonstrates the potential of telehealth systems to either hardware (e.g., Polycom/Tandberg from Cisco) or soft- reduce unnecessary hospital admission, to decrease mortality ware (e.g., Vidyo), designed for general videoconferencing. rate [11], [14], to lower costs of care per patient [3], to increase But videoconferencing is based on interaction in close prox- satisfaction among users [7], and to deliver educational content imity with a workstation, laptop or a mobile device (e.g., smart to support patient self-care [13]. phones, iPad, RP Xpress from InTouch Health), providing one Home telehealth, or telehomecare, uses ICT to provide video stream and one audio stream. A mobile device makes it health care services into a patients home [6]. Remote vital possible to provide interactions from different locations and of signs monitoring is a common example and one promising multiple perspectives in a home. However, clinicians have to market, with the use of personal health devices (e.g., pulse indicate to the patients what they want to see, and patients need oximeters, blood pressure, scales) to monitor the vital signs at least one hand to manipulate the mobile device. PTZ cam- of patients, to follow up on their recovery or to identify eras on hardware videoconferencing codecs allow clinicians to potential complications [6], [21]. The Beacon system from control what is being observed, but only from a fixed location. Health Interlink is one example of a system that does vital sign Implementing a tele-consultation system on top of proprietary monitoring using Android tables, smartphones or laptops. A hardware/software codecs involves working with the providers recent study conducted in Montreal´ reports significant benefits to include additional features to the codecs (such as the in reduction of hospitalizations, length of average hospital stay addition of a data streams for vital signs transmission), or finding a workaround solution (e.g., the A-Vu Media system, P. Lepage, D. Letourneau´ and F. Michaud are with the Depart- validated at Winona Health in Minnesota, converts vital sign ment of Electrical Engineering and Computer Engineering, Interdisci- plinary Institute for Technological Innovation (3IT), Universite´ de Sher- data as an image combined to the video stream). Consequently, brooke, Quebec´ Canada e-mail: {Pierre.Lepage, Dominic.Letourneau, Fran- any adaptation of the telecommunication platform to spe- cois.Michaud}@USherbrooke.ca. cific clinical needs (e.g., having multiple video streams from M. Hamel, S. Briere` and M. Tousignant are with the Research Centre on Aging, Universite´ de Sherbrooke, Quebec´ Canada e-mail: {Mathieu.Hamel2, the same telecommunication station, sending vital sign data Simon.Briere, Michel.Tousignant}@USherbrooke.ca. through a specific data stream, adapt audio communication to 2 specific contexts) may be difficult or impossible to accomplish depending on the priorities set by the providers. Therefore, over the last decade, we have developed and validated original telehealth systems involving video, au- dio, specialized data transmissions and graphical interfaces. The approach taken involves real trials with clinicians and patients in the field, testing commercial and custom-made tele-consultation platforms, identifying and developing the technologies required to make them a reality, not simply technologically but as a practical modality in health practices. It is based on a holistic, bottom-up, iterative and incremental approach starting from small and simple systems addressing Fig. 1. MVu teletraining system. specific needs and current practices, in situ, and designed to minimize changes to the clinical practices, rather than to response to changes in positioning of the system. Otherwise, if expect that clinicians and patients will adapt to the technology. the scene changes faster than the time required to position the In this paper, we present the characteristics of two telehealth cameras, the images provided by the system while it moves systems, one for teletraining of surgical procedures and one are not necessarily directed toward the region of interest. Real- for tele-treatment in home settings, outlining similar needs time communication (audio, video) exists between the on- and specifications. We also outlines the upcoming steps in the site emergency physician (through a wireless headset) and the development plan of the systems. remote expert (through the video streams of the two cameras II.TELETRAININGOF SURGICAL PROCEDURES synchronized and displayed on a split widescreen display). Assessment results are presented in [15]. Real-time teleconsultation with an emergency specialist Developed from 2004 to 2010, the technology was then offers significant benefits to patients in regions where no transferred to Vigilent Telesystems inc., resulting in com- specialists are available and patients are frequently transferred mercial product called MVu and available since Fall 2012. to specialized centres [4], [12]. Significant reduction in med- Figure 1 illustrates the system. For this technology, Medical ical assistance costs and in response time of professionals Simulation Centers seem to be the most promising avenue for also resulted from teleconsultation in emergency medicine [4]. early adopters. We also developed algorithms to help decrease The practice of tele-emergency through videoconferencing is the operators cognitive load to direct its attention on the remote currently available for minor injuries [4]. Tachakra et al. [27] service to provide rather than on teleoperating the system. showed concordance above 95% in comparing telemedicine The user interface aims at improving functionalities of the with face-to-face consultations for trauma management of initial interface by adding the following features: control of minor injuries, both in terms of diagnostic precision and the point of view and region of interest directly on the video quality of medical assistance. In the case of major injuries, pre- streams; automatic detection and repositioning of the point liminary studies indicate significant benefits of telemedicine of view when visual obstruction is detected, and automatic in both patient life support surveillance [26] [9] and patient tracking of specified areas while repositioning the point of management [31]. Preliminary results reported by Rogers et al. view after obstruction has been detected. Results demonstrate [23] [11] demonstrate that using two cameras was best suited that cognitive load can be minimized by controlling the for such application. cameras directly from the video feeds and by automating some Therefore, the objective of our telehealth system is to of its positioning functionalities [28]. provide assistance to local physician for training and while performing surgery procedures using proper kinesiologic ges- tual on unstable polytraumatized patients [15]. The system III.TELETREATMENT IN HOME SETTINGS we developed consists of two independently controllable PTZ For such application, we started by conducting a first set cameras, ceiling-mounted above a trauma stretcher. Each of experiments by developing a tele-consultation platform that camera is installed at the end of a two degrees-of-freedom integrates a commercially available videoconferencing system SCARA-type robot manipulator. Either one of the cameras (H323-Tandberg 550 MXP) with a touchscreen computer and is used to provide a global view while the other is focusing external biosensors [29], [30]. The platform was developed on the surgical intervention. Compared to a system which to take into consideration the needs of different rehabilitation only extend a rotating arm [9], our design provides an infinite populations: orthopedics (Post Knee Arthroplasty), pulmonary number of viewpoints, making it possible to better visualize (Chronic Obstructive Pulmonary Disease) and neurologic (post interventions on various anatomical regions on the patient stroke condition speech therapy, post stroke balance and and to compensate for potential visual obstructions caused mobility improvement). The platform is driven by custom by members of the medical team performing their duties software called TERA3 that provides an overview of all around the stretcher. Because standard pan-tilt-zoom (PTZ) the available patients, and eases the connection process by videoconference cameras stack and execute the commands allowing the clinician to establish a connection with a simple they received in a first-in first-out manner, a custom pan-tilt- double-click. The data collected during a session include zoom (PTZ) camera has been developed for fast and precise the audio/video streams of the clinician and patient site, 3

settings. According to DeChant et al. [8], this corresponds to Stage I (Technical Efficacy) and Stage II (Specific System Objectives). The next two stages would be Stage III (System Analysis – Assess global impact on access, quality and cost) and Stage IV (External Validity). However, to accomplish these stages, a complex interplay of barriers needs to be overcome to make that possible, barriers which may explain why telehealth has not yet been widely adopted in any country [22]: • Acceptability: Poor ICT skills [5], [14]; Confidentiality concerns [2], [5], [11], [14]; Lack of awareness of the available technology and its potential benefits [1], [11], [14], [24]. • Technology issues: Usability problems [1]; Poor system stability and reliability [5], [14]; Limited access to broad- band connections [11], [14]; Lack of interoperability between various telehealth solutions [1], [2], [13], [14]. • Organizational obstacles in the healthcare sector: Frag- mentation within the healthcare sector [14], [20]; Lack Fig. 2. Mobile wireless PTZ camera. of willingness to innovate [5], [11], [14]; Absence of service champions for promoting tele-healthcare services [5], [11]. data from external sensors (oximeter), network performances • Absence of clear guidelines defining roles and responsi- (bandwidth, jitter, packet loss), and results from a satisfaction bilities of stakeholders [5], [11], [14], [16]; Lack of tech- survey (for the clinician only), all recorded in a local database. nical quality standards [5], [11]; Unclear data protection The platform was deployed through standard Internet Service legislation. Provider (ISP) (cable or asymmetric digital subscriber line), • Unclear evidence for return on investment [1], [11], [14]; and the need to be able to use the cellular network has been Absence of reimbursement arrangements [1], [5], [20], identified, to reduce installation cost and time. [24]. From these trials, some of the key issues identified are: For both systems, we are currently working on solutions 1) a tele-consultation system must be easy to use, for both to overcome these barriers, which necessarily take time and the patients and the clinicians; 2) multiple video streams concerted effort. And even though both systems have distinct must be possible from the same telecommunication station; requirements that must be taken into consideration when 3) transmission of audio and video streams must be possible designing new ICT for telehealth applications, there share from many locations in the home. General-purpose com- common requirements, such as the flexibility of transmitting mercial telecommunication platforms are designed to have simultaneously multiple video, audio and data streams, and interlocutors remain close to fixed workstations, with one or share also common challenges. This is why we are currently two video stream per workstation, or use portable devices that developing a common framework for both, because the tech- have to be handheld with no optical zooming capabilities and nologies developed throughout these initiatives would greatly no specific audio filtering to improve quality in reverberant contribute to the design of an advanced and unique tele- environments. In home settings where a clinician may want consultation system, if they can be integrated efficiently. A first to see the patient in different settings (kitchen, bathroom, prototype is under development, and we are conducting trials bedroom, staircases), through a general view of the scene with different components of the system, both with the private and/or a more specific view of a specific body part, the use of health telecommunication network and with general telecom- conventional telecommunication platforms becomes problem- munication service providers, to validate and influences the atic, which consequently affects acceptability and usability. design choices. We therefore decided to develop a mobile wireless PTZ camera, i.e., a battery-powered, wireless PTZ camera for ACKNOWLEDGMENT mobile visual sensing in home settings. Figure 2 presents the device. A docking station allows the camera to be easily placed This work is supported by the Research Chair in Tereha- on top of a workstation or taken to another area. Other cameras bilitation of the Universite´ de Sherbrooke, and the Fonds de (fixed or mobile) can also be connected to the workstation. recherche Quebec´ Nature et Technologies (FRQNT) Strategic Network on Engineering Interactive Technologies for Rehabil- itation (INTER). IV. DEVELOPMENT PLAN,CONCLUSIONAND FUTURE WORK REFERENCES Both of these telehealth technologies are at a stage where [1] M. Alwan and J. Nobel, “State of technology in aging services according they have been tested in controlled conditions and have to field experts and thought leaders,” Washington: American Association demonstrated to be robust enough to be tested in real life of Homes and Services for the Aging (AAHSA), Tech. Rep., 2008. 4

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