Article: F. FELICIANI, F. M. CIMINIELLO (ITALY), Th. WEBER (GERMANY)
A Success Case of European Cooperation in Tele-Medicine
International humanitarian missions are often affected by difficult and hostile environments causing various threats to live and health not only of the operators but also of the local population. The supporting medical teams are not always able to provide all the possible expertise required. To compensate this, satellite-based medical support has proven to be an effective answer, because it enables to transfer the medical experience and expertise when and where needed, regardless the status of the terrestrial communications structures.
A growing number of operators as well as local population in remote and underserved areas are exposed to natural disasters and catastrophes, humanitarian crises and conflict situations requiring peace-keeping missions. The result is to provide international support operations, in which different partners bring specific competences and experiences.
Under such difficult and often hostile environments, the health and, therefore, the lives of people can be affected by various different threats, such as injuries, bad health conditions, epidemics, which can be worsened also by the bad environmental conditions and by the lack of suitably qualified medical support. Even if support medical teams are regularly active in the operating theatres in the field hospitals, they are not able to provide all the possible expertise that can be required, due to the shortage of specialists, also needed in the homeland.
To compensate this, satellite-based medical support have proven to be an effective answer, because it enables to transfer the medical experience and expertise when and where needed, regardless the status of the terrestrial communications structures.
A possible and sensible way to respond to the above issues has been to validate a Telemedicine solution in environments that present similarities with the natural disasters and catastrophes; medical services of the different European Armed Forces deployed abroad for peace-keeping and humanitarian missions provided an excellent opportunity for this purpose, because of the geographical isolation, the harsh operating environment and the lack of local medical specialists. This solution has been the T4MOD (Telemedicine for Medical Operations in Distant areas) Project, co-financed by ESA (European Space Agency).
T4MOD Project Description
T4MOD1 represents a good solution to implement a system able to have a cost optimization in terms of MedEvac (Medical Evacuation, i.e. the capacity to solve local medical complex situations avoiding the involvement of homeland hospitals), together with a high level of collaboration and information sharing among different Medical Communities spread in Europe together with local medical specialists; a service delivering costs reduction, decrease of medication errors, improved labour productivity and additional health care.
The Project involves:
the Industrial Consortium, led by Telespazio (Italy), formed by NDSatcom and DLR (Germany), GMV and Dialcom (Spain) and One Access (France), which has integrated the Telemedicine Platform, designed, implemented and operated the C Band Satellite Communication Network
the User Community, formed by Medical Specialists coming, respectively, from Italian, German, Spanish and French MoDs (Ministries of Defence), which are testing and validating the proposed solution.
The network, as shown in Figure 1, is currently composed by 9 sites divided into Reference Hospitals, located in Rome, Madrid, Paris, Ulm and Koblenz, and Remote Sites located in operative Military Camps in Afghanistan and in a Civil Hospital located in Chad.
The following telemedicine services will be the primary focus of the project:
- Trauma surgery
- Intensive care
- Emergency medicine (casualty care and management)
A high layer application has been developed with the purpose of managing the services within an inter-operable environment. This layer will simplify the system operations and integrate elements that could simplify the standard medical workflow while keeping the compliance with the working procedure of the end users. Finally it will help to extract, in the friendliest and automatic way, those parameters that could contribute to measuring the clinical performance gain. These important advantages will be enhanced by means of an efficient satellite architecture.
T4MOD relies on two main assets coming from Space Technologies:
- Satellite Communications
A robotised tele-echography solution initially developed by ESA to support crews onboard the International Space Station, called ARTIS2.
T4MOD aims at offering an innovative architectural solution in terms of a system and associated operational Telemedicine services; strong points will be the provision of broadband communications over very wide coverage in mesh topology, the ability to manage dynamic on-demand access using a simple and user friendly interface for the end users and the ability to handle different resources booking according to the four reference Medical Services needs.
The proposed solution presents the following characteristics:
A satellite capacity will be shared between the users and made available via a suitable scheduling or on priority basis;
A distribute deployment: hospitals have to create an ad-hoc structure in terms of logistics, inventory stocks, skilled personnel devoted to maintenance, help desk and management of satellite infrastructure distributed on single sites;
An on-demand solution, based on assignment of satellite resources according to the needs, consequent to the non-continuous nature of the T4MOD service;
An integrated algorithm also able to manage and assign medical resources and specialists;
The T4MOD Network Control Centre (TCC), main core of system and located at the Telespazio Fucino Space Centre (Central Italy).
Security: authentication and confidentiality thanks to the security framework implemented at the MoD sites.
The implementation of telemedicine services on a large scale is inherently affected by a number of barriers that the T4MOD project tries to overcome with the support of institutional entities such as MoDs, National Space Agencies and ESA.
This common effort should mitigate the hurdles of barriers, helping the project to develop an effective solution and address all the necessary issues with adequate answers.
Currently, being the technical solution implemented on a template link just validated by ESA, the Industrial Consortium is deploying the T4MOD Station along their final locations. As soon as all the Stations have been installed, the Pilot Trials Phase shall begin. The Project was foreseen to be finished in August 2014, but ESA has prolonged it with the aim to evaluate also QoE3 (Quality of Experience) features of T4MOD system with the aim to provide a turn-key commercial solution, which will give an effective and sustainable way to satisfy the needs of either military or civilian users.
The T4MOD System Description
The T4MOD Telemedicine system has a unique set of requirements distinguishing it from a normal teleconferencing system in many respects: some specific applications (as real-time consultation, ultrasound study, Assisted Surgery Service) need to be transmitted in real time, fast, reliably, and with excellent quality.
According to the needs of MoDs, the telemedicine services have been made available on top of a high layer above different Telemedicine communication platforms provided by T4MOD Consortium to collaboratively exchange, transfer, manipulate, and view a combination of text files, medical diagnostic images, audio, video in a computer network environment, sharing, in an efficient way and in a single environment, all available applications of the above mentioned Telemedicine services.
Integration has been referred to the video and medical images communication platforms as long as interoperation between application and network layer to book bandwidth, provide security, pre-empting functionalities and general network management.
Moreover, the GMV’s Antari© product has been adopted to achieve the required high grade of flexibility to connect different MoD’s Centres. This software product presents several advantages in term of flexibility, stability and interoperability and represents a state-of-the-art e-health product.
Based on that and taking into account that each Telemedicine Service is associated with a set of end user applications that translate into a set of traffic characteristics (minimum bandwidth available, jitter and packet loss constraints etc.), all of these aspects shall be taken into account by the Bandwidth Booking Module (specifically developed for T4MOD by GMV and integrated into the GMV’s Antari© product) when a telemedicine session is required.
According to this key aspect, interoperability between SkyWAN© system (provided by NDSatCom) and GMV’s Antari© software is needed to setup and guarantee that certain satellite communication parameters are provided in a multi-access environment.
Moreover, information integrity during transmission, authentication of submitted images and related data, protection from unauthorised access, confidentiality and protection of privacy are other key issues. The security policies and tools used by each MoD may be different and interconnect them could become quite impossible. In the T4MOD environment a set of common security rules and solutions has been defined at the Network and Application layers level providing a high level of data integrity protection without limiting the interoperability.
The traffic encryption is depicted in the above Figure 2, respectively for Reference, Remote and T4MOD Network Control Centre (TCC) at Fucino Space Centre. A set of VPNs4 from each field hospital to each reference hospital will be used. These VPN will use IPSec5 and AH or ESP authentication, AES-256 for encryption and Ike v2 with X509 certificates for secure re-keying, allowing all packets to pass through the VPN equipment to be encrypted and protected.
The T4MOD Satellite Component
communications system architecture has been designed in the framework of the ground segment using NDSatCom SkyWAN© product, to implement T4MOD network via geostationary satellites with transparent transponders through 2.4 m diameter antennas installed at MoD’s reference and field hospitals premises and at TCC. MF-TDMA satellite frequency channel access6 is used to provide full mesh connectivity between all network nodes and to efficiently use the slot of 2 Mbit/s full duplex transponder capacity (4 Mbit/s of total capacity) put at disposal by Telespazio for the project purposes. In the following Figures 3 and 4 the satellite footprints7 used for the communications are shown. Figure 3
represents the Uplink footprint, Figure 4 the downlink one.
The bandwidth assignment is dynamic and can be done unmanaged: when a station does not need the satellite resource anymore, the bandwidth is internally made available to other stations in the network. However the Bandwidth Management Software is able to require guaranteed bandwidth allotment.
Because different applications with varying quality of services requirements (in term of bandwidth, jitter, reliability etc.) have to be carried over this network, a suitable Quality of Service8 (QoS) implementation of the network is provided. QoS features shall be enabled on SkyWAN© system to provide, through a set of common policies coordinating all different devices, specific forwarding treatments giving the packets the appropriate delay-bound, jitter-bound, and bandwidth.
The operation and management of a SkyWAN© satellite network are independent: any station is still accessible for management access even if the IP network for user traffic is down and vice versa SkyWAN© satellite network will be still online if the SkyWAN© Network Management PC, located at TCC, is down.
The T4MOD Collaborative software
The most important aspect of the T4MOD project is the integration of the whole set of Telemedicine and consultation functions to collaboratively exchange, transfer, manipulate, record and view a combination of text files, medical diagnostic images, audio and video on a common platform enabling the user to perform different types of remote medical sessions (Assisted Ecography Service, Radiology Service, Assisted Surgery Service and Patient Monitoring Service, Training Service, Tele-consultation Service, Diagnosis Service)
In the T4MOD framework it has been possible, through a common software layer, to perform integration of medical platforms and ICT components, so enabling the provision of similar and complementary services working with existing or future systems. Remote assistance sessions may be provided at the same time via the different video communication platforms provided by T4MOD, i.e. Spontania© videoconference platform from Dialcom. The software interaction shall be anyway from Spontania© server to Spontania© client. Moreover, Covotem© software from Covalia9 has been used to transfer and analyze DICOM images (collaboration on medical images).
In order to provide a remote medical support session between a Reference and a Field Hospital, every Reference site shall be equipped with a Telemedicine Station and a Telemedicine Server, where a Field Hospital has to be equipped only with a Telemedicine Station. The Telemedicine Station is the user client station that a healthcare specialist in a Reference/Field shall use during a telemedicine session and it is provided with a Videoconference Client, a Medical Image Management software (Covotem software) and a web browser. On the other hand, each Reference Site shall contain a Telemedicine Server whose main function is to allow the execution of a videoconference requiring just one satellite hop and the storage and management of medical images. Each Telemedicine Server shall be composed of a Videoconference Server and a Medical Images Management (PACS server and storage, through Covotem Server, autonomous from the Reference Hospital PACS).
Finally, the T4MOD Control Centre (TCC) shall be the core of the network, managing the NDSatCom master station, the Antari© server, the monitoring system and giving an external access to the network for troubleshooting purposes.
Given that intra-operability is a key factor for the system, a centralized approach is more convenient compared to a master-slave schema based on having independent full functional Telemedicine servers in each hospital and configured to allow collaboration between different hospitals. The necessary resources to schedule new Telemedicine sessions shall be managed in a common repository. Specialist, Work Position, remote healthcare providers, stations, etc., shall be registered in a centralized information repository while providing each MoD with individualised management capacity. Each MoD shall only have access to manage its own resources that shall not be available for other MoDs, unless it is agreed among MoDs to do otherwise. In this respect, a domain administrator shall be able to create new resources (medical centres, work positions, professionals, stations) and relationship between centres offering full flexibility to define any collaboration schema among different MoD Centres.
The T4MOD Traffic characterisation
To allow the provision of Telemedicine Services over a bandwidth restricted satellite connection, those services have been carefully analysed and characterised. Also, this characterisation of the Telemedicine Services has direct implications in the design and operation of core components of the services layer. This analysis results in a list of bandwidth and Quality of Service requirements for each Telemedicine Service.
The design proposed contemplates a Bandwidth Booking module (BWB) that schedules the satellite resources required to carry out telemedicine sessions and issues commands to the communication SkyWAN© equipment when the session has to be initiated with a specific bandwidth and QoS, depending on the requested Telemedicine Service. The BWB is responsible for scheduling resources related to satellitecapacities taking into account the maximum number of T4MOD booked sessions allowed, the start time, the duration, the stations involved and the service type.
The quality of a videoconference is subject to parameters that are not easy to quantify. For example, the maximum tolerable delay is a parameter highly dependent on the user evaluation. In this framework there are three main parameters that can be configured that affect quality, i.e. Resolution, Frame rate (fps, or frames per second) and Bandwidth (bits per second). The user requirements specify values for the resolution and the frame rate. With those parameter fixed, the bandwidth determines the quality. For example, a video at 640x480 pixels and 25 fps shall be seen the better the greater the bandwidth. The quality thus is a subjective parameter and should be stated by a medical expert.
The following Table 1 shows a matrix between different services and optimised satellite bandwidth.
| Resources || Nominal|| Required Bandwidth|
| High Quality Video (Spontania, 640x480, 25fps)|| 512 kbps|| 721kbps|
| High Quality Video (Spontania, 640x480, 25fps) with audio|| 512 kbps|| 780 kbps|
| Normal Quality Video (Spontania, 320x480, 25fps)|| 128 kbps|| 180 kbps|
| Normal Quality Video (Spontania, 320x480, 25fps) with audio|| 128 kbps|| 241 kbps|
| Audio (Spontania)|| 41 kbps || 62 kbps|
| Shared application (Spontania)|| 256 kbps|| 315 kbps|
| Covotem for interactive collaboration|| 15kbps|| 18 kbps|
| Remote ecographic Robotic control|| 10 kbps|| 12 kbps|
| Basic DICOM Image Transmission (Covotem)|| 100 kbps || 123 kbps|
| Urgent DICOM Image Transmission (Covotem)|| 500 kbps || 615 kbps|
Table 1: Required Bandwidth for Tele-Medicine Services
Source: MCIF 1/15