Making a Selection: Considering Organizational Needs When Selecting a Desktop Videoconferencing System

Deciding which desktop videoconferencing (VTC) platform to use in an organization can be challenging. The increase in the availability of PC-based VTC applications in the personal lives of providers, patients, and support staff has resulted in many healthcare professionals wanting to know how and when their organization plans to implement a desktop VTC system.

While the market itself is not overly large, the few players in the field have created products that meet different needs and provide different features.  Thinking through what needs the software is meeting will help decide which product to choose.  This document aims to help walk through why an organization would want to use either a standards-based or consumer-grade desktop VTC solution, including a look at different implementation options and what they will mean.

A basic understanding of desktop videoconferencing is presumed in much of this document.  Background information and an overview of the technology is provided elsewhere in this toolkit, specifically in the Technology Overview, where we define the terms and the basic infrastructure needed to run a desktop VTC system.

Assessing Your Needs

The first step in deciding which desktop VTC product your organization will use is to determine what the users and organization expect to do with the technology.   By establishing these user requirements it is possible to make a more informed decision as to which products will meet your organization’s needs.

An increasing number of organizations are looking at the possibility of using a combination of standards-based and consumer-oriented technologies to meet different organizational needs; the outcome of the needs assessment process may result in a similar decision for your organization.  Aside from the topics discussed later in this document, the TTAC has created a decision-assisting tool that will help walk through specific organizational needs to select which products may be the best fit.

Communicating With Existing Devices

One of the largest drivers when deciding which product to use is the need to communicate with existing videoconferencing infrastructure, such as room-based codecs and portable VTC carts.  Standards-based systems support communication with these devices, though there may be additional infrastructure requirements to support interoperability.  Consumer-grade applications are generally limited to communicating with other instances of the manufacturer’s software, and do not support calls to existing VTC equipment.

Multipoint Conferencing

Many organizations would like to facilitate VTC sessions between multiple people in the same call.  Standards-based applications support these multipoint conferences, though some manufacturers require that additional devices are purchased to support this functionality.  Some of these systems also provide the ability to control how multiple active participants are displayed, ranging from “Hollywood Squares”-style boxes for all attendees to only showing the active speaker.

Some consumer-grade applications do provide the ability to engage in calls with multiple people, although they tend to limit the number of participants to between 6 and 10 people in one call.  Support for multipoint calls is typically a cost-added feature, meaning that free versions of consumer-grade applications are limited to 2-way conferences.

High Definition

A lot of interest exists in the possibility of performing high-definition (HD) video conferencing.  Hardware codecs have supported HD for some time now, and many of the standards-based software applications now claim the ability to “do HD.”  Consumer-grade products tend to steer clear of claims to provide HD capabilities, although they do use terms such as “high quality” or “high resolution” video.

It should be noted that, as of this writing, most implementations of desktop videoconferencing will struggle with providing true HD, even if the software supports it.  There are limitations to how fast data from web cameras can be transferred via USB 2.0, which results in highly-compressed images, and processors face enormous strain to decompress the video being sent and received.  The ongoing increase in computer performance and the adoption of the USB 3.0 standard will gradually make these concerns less relevant.

Far-End Camera Controls

For organizations looking to integrate desktop video conferencing with existing hardware-based endpoints, far-end camera control is a common request.  Far-end controls allow users to control the pan, tilt, and zoom features of hardware-based systems while logged into the desktop client.  Standards-based applications support this functionality for the hardware-based endpoints, but cannot provide any controls for web cameras due to the lack of a hardware interface.  Consumer-grade applications do not provide a method for enabling far-end camera control.

Additional Infrastructure Requirements

An enormous differentiating factor between standards-based and consumer-grade products is the need for additional infrastructure.  Standards-based systems often require additional devices to connect to entities outside of organizational firewalls, communicate with existing hardware-based systems, or engage in multipoint conference calls.

Consumer-grade products, on the other hand, do not provide the option of hosting key infrastructure devices or communicating with existing videoconferencing technologies, which means that there is no need to purchase additional equipment.  If your organization needs to control all elements of the VTC infrastructure, a consumer-grade system may not be appropriate.

Encrypting Communications

The desire to keep the contents of communications inaccessible to unauthorized observation drives the need for encryption.  Standards-based systems utilize encryption for their communication, though it may be turned off at an organizational level.  Some consumer-grade systems do provide a level of encryption for their communications, but some of these protocols have been questioned in the past due to a lack of transparency into how manufacturers implement them.

Using the Desktop Client Outside of Organizational Networks

Many organizations are interested in the possibility of using desktop VTC software from home or a remote office.  On the other side of the spectrum are other organizations that may want a solution that operates within their own closed network, without providing access to people outside of their network.

If your organization intends for internal-only use, standards-based systems provide the benefit of not requiring any external equipment for authentication or call routing.  Consumer-grade applications will, by design, require access the internet.  An organization cannot use consumer-grade software while disallowing its access to outside entities.

Opening the VTC network to people physically located outside of your network can be done in several ways, depending on the application type.  Standards-based systems can support Virtual Private Network (VPN) connections, which allow a user with network credentials to log in and access network resources.  This has limitations, as users from external networks who do not have credentials for your organization’s network will not be able to establish a VPN connection.  Additionally, connectivity issues may result in a degraded videoconferencing session due to the extra steps required to bring a user into the network from an outside location.

If an organization with a standards-based system wants users to access the videoconferencing system from outside the firewall, yet does not want to require users to open a VPN connection, a proxy device is required.  These devices sit on the “edge” of an organization’s connection to the internet and allow external users to enter the network through specific ports and with specific content.  This allows a user to launch their desktop VTC client from a remote location and interact with other VTC clients as if they were directly a part of the network.

Proxies can also allow external parties to participate in a VTC session, as they can use a properly-configured VTC client from outside the network, all without requiring local network credentials to use the system.  Some systems also require another type of proxy device to communicate with outside networks, such as another organization’s own VTC system.

For consumer-grade applications, use of the product outside of an organization’s network is typically as easy as placing a call.  Various issues may arise in establishing a call with computers with a “NAT’ed” address or behind an organization firewall, but consumer-grade applications tend to utilize protocols that bypass these issues.  Changes to the firewall may be needed for optimum performance, but no additional hardware is required to facilitate the calls from outside of a network.

Managing User Accounts

The ability to free users from room- and cart-based videoconferencing hardware is a strong reason to implement a desktop-based system.  With the newfound freedom, however, there is a need to manage who can access the system.  Whereas before, when users were required to use a fixed resource in a relatively fixed location, there is now the possibility that users can be signing in from their rural home, their work desk, or a conference room.

Standards-based systems provide the benefit of tying into existing Active Directory (LDAP) infrastructure, allowing user accounts to be managed with tools that are already familiar to most systems administrators.  A great deal of control is afforded with this design.

An extra set of account-management tasks arise with standards-based systems if patients, business partners, and other external users are expected to be accessing the system.  As an organization, the decision will have to be made as to how these accounts are managed, how they are activated and closed, and how they will be deployed.

Consumer-grade systems typically do not provide LDAP integration, meaning that user accounts are not as readily managed by existing infrastructure.  Some products, such as Skype, do allow for the centralized management of user accounts if using the business version of their software.  Other platforms may not provide any management interface, meaning that accounts must be created and managed by individual users.

Regardless of the account-management interface provided by consumer-grade systems, a process will need to be put in place that dictates how and when accounts are created, used, and terminated.  A benefit exists in this freedom from controlling accounts, in that patients and external partners will not need access to internal systems to create their own accounts.

Collaboration Features

Some users will not want a desktop solution that only provides audio-video communications; collaborative functions such as instant messaging, content sharing, file transfers, and “whiteboard” applications may also be desired.  Knowing which of these features your users want, and which your organization wants, will help to decide which platform to use.  Most modern desktop VTC applications support instant messaging.  Likewise, most products support some capacity to share content within a video session, meaning that an electronic document or computer screen can be viewed by both parties.

Consumer-grade applications often have additional features that are not available with their standards-based counterparts.  Some of these applications have the ability to send a file from one user to another, which opens up the ability to send educational materials, treatment plans, study results, and other pertinent information.  This may pose a risk, however, in that malicious content may be transferred between computers.

“Whiteboarding” functionality, which is the ability to dynamically draw and annotate an electronic on-screen canvas, is another feature that some consumer-grade applications support.  While not relevant to all users, it can provide the ability to graphically illustrate key concepts, diagram ideas, and share information in an interactive way.

Cost Concerns

Providing licenses for standards-based systems can become expensive in comparison to the fees associated with consumer-grade systems.  With standards-based systems, as the need for more users grows, so too does the need for more licenses and, at some point, more infrastructure or updated hardware to support all of the communication occurring through the core VTC components. Consumer-grade technology, which uses internet-based and peer-to-peer communications, does not have the same hardware demands, and licenses may only be needed for professional or business versions of the software.

Organizational Risk Aversion and Mitigation

Perhaps the most important questions that all organizations must ask when implementing a desktop VTC product increases patient safety and privacy risks.  Four key risk elements include:
whether or not the product itself is an inherent risk (unsecure communications, patient information too easily disseminated, etc)
whether the intended uses of the product exposes the organization to any risk
how any unintended uses of the product might expose an organization to risk
mitigation strategies that the organization will have in place to handle perceived risks

Standards-based systems are generally viewed as being less of a risk for an organization, as they provide encryption, can be managed by organizational IT staff, and use established and open protocols for communication.  While the incorrect use of any technology can expose an organization to risk, standards-based systems may be more appropriate for risk-averse organizations.

A lot of questions surround consumer-grade applications, particularly related to how much risk they pose to an organization.  More specifically, organizations often want to know, “does this meet HIPAA requirements?” in relation to encryption and access controls.  Many of these questions have not been answered concretely, which may cause some organizations to shy away from the issue until it has been more clearly resolved.  Some organizations, such as the UCSF and Mayo Clinic, are leading the way in demonstrating that this technology can be used in a healthcare setting.

Summary

Selecting a desktop videoconferencing system is not a simple decision.  The wide array of features need to be considered to know which tool will provide the best solution for your organization.  Generally speaking, organizations find themselves most comfortable using standards-based systems, yet the different features and strengths of consumer-grade applications provide a compelling argument that may warrant use of the products in certain areas to meet specific needs.

Standards-based systems provide the interoperability with existing infrastructure that many organizations need, as well as a level of encryption, functionality, and manageability that is in high demand by healthcare organizations.  With that in mind, though, the products are more expensive than their consumer-grade counterparts, and may be inaccessible to outside users without an additional level of management and costs on both the hardware and procedural side of organizational operations.  Standards-based solutions are the better option for organizations with known end-points as part of a closed WAN, where the desire is homogenicity, high functionality and maximum end-point control.

Consumer-grade applications continue to be viewed skeptically by healthcare organizations due to concerns about encryption and compliance with standards, but an increase in functionality and the gradual adoption of the products in the business and consumer worlds has placed these products in the spotlight for healthcare delivery.  While they may not be appropriate for especially risk-averse organizations, and while they may not meet all of an organization’s needs, these applications may have uses within certain facilities if appropriate policies and procedures are put in place to support their use.  Their low cost and relative ubiquity on a national scale have put them on the radar for many healthcare organizations.  They have a distinct application when low cost access is needed for small distributed locations (or changing unpredictable locations) outside of a standard network.