Video conferencing / telehealth integrations

I am trying to solve my current mystery of integrating a reliable and low cost telehealth with openEMR.

I have created a video app in Vonage’s cloud sandbox. It works great in my charting system. The cost ($0.04/connection/min) is hard to justify for small scale (50 providers at 25 hours/week.). Vonage is clearly looking for large physician hospital networks (1000 providers) before giving a price break ($0.002/connection/minute last time I checked).

Windows allow openTok client to client connection without a server between both clients.
OpenTok has limitations when using iOS. You can’t use Opentok on a client to client basis reliably. The patient has to download a client app to work reliably on iOS machines.

We stood up Jitsi and it works well enough but requires some customization. Their download version has no privacy. Perhaps there is an open source version for EMRs that I have not found yet.

What are people in the openEMR community using? I would prefer to adopt something that others are using and contribute to that evolving solution rather than invent my own app openEMR.

I would greatly appreciate any suggestions and will gladly contribute to supporting a solution that works well with openEMR. I don’t want to record sessions.

I am using v600

Thanks, Mike

hi @AMHA-OR, it is on the list of important projects for GSOC 2021 students hopefully someone will pick it up and an experienced dev/mentor will make this dream come true.

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I am going to through this out there because everybody likes free.

As must of you know that jitsi was purchased by 8x8. They have kept the platform free to use.
Anyone can go to the page above and create a room to video chat in.

I have found that you don’t have to go to the site to generate a room. Anyone can create a room by simple adding to the URL.

This is all it takes to create a meeting room. It just has to be unique. All the parties that have this link can meet up in the video chat.

In OEMR when an appointment is generated, this kind of link can be created from the patients UUID and phone number. The provider and patient has the room ID and can meet. No cost for use of the video chat.

Just my itty bitty idea.
Who wants to code this up?

per hipaa wouldn’t it have to be on your own server or have some baa agreement?

To me that would be like saying that OpenEMR would have to be on your own server. A BAA is available from 8x8. Not a HIPAA guru, I will ask @APerez who is and see what he says.

Per a source and GMU, HIPAA rules at the moment are relaxed because of the Covid situation.

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right, but if you’re in the states and if it’s not, think you have to have a baa

I am as we speak looking to put some necessary hooks into openemr to support video chat if I can find a graceful way to do this. Appointments/Users/Encounters/portal.

The idea way to do this would be to have a generic interface/abstract class for all openemr telemedicine routing in core. These classes would then be extended by a particular vendor module for their specific api using our modules interface. This is similar to how I do fax/sms where a sendSMS() is the same for RC or Twilio depending on who is current setup vendor.

I always liked the idea of Jitsi as a standalone companion server with openemr as an enterprise. This way many concerns such as security, privacy and cost are within openemrs purview.

Just spitballing

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Here is some more spit.
The use of site is ok because the video is not being recorded. Since there is no record of the conversation. It is HIPAA ok. 8x8 charges a fee to record the conversations. The site is as secure as any HTTPS site can be and the meeting room id is only known to the participants that can be anything.

I like @sjpadgett’s idea of the abstract class to do telehealth. It would be nice to look over his shoulder while the class is being constructed. But I guess I’ll have to be like everyone else and wait for the release.


All I know is that this is something i’ve wanted in code for a long time.
It needs to get done soon and I wish I had time to at least get the core structure in place for folks to build against.

I’m trying to work it into a project i’m currently working or at least get some of the building blocks in place in hopes others will pick it up.

Most times though, folks take it, customize and then not contrib back.

This may not be helpful to the task, but my understanding (or confusion) may have some small value.

A video transmission has PII and PHI if there is a healthcare service provided. A BAA is only required if you are not the server host.

You are good to go if there is no recording, the perimeter is protected and tested periodically, and the provider has a HIPAA agreement with the patient and informed consent.

I think Sherwin is right. “The site is as secure as any HTTPS site can be and the meeting room id is only known to the participants.”

The problem I found in the Jitsi version that is free to the public was that you can’t reuse the link that has the session ID in it. Anyone with that link can join, invited or not.

Appointments need to be prompt or you need a waiting waiting room to let people in and keep other out if the appointment go long.

As with any of the flock of vendors now doing video/chat, one just doesn’t know what the future will hold. The fewer service make/break points the better. Relying on external services for video call/meetings or streaming in general should be avoided imo. The more options we provide the user, the better.

In this sense and while still developing our telemedicine api to provide a generic interface to the various video streaming services, our default go to would be an open source streaming server such as Jitsi.

If done right, a Jitsi standalone server is very doable with not having to worry about future changes in various fees associated with say, Zoom or Jitsi accounts.

The stand alone would be an option where the free accounts could be used for smaller installs as the Jitsi apis would be used for both.

Now we could take the easy road and just lock ourselves into one service and hard code it however, for an application with the diverse user base we have, a more open solution would be the best route.

Reusing the link is a no, no. In my opinion, it should be one and done to have the privacy of no one knowing where the meeting is taking place, accept the notified participants. That is my two cents.

I apologize. My brain goes to my idea of an affordable and reliable standalone that connects to the internet.

Admittedly I have already made a run at an in-house telehealth and went the wrong way for group of 100 providers. I installed Jitsi on my server. I thought “why don’t we adapt this?” I thought open source and community made sense.

But as I live and learn, my engineers did not want to use openTok or Jitsi. They wanted the ease of using Vonage which made telehealth more expensive than the entire EHR and Clearinghouse portal/api. $0.004/minute/month means per connection. A small group of 100 provider and staff will use about 120,000 minutes/month for at least 2 connections or $0.08/minute/month.

These are what I wish I had investigated more closely…

What is a small install?

Unsure, maybe a small practice of a couple physicians and RN’s. I haven’t looked at Jitsi in over a year so i’m not up to date on their offerings.

So i’m unclear. Did the Jitsi not work out or did your engineers decide Vonage would be more appropriate? My understanding is that the server used by Jitsi free accounts is their open source version with maybe some addons.

I’d be nice if someone would do a little more research on the Jitsi server current offering and perhaps find a couple cites of use cases. I just don’t have time currently but my cursory look into last year proved promising.

Though this seems the more daunting approach, too me, it’s more sound from an open source POV.

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The engineers decided Vonage would be quicker. Vonage had a very inviting technical support and sandbox to get started.

I found several case uses for Vonage. We were a case use. It was easy to connect, expensive to use at moderate to large scale, and built to support large trainings, convention and events. They provide sessions for telehealth sellers that charge more for telehealth than EHRs that offer telehealth more like like Jitsi (i.e. they download an app on the client side).

I just found this when I searched “what EMR uses Jitsi?”

I know less than nothing about this.

Okay thanks for the feedback.
I’m looking into this further as some of it coincides with a project i’m working now. Perhaps I can get a good starting point in codebase we can expand on…

I need to figure out how to get this into a module.

I am glad to see the advancement. Jitsi was the solution I should have pursued. The cost for a cloud meeting room make sense for conference and classroom learning. Client to client has to be cheaper because it eliminates the middle person. Vonage charges $0.08 per minute for session between 2 people.

Sherwin Gaddisjuggernautsei was right re HIPAA and telemedicine providers.
My expertise is reading CMS’s documentation on this.
TL;DR version-
You do not need a BAA with your phone carrier, the Post Office or similar services.

You can use Skype, Webex, Zoom, Whereby, Google Duo, etc.

If the video service STORES PHI, then you need a BAA, but if they only transmit it, you do not.
This was INFINITELY complicated last spring when the admin of CMS made an uninformed statement about video providers being temporarily waived that doesn’t follow his own org’s rules. Here’s the rules re STORED PHI and in the first link, mere ‘conduits’.