An Open Source VoIP Solution for Healthcare Capstone Research Project Report April 25, 2015 Partha Pratim Roy Subhamoy Pati Suriaa Mathivanan Debasmita Hazra Interdisciplinary Telecom Program University of Colorado Boulder Abstract — This paper explores the feasibility of an open source Voice over IP (VoIP) solution in rural healthcare. The impact of technology on healthcare organizations has expanded manifold as it helps them to streamline their various processes. With the emergence of VoIP, many healthcare organizations have moved from the legacy Private Branch Exchange (PBX) systems, to VoIP systems. This shift has observed significant reduction in the system down time, and an improvement in the response time while tackling any emergency situation. However, these technologies have not yet been adopted to the full extent in rural areas as well as in many developing countries due to the high cost of deployment and maintenance of VoIP systems. This research suggests that open-source systems can be used to build a low-cost but effective VoIP solution. This paper demonstrates an implementation using Asterisk open source framework over wired and wireless network infrastructure. The wireless solution is deployed using open source DD-WRT firmware. The cost benefits of the solution is compared to both traditional PBX systems as well proprietary solutions. The results can lead to potential increased adoption of VoIP in economically constrained rural hospitals and maximize efficiency in delivery of healthcare. Keywords - VoIP, PBX, Asterisk, Open source, Wireless I. INTRODUCTION i. STATEMENT OF THE PROBLEM The impact of technology on healthcare organizations has expanded manifold as it helps them to streamline their various processes. With the emergence of Voice over IP (VoIP), many healthcare organizations have moved from the legacy Private Branch Exchange (PBX) systems, to VoIP systems. This shift has observed significant reduction in the system down time, and an improvement in the response time while tackling any emergency situation. However, these technologies have not yet been embraced completely in rural areas as well as in many developing countries due to the exorbitant cost of deployment and maintenance of VoIP systems. This research suggests that open-source systems can be used to build a lowcost but effective VoIP solution. Jeffrey D. Dimaio Adjunct Faculty Interdisciplinary Telecom Program University of Colorado Boulder ii. RESEARCH QUESTION Can a customized Open source VoIP solution be provided for the rural healthcare community that is not only cost effective, but also meets the requirements of the healthcare organization? The following sub-problems have been identified to answer this question: A. Which VoIP features are most important for a rural healthcare organization? The healthcare focused VoIP solutions available in the market today provide a wide array of features, but it comes with a huge price tag. Considering a rural hospital with low capital to invest on VoIP solutions, it is important to identify which features are absolutely vital to that organization. Collecting these requirements helps to understand what type of Open Source products can be used to cater their needs. B. Can customized solution meet the requirements of rural healthcare industry? Healthcare industry has some specific requirements like integration with other technologies like Electronic Health Record (EHR), Nurse Call Communication System and Patient Monitoring Systems. Further the VoIP solution needs to provide additional benefits in form of better collaboration among medical professionals and make critical staff more accessible. Unless the benefits provided by the Open Source VoIP solution meet the basic requirements and provide greater efficiency, there will be no motive to adopt it over legacy PBX’s. C. Can our customized solution be cost effective? The proposed solution needs to tackle cost concerns on two fronts. Firstly we would need to analyze what the cost incentives are to adopt an open source solution compared to the existing proprietary options, and secondly, what the cost savings are from transitioning to a VoIP solution over traditional PBX. 1 D. Is the proposed Open Source solution easy to deploy? Since the target audience for this Open Source VoIP solution is rural healthcare facilities, it is imperative to make the solution very easy to deploy, with minimum operational overhead. However since this project will involve open source coding and integration modules, it may appear complex to the end-user. II. LITERATURE REVIEW The problem that persists today is that most VoIP based proprietary healthcare solutions provided by Cisco, ShoreTel, and Ascom comprise of closed and expensive components. Contrary to this, the relatively inexpensive open source solutions have not yet fully demonstrated their role in resolving healthcare issues like nurse calls. Initially, legacy telecom vendors started controlling the PBX systems [2]. With the advent of IP PBX systems, companies like Cisco and ShoreTel entered the market and there was a considerable shift from hardware based PBX systems to software based PBX systems [2]. However, this gave rise to proprietary constraints, such as lack of flexibility and stability in product versions, and caused less savings. The backend code for the proprietary systems is closely guarded and any change to the same would be released in accordance with the developing company’s own interests. Chava and Ilow’s paper on integration of open source and enterprise PBX system discusses the same with an example of the Cisco Call Manager or the CCM, which is the software-based call processing equipment of the Cisco IP Telephony Solution [3]. It is also a part of the Cisco Architecture for Voice, Video and Integrated Data or AVVID [3]. The CCM necessitates the usage of Cisco’s Unity box for an overall unified messaging system, which sends voice, fax messages and emails to a single inbox [3]. Open source is continuing to reshape these barriers and provide easily available Application Programming Interface or APIs for development by any interested party. Open source IP PBX systems allow for modification of the data systems by those who have the will to change the existing, freely available source code to suit the company needs. The IP PBX market currently has several open source options in the form of Asterisk, SipXecs, Clearwater, and XorCom. The source code of these Imaging Software or ISO can be very easily downloaded from the market frontiers such as tribox CE, elastix, FreePBX, and PBXinaflash [4]. As compared to the commercialized VoIP products, the mentioned Software ISO are available without a simultaneous call license fee, per user license fee, or a phone license fee, and are free from any mandatory support and maintenance contracts [4]. Additionally, support for these software are also available easily both via free and paid options. Another advantage of open source facilities is that it has customization capabilities unlike proprietary solutions [4]. Asterisk and other solutions like FreePBX, trixbox, PBXinaFlash allow integration of services like click-to-dial, databases, and other customer management tools [4]. All these can easily be configured in the Command Line Interface of any of the open source systems [4]. Contrary to this, proprietary solutions do not provide access to their CLI and any modifications can be brought about only via the application’s web Graphical User Interface or GUI, and by the system’s developers alone [4]. Open source systems started with the embrace of the software depended modules, thereby gearing the drive towards inexpensive and innovative alternatives to hardware based solutions. Intel’s Host Media Processing software is one of the earliest mainstream examples [3]. Using Intel’s software, regular purpose computer platforms were able to create applications involving both video and voice. While proprietary systems are more robust compared to open source systems, there are certain limitations to the same. The ShoreGear 120/24 is specially designed for 120 IP users or 24 analog users. Depending on the density of the location, these gears can be customized accordingly [5]. However, additional technical support is required every time the slightest of modifications is required in the software. It is agreed upon that most proprietary systems have an established global presence. However, they also have serious restriction on the choice of hardware and are fraught with stringent license requirements. Cisco is one of the leading market frontiers in PBX healthcare systems. Even then, it is bound to its own products. While digital T1/E1 packet voice trunk network runs on Cisco 2600 series and Cisco 3600 series routers, the two-port T1/E1 digital voice port adapter modules operate on Cisco 7200 series and Cisco 7500 series routers [6]. Correspondingly, Cisco MC3810 multiservice concentrators are mostly observed in case of digital voice modules. Similar is the case with ShoreTel [6]. This system comes with the whole ShoreGear Voice Switches and ShoreWare Director V.6 [6]. On the other hand, Asterisk is a completely open source PBX software system that can run on Debian, Free BSD, Linux and Centos [3]. Additionally, it can operate on almost all equipment that is compliant with VoIP standards, employing comparatively inexpensive hardware. For VoIP purposes, Asterisk doesn’t require any additional hardware. It even supports an extensive range of hardware devices for establishing interconnection with either digital or analog telephone equipment [3]. Digium is the most noted hardware vendor for Asterisk products. However, these products are equally compliant with vendors like RedFone and Sangoma [3]. It even replaces the traditional switch network as a Public Switched Telephone Network or PSTN gateway, soft switch, and voicemail server, Plain Old Telephony Service or POTS gateway, voicemail server, and music on hold server [3]. Open source solutions also provide the advantage of interoperability with almost every VoIP endpoint in the market, spanning Peripheral Component Interconnect or PCI cards, Gateways Wi-Fi Phones, Session Initiation Protocol Digital Enhanced Cordless Telecommunications or SIP DECT solutions, etc [4]. This interoperability also allows the mapping of the open source based PBX system to any phone model and manufacturer. Apart from Asterisk, there are other popular open source applications in the domain of IP PBX systems like sipXecs, OpenSIPS, Clearwater etc. Their common features include unified messaging, voice messages and presence features, all of which can be heavily used to improve the healthcare sector. In addition to that, applications like SipXec follows a 2 centralized distribution system along with Point to Point routing which provides for unlimited simultaneous calls and improved voice quality and even prevents the Private Automatic Branch Exchange (PABX) from becoming a single point of failure [7]. Another relatively less popular open source PABX is Yate, whose kernel is written in C++ but supports Python scripting. Additionally, Yate provides Interactive Voice Response, conferencing and allows VoIP-toPSTN gateway among other services [7]. FreeSWITCH is a switching engine that is usually interfaced with other open source PABX systems like sipXecs, CallWeaver, Yate or Asterisk. It is also independent of the operating systems, ranging from Solaris, Linux, Windows, and the BSDs [7]. It is with the help of such platform independent and flexible open source solutions that this proposal aims to resolve some major healthcare issues. III. RESEARCH METHODOLOGY To research the solutions to the above mentioned sub problems we implemented the following methodology. Firstly, we researched some of the common barriers to entry in VoIP and current state of the art in market. To understand the needs of the rural healthcare organization we decided to conduct a short survey at a private eye care hospital in eastern India. Disha Eye Hospitals and Research Centre is a chain of multi-specialty eye care hospital with locations in both urban and rural areas. We interviewed IT administrators as well as hospital staff of nurses and doctor. Based on their feedback we determined the current challenges they face with legacy phone system and their needs. Second, to analyze the feasibility of an all open source based VoIP solution, we deployed a lab set up. To build our network infrastructure we decided to use the following hardware and software. Table 1 - Hardware and software requirements HARDWARE Dell PowerEdge R805 Server Cisco 3800 Router Cisco Catalyst 3560 Switch Linksys E1200 Wi-Fi Wireless Router TP-LINK Wireless N300 Home Router Raspberry Pi B+ SOFTWARE VMware Esxi 5.1 Ubuntu 12.04 Asterisk Communications Framework OpenLdap Zoiper (desktop and phone app) Secondly, we deployed the network infrastructure as shown below to implement our open source asterisk based VoIP solution and test out the requirements suitable for the rural healthcare organizations. Figure 1 - Network Diagram of Deployed Infrastructure 3 Thirdly, to enable mobility to the hospital staff we deployed a wireless network. We used open source firmware DD-WRT to build the underlying wireless infrastructure in order to facilitate mobility for VoIP solution [11]. We used cheap wireless routers flashed with DD-WRT open source firmware making them robust. DD-WRT leverages full hardware capabilities of the devices. Routers with this were used in different network modes including Access points (Wireless Gateways), Repeater bridge (wireless range extender with wireless WAN) and Client bridge mode (wireless range extenders) to provide full wireless coverage. The default wireless parameters were adjusted to provide better performance. Finally, to quantify the cost savings from our open source VoIP solution we first performed cost analysis of transitioning to a VoIP based system from legacy TDM based phone systems. We based this cost analysis on three parameters, fixed monthly cost, one time installation cost and yearly cost. For this research we assumed our rural hospital to have 50 employees, out of which 10 are remote workers. Based on the result we then calculated our Return on Investment (ROI). Next, we compared the cost of our customized open source VoIP solution against proprietary solutions like Avaya, Cisco and Nortel based on the Total Cost of Ownership (TCO) of each model. This comparative study was based on the requirements of a small healthcare organization having 20 end users. The cost from the vendors are quotes received from them for the deployment. For this research we focused on the infrastructure cost perspective as currently we do not have a maintenance and onsite support capability. IV. RESEARCH RESULTS Our research showed that VoIP is gradually being adopted in healthcare sector as shown by the industry wise sale of VoIP below. Figure 2 - Demographics of VoIP Market [12] However rural healthcare has its own set of challenges and to understand that we surveyed an eye hospital in eastern India. Based on our interaction with the staff at Disha Eye Hospital and Research Centre, below is our survey result: Table 2 – Survey Analysis Survey Question Answer Do you have access to Internet? Yes, a data circuit of 1 mbps bandwidth is provisioned. Have you deployed VoIP? No current VoIP infrastructure. What are the factors that have led you to not deploy VoIP? Primary reason is cost of implementation, secondly lack of expertise in deploying and maintaining VoIP solution. What are some of the issues that you wish technology could manage for you? I. Better call handling capacity – Currently many patients are unable to talk to the receptionist because the receptionists are busy speaking to someone else on the phone. II. Ability to collaborate with remote doctors and patients – Some of the rural branches of Disha Eye Hospital lack senior doctors. In some cases it becomes necessary to refer a complicated patient to city hospitals. III. Integrating patient monitoring systems – Currently the patient monitoring systems are separate entities deployed on the hospital premises. An ability to bring them under a common IT infrastructure to provide “smart healthcare” is desired. Next we set up a lab network using Asterisk Open source framework as our communication server. Based on our survey result we decided to implement not only basic calling feature but also collaboration tools like video and Voicemail. By configuring support for H.264 and H.263p codec, our VoIP system is able to support video calling. We were able to support voicemail capability by simple configuration of voicemail.conf and modifying user context in extensions.conf configuration file. We also enabled ring group feature on our asterisk system to support ring to simultaneous end devices. To ease the automation of adding end users, we successfully integrated OpenLdap [13], which is an open source light weight active directory, with our Asterisk PBX. Further our open source VoIP solution is compatible with IP based patient monitoring systems. Using raspberry pi we implemented an SIP based panic button which when pressed would send an alert email to configured mail addresses as well as a call to an emergency number 100 configured on our Asterisk PBX. We were able to achieve mobility for VoIP solution by deploying a robust underlying wireless infrastructure. Transmission power, sensitivity, channel 4 bandwidth were altered to increase the signal to noise ratio allowing increased coverage by at least 100 hundred more meters and better performance. With the extenders in bridge mode, the layer two domain is extended to cover the complete infrastructure, thereby, alleviating the issues related to hard hand-off (IP address change) during roaming between access points. The results of our first and second part cost analysis is given below. Table 3 - Average Monthly cost of traditional PBX v/s IP PBX (VoIP) Description Quantity Legacy circuits required SIP Trunks DID Trunks 1 17 50 Existing Network and PBX costs (Monthly) $450.00 N/A $100.00 Long Distance Charges 220 $330.00 20 min / emp / month 10 1 N/A Audio Conferencing Remote Worker Costs Move, Add, Changes Maintenance and Service Facilities Cost (power, insurance, space allocation, etc) N/A TOTAL On site VoIP PBX and SIP Trunking $0.00 $425.00 $0.00 N/A Long distance charges are included in the Trunk Charge $240.00 $0.00 $874.90 $50 $208.33 $0.00 $0.00 Included in equipment cost $1200 $300 $3453.23 $725 Table 4 - Initial one-time cost of deploying Traditional PBX One-time costs of traditional PBX Alcatel OmniPCX 4200, including 3 DLC 8 extension cards and CTI add on module Alcatel 4019 digital business phones One-time costs ADSL (modem/installation) Protection against power outage: APC Smart-UPC SC 420 Amount Price Subtotal 1 $1716 $1716 50 $160 $8000 1 $556 $556 1 $100 $100 TOTAL $10,732 Table 5 - Cost of Open Source VoIP solution against proprietary solutions for 20 phone system [12] One-time cost of IP PBX Quantity Price Subtotal Digium G200 VoIP Gateway 1 $1,995.00 $1995.00 Asterisk based Server 1 $420 $420 TP Link PoE Switch 4 $45 $180 Grandstream GXP 1400 IP Phones 50 $40 $2000 TOTAL $4595 5 Table 6 – Acquisition Cost of Open Source VoIP solution against proprietary solutions for 20 phone system [14] Asterisk Based Open Source solution $800 (no license fee) Acquisition Cost Cisco Alcatel Omni PCX Shoretel Avaya IP Office Phones (including license cost) $8,100 $5840 $8160 $6160 Equipment $10,681 $18,850 $12,158 $18,992 $2595 Installation/ training $12,000 $3576 $4291 $3823 $3000 (training cost per person) TOTAL $30,791 $28,446 $24,609 $28,975 $6395 V. DISCUSSION OF RESULTS From the results we are able to prove that using open source Asterisk communication framework we can set up a VoIP system suitable for healthcare requirements. The impact analysis of implementing a feature like video conferencing is that now rural healthcare staff can connect with their peers in cities and get real time consultation on issues. Using ring group, an incoming call can now be configured to either ring a set of phone numbers simultaneously or ring phone 1, then phone 2 (if line 1 is busy) and rest of the configured numbers sequentially. This will be useful in emergency calling and reception areas. For example, in case a nurse wants to speak to a doctor immediately she will ring a helpline number, the call will ring the phone of all the configured doctors and then whoever picks up the call first will answer it. By deploying our solution over both wired and wireless infrastructure, we have enabled mobility in a dynamic work environment. Thus, this will allow users with smartphones to talk on the move by installing readily available free Session Initiation Protocol (SIP) endpoint applications like 3cx and Zoiper. This also presents an opportunity for hospitals to cut costs on hardware based phones. Figure 3 – Cost Analysis of Traditional vs. IP PBX 6 The cost analysis of traditional PBX based system v/s our IP based PBX solution shows a huge impact in savings (fig. 4) for a healthcare organization. The five year ROI calculation shows that we can save up to 78% with open source VoIP implementation. This boosts our argument that VoIP can be a cost effective solution in the long run for a healthcare organization. The comparative analysis of our open source VoIP implementation to proprietary solutions shows that open source can be a much cheaper alternative than enterprise solution from big vendors. The graph in Figure 4 shows that our solution is almost 74% cheaper than the nearest competitor (Shoretel). However, it is to be noted that when you buy a proprietary solution you get customer support for the product, but our solution currently has no support organization. VI. CONCLUSION AND FUTURE RESEARCH The rural healthcare community is still a laggard in adoption of VoIP technology primarily due to concerns over cost. Through our research we have demonstrated how open source VoIP platform can be leveraged to build cost effective solution for a small to midsize healthcare facility. We have performed cost analysis of our solution against enterprise solutions like Cisco and Avaya and compared the cost savings for a similar set of features. Our research is based on both wired and wireless infrastructure, thus providing the necessary flexibility in a healthcare organization. The solution presented will not only reduce operational expense of the organization but also enable rich multimedia features. The open nature of the components involved makes the solution vendor neutral, which will enable greater adoption of VoIP in developing countries where proprietary solutions are not available or too costly to afford. Furthermore, although the solution is designed for rural healthcare, the benefits can be easily realized in other underprivileged sectors like rural education and cooperatives. Future research should encompass the current limitations of the solution, such as maintenance and fault resolution. As rural organizations face a shortage of talented IT staff, a support network will be required to facilitate management of our proposed VoIP solution. The support network will be a not-for-profit organization and can be funded by NGO’s working for rural development. The support organization can become a strategic partner of existing open source organizations like GNU Health, to bolster adoption open source VoIP. However the feasibility of such an organization needs to be analyzed. Further research needs to be done on developing healthcare specific “apps” that can run on top of our VoIP solution and provide greater functionality like health profiling, and electronic exchange of patient information over unsecure medium. A long term strategic direction would be to host the VoIP solution on cloud platform. Offering Unified Communications as a Service (UCaaS) would ease the burden of onsite maintenance and support. However it would also bring interesting challenges and the results are yet to be seen. VII. REFERENCES [1]. M. Daniel, and M. Emma, “Delivering Voice over IP Networks”, Wiley Computer Publishing, 1st edition, 1998, ISBN 0-471-25482-7 [2]. “The evolving role of hardware as a key enabler of open source telephony in the business market,” InfoSecToday, J. Arnold and Associates, Jul 2006. Available: http://www.infosectoday.com/ITToday/SangomaWPJuly06. pdf [3]. K.S. Chava and J.Ilow, “Integration of open source and enterprise IP PBXs,” in Proc. of the 3rd International Conference on Testbeds and Research Infrastructure for the Development of Networks and Communities, May 2007, pp. 1-6. [4]. G. Smith, “The upsides and downsides of open source voip systems,” Jun 2010. Available: http://www.voipsupply.com/blog/voip-insider/open-sourcevoip-systems-pros-cons/ [5]. W. Rash, “Easy management makes shoretel pbx a delight,’ in InfoWorld, vol.28, Trade Publications, 2006, pp.36. [6]. “Configuring pbx interconnectivity features”, in Cisco IOS Voice, Video, and Fax Configuration Guide. Available: http://www.cisco.com/c/en/us/td/docs/ios/12_2/voice/config uration/guide/fvvfax_c/vvfpbx.html [7]. R. Gedda, “Five open source to IP telephony projects to watch,” in CIO Magazine, Oct 2009. Available: http://www.cio.com.au/article/323016/five_open_source_ip _telephony_projects_watch/ [8] M. Ahmed and A.M Mansor ,"Cpu dimensioning on performance of asterisk voip pbx,” in Proc. of the 11th communications and networking simulation symposium (CNS '08),New York, pp. 139-146, 2008, doi: 10.1145/1400713.1400737 [9] A. D. Keromytis, “Voice over IP: Risks, threats and vulnerabilities,” in Proc of the Cyber Infrastructure Protection (CIP) Conference, June 2009. [10] V. K. Gurbani and V. Kolesnikov, “A Survey and Analysis of Media Keying Techniques in the Session Initiation Protocol (SIP),” IEEE Communications Surveys and Tutorials, 2011. [11] DD-WRT. Com, Main page- DD-WRT, [online]. Available: http://www.dd-wrt.com/wiki/index.php/ [12] J. Jones. (2014, Aug 18). voip software small business buyer, Buyerview [Online]. Available: http://www.softwareadvice.com/voip/buyerview/report2014/ [13] The OpenLDAP Project, OpenLDAP software, [online] 2014. Available: http://www.ittc.ku.edu/~krsna/citing.htm# 7 [14] Evaluating the total cost of ownership for small to medium business voip phone systems, Savatar, 9 Harcourt Street Boston, MA, pp. 1-9. Available: http://www.adtran.com/pub/Library/White_Papers/Evaluati ng_the_Total_Cost_of_Ownership_for_Small_to_Medium_ Business_VoIP_Phone_Systems___Savatar.pdf VIII. ACKNOWLEDGEMENT Our sincere thanks to Prof. Jeff Dimaio for his insightful comments and expertise that greatly supported this project. We would also like to thank Prof. Jose Santos for assisting us with his valuable advice and with the hardware required for our research. We are also thankful to the staff of Disha Eye Hospitals and Research Centre for their kind co-operation and participation in the survey that helped identify the goals of this effort. We extend our sincere thanks to Dr. David Reed for his constant guidance and supervision in pursuit of the successful completion of the research work. DSCP Differentiated Services Code Point EHR Electronic Health Record GUI Graphical User Interface HIPPA Health Insurance Portability and Accountability Act PABX Private Automatic Branch Exchange PBX Private Branch Exchange SIP Session Initiation Protocol VoIP Voice over IP QoS Quality of Service WAN Wide Area Network WLAN Wireless Local Area Network Appendix 1: List of resources Hardware Asterisk SIP Server PoE switch, 3rd Party Sip Phones Firewall Juniper/ Cisco/ Checkpoint User Administration OpenLDAP Voice Gateway Cisco with PRI card slots Software Avaya Call manager, DDWRT (Linux based alternative Open Source firmware for WLAN routers) Appendix 2: List of Acronyms API Application Programming Interface AVVID Architecture for Voice, Video and Integrated Data CCM Cisco Call Manager 8
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