Published: 26/09/2002, Volume II2, No. 5824 Page 22 23 24

Voice over IP came in as a cheaper, faster alternative to telephone networks but failed to deliver.Now It is making a comeback, and some hospitals are already taking this technology on board. Sally Whittle reports

If you have never heard of Voice over IP, you might be surprised to learn that it has been and gone and is now on the comeback trail.

Voice over IP (or VoIP, where IP stands for internet protocol) first emerged back in 1995 as a cheaper, faster alternative to the networks that had delivered telephone services for more than 100 years.

It promised to free organisations from the tyranny of local telephone operators, such as BT and AT&T, by replacing archaic voice networks with a single computerised system that would carry both computer data and voice traffic - the converged network.

Unfortunately, the products didn't deliver. Early versions of VoIP suffered from dropped calls, patchy quality and cumbersome integration issues (see box overleaf).

'Running VoIP was a lost endeavour in the early 1990s, ' says Steve Brady, IP manager at BT Ignite, the company's business services division. 'The data made it from one end to the other - just not necessarily in the right order.'

Almost a decade on, VoIP is back and once again aiming to be at the top of the IT manager's agenda.

This time around, the focus is less on cheap phone calls and more on the types of services that can be delivered through converged voice and data networks. For example, telephone operators can intelligently route calls and integrate information gathered on the phone with information pulled from databases or websites. In the future, it is also hoped that VoIP networks will carry multimedia, perhaps even real-time video footage.

The other big advantage of VoIP is that running one converged network is simpler than running a voice network alongside a separate data network.

Analyst Gartner Group reports that the savings can be as much as 80 per cent in some cases, thanks to the greater economies of scale and ease of management.

York District Hospital became the first NHS hospital to roll out VoIP when it replaced its ageing PBX (private branch exchange) system last year with a new, converged network.

This replaced traditional phones with IP handsets that let users browse the hospital's Microsoft Exchange directory. They can also find numbers at the touch of a button, doing away with paper-based directories. 'The network can support a range of text-based facilities, and That is ideal for staff who need to access information but do not have a PC, ' says Sue Rushbrook, head of systems and networks at York Health Services trust.

When the Royal Hampshire County Hospital in Winchester rolled out its new IT architecture, convergence was a key aim, says IT director Alan Jones. The hospital is a flagship site for the implementation of technology for healthcare and has a complex infrastructure. This includes two telecoms networks (one fixed-line, one mobile), one wireless network (providing nurses on wards with access to back-end electronic patient records), one conventional telecoms network and a further asynchronous transfer mode network connecting the hospital's PCs and servers.

The plan is to converge all these networks into a single IP-based system and thereby cut the cost of management and support, says Mr Jones.

'We are in year one of a five-year programme for implementing technology in the NHS but There is no more money, ' he says. 'We have to find ways of generating that finance without using funds assigned for patient care.'

With a VoIP network, Mr Jones could offer a single interface for all the communications networks that would link into telephone-based services such as NHS Direct or hospital reception desks and wards. The improvement in service would also be matched by a cut in administration and bandwidth costs, he believes. 'Nobody wants layers of overlapping infrastructure. It is easier to make a business case for the technology if we can manage them all on a single network.'

The IT team at the Royal Hampshire County Hospital has been testing converged networks for several years, but Mr Jones has only recently become convinced by their performance.He now considers the installation of converged networks a logical choice for hospitals that are undergoing rebuilding or refurbishment.

Certainly, performance of VoIP technology has improved dramatically in recent years. The latest products allow voice calls running over an IP network to take priority over less urgent e-mails, cutting the risk of the dropped calls that so frustrated early adopters.

At York, performance has matched all expectations, says Ms Rushbrook. 'We operate a truly 24/7 operation, and the network had to be robust and resilient now and in the future, ' she says.

York's network was designed using a resilient local area network that used high-bandwidth fibre optic cabling between buildings to improve performance.

The results have been impressive and York already plans to extend the use of VoIP technology. For example, in the near future consultants will have the ability to access x-rays from their PCs instead of waiting for hard copies to be processed.

The upgraded network also has the ability to electronically transmit other clinical images and implement EPRs and electronic prescriptions.

As VoIP technology has matured, the price of VoIP systems has fallen so far that they are now up to 40 per cent cheaper than the PBX systems most companies use to manage conventional voice networks.

PBX aggregates a relatively small number of external phone lines provided by a telecom operator and uses computer software to share those lines across all of an organisation's internal lines.

However, the VoIP comeback is not assured by any means. 'The problem for vendors is persuading companies that these new benefits can be delivered without sacrificing reliability or performance, ' says Neil Dipple, IP development manager with Alcatel eBusiness Solutions.

It could be quite a challenge. According to research conducted by BT in 2001, only 16 per cent of a sample of (non-IT) managers from across the private and public sector could define convergence or VoIP, and 46 per cent do not use the technology.

'VoIP is not something many of our customers are thinking about, ' admits Mark Tindall, a network consultant with Compass Consulting. 'They want more evidence of savings before they commit.'

While VoIP is more mature and reliable, industry standards are still shifting, making big investments unwise. The fundamental problem is that IP itself is simply a way to move data - it doesn't guarantee delivery.Vendors selling VoIP must add that capability to the product - and each vendor does so in a slightly different way. This brings purchasers the age-old problem: buy from a single vendor and risk lock-in to a poor supplier; or buy from several and risk incompatibility.

A further problem uncovered by experience in the private and public sector is that the savings promised by VoIP do not always materialise. 'Despite the hype, there are no real cost savings in migrating to an IP platform today, ' says Elizabeth Herrell, a senior analyst with Giga Information Group.

The price of IP phones is extremely high, with handsets costing up to five times the amount of traditional models. Though a new VoIP network built from scratch is still probably cheaper than a PBX system, few companies have the luxury of starting with a clean slate.

Bringing IP networks up to scratch and adding the monitoring and bandwidth required for VoIP could add as much as 40 per cent to total project costs, Ms Herrell warns.

All of this means healthcare providers, particularly those in the public sector, should probably not commit to large-scale rollouts of converged networks today. Ripping out PBX systems that work perfectly well, to replace them with VoIP systems that could suffer teething problems, is not a good idea.

However, it is worth trialling VoIP now. One possible route is to run PBX and VoIP networks in tandem by adding VoIP cards to an existing PBX exchange.This gives the company the advantage of VoIP without sacrificing the investment already made in a sophisticated - and reliable - phone system.

Alternatively, some vendors are offering a gentle introduction to VoIP. BT Ignite has introduced a trial network-hosted service with Open, which lets customers make VoIP calls over their PBX networks.Cable and Wireless, meanwhile, offers its customers a gradual migration to VoIP on three, five and seven-year contracts.

This allows migration to take place slowly and is charged on a per-user per-month fee - allowing organisations to spread the cost of an IP deployment.

'We would definitely advise customers to introduce VoIP networks to small offices or divisions in the first instance, alongside PBX systems, 'Ms Herrell says. 'This provides a way for enterprises to evaluate the technology and performance issues in a lowimpact environment.' l A manageable package: what exactly is Voice over IP?

Sending information across the internet is a difficult business.Large files, such as pictures or Word documents, can easily get stuck in data traffic jams or a bottleneck in the web. Internet protocol is designed to overcome this problem.

IP breaks computer messages into smaller 'packets'which can travel quickly across the internet by a range of routes.

Each packet contains part of the original file and a label detailing the unique identity (known as an IP address) of the machines sending and receiving the message.When the information reaches its destination, it is reassembled into the original document or picture.

Voice over IP involves breaking voice data down into small packets and sending them across IP networks in the same way as other data.The advantage is that, instead of making phone calls via an operator like BT, VoIP routes calls through your flat-rate local internet service provider, cutting the cost of long-distance calls enormously.

The downside is that if a packet gets lost or delayed on its way during a voice call, the effect on performance is far more serious than for a traditional data communication. Early VoIP suppliers were unable to guarantee good enough performance for businesses, so adoption has been slow until now.