A case study on Telemedicine and Telehealth. It is how VM Ware vSphere turns into a cornerstone for the hybrid cloud solution of City Clinic, which is then easily utilized for Telemedicine

1. VMWARE CASE STUDY
INDUSTRY
Healthcare
LOCATION
Sofia, Bulgaria
THE CHALLENGE
Building an open telemedicine
platform for mobile medical
examination rooms, capable
of accommodating any kind
of standards-based medical
instruments and integrating it
with Electronic Medical Records
systems.
THE SOLUTION
Aossia’s Sphere of Care solution
based on vSphere for Desktop and
Horizon View VDI software as the
core enabling technology.
THE BENEFITS
• a leap in medical examination
availability and quality,
especially for small communities
and rural areas
• more patients served with
existing budget and resources
• productivity gains and reduced
cost per patient
• flexibility from easily adding
extra resources
• reduced waiting times, public
service obligation fulfilled
• lower risk and cost from early
diagnosis and treatment
• easy cross-examination with
many doctors available online
• fast and cost-effective access to
new markets
• numerous options for revenue
and profit growth
• better service for chronical
conditions and the elderly
• avoiding unnecessary patient
transportation and related cost
City Clinic taps VDI technology to save lives
and cut costs
City Clinic implements an innovative cloud-based mobile
telemedicine solution combining state-of-the-art medical
instrumentation and proven virtual desktop technology
from VMware to expand the reach and lower the cost of
medical examination. Applications include disaster response,
prevention programs, chronic condition monitoring, distributed
first-contact care, home care and many more. City Clinic blazes
the trail for both private and public healthcare organizations,
gaining the ability to provide high quality care to more people,
faster and cheaper – all at the same time – and with existing
human resources.
For all the hype it gets, telemedicine is often just that, a hype. The reason is simple: most
solutions have limited features accompanied by high price tags and thus, little chance for
broader adoption. This is, however, not the case with Aossia’s Sphere of Care.
The challenge
As an IT solution integrator Aossia works
with a large number of technologies
using them to build industry-specific
solutions for customers. One of them
is City Clinic, the leading healthcare
provider in Bulgaria who recently tasked
the company with developing a solution
for remote medical examination. The
reason was City Clinic doctors’ frustration
while evaluating various telemedicine
solutions available on the market. In
short, in their view, most of them did
not deliver on the initial promises of
productivity improvement and long-term
cost-efficiency gains, while also imposing
compromises in other areas, such as
openness or mobility.
“We were not interested in integrating
many single-purpose, often proprietary
solutions. Rather, we wanted to see an
open platform enabling us to perform
a multitude of medical examination
procedures as well as tests remotely. That
essentially meant having one solution
integrating many medical instruments.
We also stressed the need to tightly
integrate remote examination with
centralized, standards-based Electronic
Medical Record systems. Without such
integration, the solution would not be
much of an improvement for our doctors’
productivity” – explains Ilian Grigorov,
CEO, City Clinic.
Aossia took all those remarks home with
the aim to give the idea a serious try.
After further consultations, technology
tests and investments the company
came up with a solution being exactly
what City Clinic hoped for. “Internally, we
developed a set of projects, each with
goals addressing specific challenges on
the way to the envisioned solution. These
were, for example, device integration,
interoperability and standards,
security, compliance, management,
teleconferencing, usability, mobility,
cost and a lot more” – explains Miroslav
Ivanov, Sales Manager, Aossia.
The solution
“Working with City Clinic we have
developed, tested and productized
a general purpose remote medical
examination solution. It enables
hospital-type medical examination just
anyplace with a cellular or fixed Internet
connection. Combining any IoT medical

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VMWARE CASE STUDY
devices with the latest medical and
information technology innovations,
the Sphere of Care gives City Clinic new
service delivery options as well as radical
cost savings”– says Ivaylo Petrov, CEO,
Aossia.
Conceptually, the solution imitates
a medical examination room in a clinic
or hospital, the key difference being
both the patient and the doctor can be
anywhere in the world, teleconferencing
in real time. The patient is attended by
a nurse who acts the ‘doctors’ hands’,
physically operating medical instruments
e.g. a stethoscope, a heart monitor,
a blood pressure monitor, an ultrasound
scanner, a glucose-level meter or
a laparoscope set. In fact, any digital
medical device can be used as long as
it can transfer data over a USB, Wi-Fi or
Bluetooth to a laptop (Windows, Mac
OS), a tablet (Android, iOS) or even
a smartphone (Android, iOS) running
VMware Horizon View 6 software.
The VMware vSphere for Desktop and
Horizon View are VDI, or Virtual Desktop
Infrastructure software products which
are the core enabler for the Sphere of
Care solution. Both the nurse and the
doctor use it to access their virtual
desktops running in Aossia’s cloud.
“VDI is a crucial part of the solution
because medical desktop applications
often require a lot of computing
resources and high speed networking
available as well as some special
operating system. These, of course,
may be hard to get under truly mobile
circumstances. Centralizing desktops
is also essential because of information
security and compliance requirements.
With vSphere for Desktop and Horizon
View, no data is stored on a remote
location – it is only displayed while
constantly residing in the security vault in
the cloud. We have chosen VMware’s VDI
technology for its flexibility, reliability and
proven track record worldwide” – stresses
Aossia’s Petrov.
Secure access to patient information
is based on dedicated server software,
distributed hardware security modules
and user’s smart cards. The solution
assumes two separate HD screens
are used – one for the patient-doctor
teleconferencing using telepresence
software and the other for imaging
and medical applications. In the case
when a tablet or smartphone are used
for urgent cases, screen switching is
inevitable, but it is still very usable.
As for connectivity… “Any decent
broadband can handle the connection.
The bandwidth requirement is 5 Mb/s or
more. In the case the connection slows
down the solution automatically drops
the frame rate while keeping the picture
and voice quality intact. The solution
reliably works even over a 3G cellular
“We were not interested in
integrating many single-
purpose, often proprietary
solutions. Rather, we wanted
to see an open platform
enabling us to perform
a multitude of medical
examination procedures as
well as tests remotely. That
essentially meant having one
solution integrating many
medical instruments. We also
stressed the need to tightly
integrate remote examination
with centralized, standards-
based Electronic Medical
Record systems. Without
such integration, the solution
would not be much of an
improvement for our doctors’
productivity”
Ilian Grigorov, Chief Executive Officer,
City Clinic
SOFTWARE
• vSphere for Desktop
• Horizon View 6
“Any decent broadband can
handle the connection. The
bandwidth requirement is
5 Mb/s or more. In the case
the connection slows down
the solution automatically
drops the frame rate while
keeping the picture and voice
quality intact. The solution
reliably works even over a 3G
cellular data link which speaks
volumes about the robustness
of the Horizon View 6 and its
PCoIP remote protocol”
Roch Norwa, Lead System Engineer,
VMware who validated the architecture

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VMWARE CASE STUDY
data link which speaks volumes about the
robustness of the Horizon View 6 and its
PCoIP remote protocol” – declares Roch
Norwa, Lead System Engineer, VMware
who validated the architecture.
Indeed, the mobility is a game changer
for the patient. The quality of diagnosis
and adequate care during the first 60
minutes often determine the results of
all further efforts doctors undertake.
“Within these 30 or 60 minutes we
can adequately react and we can base
treatment and diagnostics on accurate
facts and information about the patient”
– City Clinic’s CEO, Ilian Grigorov explains.
Initially, City Clinic considered the
Sphere of Care as a disaster response
solution to be used just about anywhere.
This required the whole set to be put
into a dome-shaped environment-
resistant tent of special material, with
special flooring etc. Anywhere means…
anywhere, after all. The characteristic
spherical shape of the tent inspired the
name, even though the ‘tentless’ use
scenarios now seem to be even more
prospective for City Clinic.
The benefits
“Whether the doctor is in the hospital
or in some other location he has
access to current medical information,
at any time, and at any stage of the
patient’s treatment” – notes Ilian
Grigorov.
It doesn’t take much imagination to
envision a broad array of use cases for
the Sphere of Care. Working with Aossia,
City Clinic has crystalized real-world
requirements for telemedicine and
essentially blazed the trail for many new
initiatives, including in public healthcare.
“Public healthcare faces ever mounting
demand for services while budgets
and human resources are already very
strained. Long waiting times even for
basic public medical service have become
a norm across the world. We believe
we can help local governments address
the ever mounting cost and resource-
shortage issues” – City Clinic’s CEO,
Grigorov argues.
These arguments are fair but obviously,
this is just a tip of the iceberg in terms of
optimization opportunities. “The Sphere
of Care provides a practical means to
solve a long list of problems. For example,
better prioritizing patients in time critical
situations, avoiding unnecessary medical
transport, speeding up diagnosis and
preventing deterioration, better serving
the chronically ill and the elderly as well
as enacting prevention programs. Being
able to quickly consult many doctors in
real time reduces the risk of inappropriate
diagnosis or treatment which is highly
desirable not only by patients but doctors
as well” – Aossia’s Petrov adds.
This is not to say City Clinic stops being
a private healthcare provider. Just to
“Whether the doctor is in the
hospital or in some other
location he has access to
current medical information,
at any time, and at any stage
of the patient’s treatment”
Ilian Grigorov, Chief Executive Officer,
City Clinic
“AOSSIA IT Healthcare
Innovations, working closely
with End User Computing
solutions from VMware, has
developed “Sphere of Care”,
a revolutionary and world-
leading mobile healthcare
delivery solution that can
be rapidly deployed to rural
areas, areas of emergency
need such as natural disasters,
large scale outdoor events,
military and refugees camps
and etc. Well, you don’t have
imagine any longer as the
remote medical examination
is no longer in the realm of
science fiction”
Miroslav Ivanov, Sales Manager, Aossia

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may be trademarks of their respective companies. Item No: 16Q1 Aossia's Sphere of Care at City Clinic UK ALT
VMWARE CASE STUDY
“VDI is a crucial part of the
solution because medical
desktop applications often
require a lot of computing
resources and high speed
networking available as well
as some special operating
system. These, of course,
may be hard to get under
truly mobile circumstances.
Centralizing desktops is
also essential because of
information security and
compliance requirements.
With vSphere for Desktop
and Horizon View, no data is
stored on a remote location
– it is only displayed while
constantly residing in the
security vault in the cloud.
We have chosen VMware’s VDI
technology for its flexibility,
reliability and proven track
record worldwide”
Ivaylo Petrov, CEO, Aossia
the contrary, the hospital stands to
potentially gain many more benefits using
the telemedicine solution for business
development. “For any private healthcare
provider growing the potential patient
base is a long-term imperative. With
Aossia’s Sphere of Care we can quickly
and cost-effectively enter new markets.
Setting things up takes less than a day,
even with the dome. A remote point
of presence can bring revenue stream
directly from services rendered as well
as indirectly, by marketing and selling
services provided centrally” – Grigorov
remarks.
That said, human resource efficiency
and cost management clearly are
central to telemedicine’s future which
City Clinic’s case definitely confirms.
Meanwhile, Aossia sees even more
advanced scenarios looming.
“Private healthcare providers can offer
premium services to patients who want
to implement Sphere of Care at home.
This would probably include a limited set
of medical devices due to significant cost
but… there are people who can afford
even the full set. On the other hand,
in many typical cases, especially with
chronic conditions, one or two specialized
devices would be enough. In terms of
long-term operational efficiency and
profitability, home-based service delivery
coupled with subscription-based business
model is preferable. I can easily imagine
device subsidies offered, telco style” –
Ivanov opines.