july report 2cjspeaks.com/wp/wp-content/uploads/2018/07/snapshot-7-18.pdfcj)speaks)|)conﬁdendal)...

Community Broadband Snapshot Report ™ July 2018

© Cop

yright 2017 CJ Spe

aks

Authored by:

Craig Se@les President, CJ Speaks

Sponsored by:

Telehealth & Broadband: In Sickness and in Health, Part 2

Contents

01 Execu@ve Summary 4

02 The Doctor Is Always In with Broadband and Telemedicine 6

03 Telehealth and community broadband share marke@ng mission

9

12

05 Telehealth apps can sell broadband network subscrip@ons 16

06 Mental health, broadband, and telehealth 19

07 Home healthcare through telehealth and broadband 23

08 The telehealth pilot – where we go from here 29

04 Community broadband and telemedicine together tackle digital inclusion

09 Recommenda@ons 32

01 Execu@ve Summary

CJ Speaks | ConfidenDal

By definiDon and by default, you cannot have telehealth without highspeed Internet. By design and by default, you cannot have a gig network without conDnually pushing the innovaDve edge.

Telehealth and community broadband define the essence of symbio;c rela;onships.

Deb Socia, ExecuDve Director of Next Century CiDes, remarks, “We could save so much money that's going to healthcare if we just take advantage of all these telehealth and telemedicine tools. That should influence the U.S. to spend more money for broadband. Broadband owners can sell their technology be@er if they embrace the transformaDve nature of telehealth.”

In November 2017, my report addressed community broadband and telemedicine that is pracDced within and between healthcare faciliDes. This current report examines telemedicine that is a targeted to individuals, with an emphasis on applicaDons that can make community networks more popular with subscribers and ulDmately generate more revenue.

Some media and poliDcians tend to suffer from myopia when they focus on the lack of rural broadband and telehealth when there also are expanses of urban areas that are underserved. Is it important to emphasize that both broadband and telemedicine face challenges as well as opportuniDes within communiDes that each technology hopes to improve.

Those in the community broadband and telemedicine industries would do well to help each other drive adopDon through the three-‐legged stool that is digital inclusion: broadband, devices, and digital literacy. Both groups share two missions, which is the need for plenty of customers and markeDng clout, and the commitment to serve disadvantaged and low-‐come income residents.

The bulk of the report gives three categories innovaDve and effecDve telemedicine applicaDons: 1) general medical services, 2) mental health services, and 3) home health care. The summaries present how or why these are ideal to offer community broadband subscribers. The report concludes with highlights on developing a telemedicine pilot project, and helpful recommendaDons

One cauDon about over-‐cauDous thinking. In a story about Lincoln, Nebraska’s broadband project, Fiber Infrastructure and Right of Way Manager at City of Lincoln, David Young says, “Stop wasDng Dme talking – just make the agreement and go forward. CiDes waste an inordinate amount of Dme on studies, figuring out best deal. Geeng the infrastructure deployed is the best deal!” Find a happy medium between recklessness abandon and glacially slow. Then act!

Execu@ve Summary

5

02 The Doctor Is Always In

with Broadband and Telemedicine


“The public has been misinformed,” said Eric Brown, President of California Telehealth Network (CTN). “Ojen in the public discourse when telehealth is discussed, rural health gets the headlines. There’s no doubt that the rural areas need assistance. But there’s a lot of work sDll needed in urban areas, more than people think.”

Telehealth is an opportunity – and a challenge – that faces both rural and urban communiDes. Likewise, community broadband is an opportunity and a challenge for many of the same communiDes. If telehealth providers and community broadband owners unite, communiDes’ economies and their residents will be healthier.

I interviewed Brown in September 2014 on my Internet radio show, Gigabit NaDon. At that Dme, CTN had enrolled statewide over 360 rural hospitals, criDcal access hospitals, federally qualified health centers, and community health centers that provide primary care. Those faciliDes were connected to the state's academic and medical centers in major metropolitan areas.

Brown condensed a telehealth evoluDon path that conDnues to evolve. Brown’s observaDons, insights, and Dps four years ago are relevant today.

“We started CTN with a focus on rural communiDes, and within those communiDes the iniDal focus was on the hospitals and other healthcare insDtuDons that served these areas,” Brown said. “As we move forward, we're going to expand our focus into other seengs where we don't normally serve. Soon many telehealth services will be available in people’s homes through broadband connecDons.”

Urban broadband availability will sDll be a problem, though. We suffer from the legacy of the early days of broadband when suburban areas received more a@enDon than inner city communiDes.

The Doctor Is Always In with Broadband and Telemedicine

7

“The public has been misinformed…There’s a lot of work sDll needed in urban, more than people think.”


CEO Milton Chen of telehealth company Vsee explains why, when we assess the health of telemedicine and telehealth adopDon, we have to assess the health of broadband as well. “Whether you’re looking at rural communiDes or metropolitan areas, without the Internet there’s nothing to talk about. You can’t drive telehealth without it.

The digital divide’s impact is that many low-‐income and lower middleclass residents do not have Internet access available, and so by extension they will have a hard Dme geeng telehealth. Significant numbers of these individuals can’t afford access even if broadband reaches their neighborhoods. And if the infrastructure is poor, even well to-‐do folks cannot get good broadband.

My November report on telehealth addressed the lack of broadband in rural areas. Only 62 percent of rural Americans have broadband installed in their homes, according to the think tank New America, and those who do ojen pay exorbitant prices for sluggish speeds.

But what about urban areas?

Ron Deus is CEO of regional wireless ISP (WISP) NetX in Cleveland, Ohio. Deus feels, “What happens in the suburban and urban areas amounts to redlining as incumbents’ buildouts, upgrades and broadband adopDon efforts happen in the most profitable areas first. Areas just a mile or two away become broadband deserts. A lot of incumbents are shareholder driven, so their first concerns are their profits and cherry-‐picking.”

These stats from the most disconnected large and midsize U.S. ciDes paint a stark picture of just how serious our digital divide is in urban areas. The 2016 American Community Survey lists the total numbers and percentages of the household in these ciDes without fixed broadband (cable, DSL, fiber).

One of the main reasons for this imbalance is the lack of meaningful compeDDon. “In reality, when you talk about a solid wired compeDtor, there really is none against Verizon, Comcast, Time Warner and the other large telcos in their respecDve markets,” says, Anne Schwieger, Broadband and Digital Equity Advocate for the City of Boston. ‘These companies rarely go into each other’s territory.”

The FCC’s recent repeal of net neutrality does not help broadband and telehealth. “It’s not going to destroy telehealth, but it can definitely make ma@ers worse,” warns Dr. Mike Greiwe, CEO of telehealth vender OrthoLive. “The way the repeal is wri@en, the cost of Internet service is likely going up for the people who need it the most, and many consumer protecDons are gone.

Community broadband networks run by municipaliDes, co-‐ops, wireless ISPs and other local providers can deliver much needed compeDDon as well as deliver telehealth to urban and rural areas.

The Doctor Is Always In with Broadband and Telemedicine

8

Lack of broadband threatens telehealth

Brownsville, TX 33,711 67%

Detroit, MI 147,067 57%

Hialeah, FL 42,258 56%

Shreveport, LA 38,200 51%

Memphis, TN 126,428 49%

Cleveland, OH 81,757 49%

Laredo, TX 33,077 47%

Miami, FL 81,424 47%

Jackson, MS 30,351 47%

Topeka, KS 23,775 46%

03 Telehealth and

community broadband share

marke@ng mission

9


Merriam-‐Webster: Symbio;c – a coopera;ve rela;onship (as between two persons or groups).

The be@er quality broadband a community has, potenDally the more effecDve will be the telehealth applicaDons and services. These vendors can prosper through aggressive markeDng relaDonships with municipaliDes, co-‐ops, wireless ISPs, and other Internet providers that grow their subscriber rolls. Everybody needs healthcare.

On the other side of the coin, over 750 municipal and co-‐op community broadband network currently exist, and new projects begin each month. These networks can cost a lot to build, so owners have to get and keep has many subscribers as possible while fending off compeDtors. Nothing grows a subscriber base like innovaDve leading edge technology, of which telehealth has an abundance.

Bo@om line – both the vendors, parDcularly start-‐ups and medium size companies, and broadband owners share a mission – the need for plenty of customers and markeDng clout. In addiDon, many of these organizaDons are commi@ed to serving communiDes’ disadvantaged and the low-‐come income residents, so there’s a shared social as well as markeDng mission.

Telehealth and community broadband share marke@ng mission

North Georgia Network CooperaDve (NGN), Inc. is actually four electric co-‐ops that united to create a 1,600-‐mile broadband network: Habersham Electric Membership CorporaDon (HEMC), Blue Ridge Mountain Electric Membership CorporaDon (BRMEMC) and NGN Connect. They currently have fiber connected to 10,000 homes in north Georgia, libraries, schools, and hospitals, and recently added 100-‐gigabit capacity to their fiber backbone. This is a great opportunity for telehealth.

“We linked 300 schools with a 10-‐gig connecDon to create an educaDon exchange,” says Michael Foor, NGN’s Vice President of Market and Member Services. “All of the schools share digital educaDon resources. We can do the same thing with a telehealthcare network. If talented telehealth providers come to us that can make our communiDes healthier, we are open to that.”

Word from the Trenches

10


Good Internet access produced by high capacity infrastructure is a prerequisite to any kind of full-‐scale telehealth applicaDons. Recalls Deb Socia, ExecuDve Director of Next Century CiDes, a broadband public advocacy group, “I went to a briefing on Capitol Hill when a group of vendors were showing various telemedicine applicaDons, and each one of them required significant broadband access.”

Ben Lewis-‐Ramirez, Business Development Manager at Foresite Group, feels, ”Economies of scale realized by dedicaDng porDons of broadband to telehealth would make the barrier to entry into broadband service lower for smaller business and more achievable.”

Jennifer Amis, CEO of Encounter Telehealth, is frustrated every Dme they partner with a facility that can’t meet the vender’s basic bandwidth requirement. “One prospect’s connecDon was so poor the audio was always out of sync. It was a group of 15 faciliDes and we weren't able to connect with any of them. I’m sure all of those paDents need specialized care they can’t get.”

An increasing number of community broadband owners see the benefit of using telehealth to sell broadband subscripDons.

“When you give your customers the opportunity to connect with more than just videos and entertainment, that drives adopDon and connectedness,” says Robert Hance, President and CEO of Midwest Electric CooperaDve. “In our broadband network buildout area, we are hieng 62% take rates. As we give more our members telehealth and other opDons we expect to get all of them connected.”

Cha@anooga is living up to its broadband “pacese@er” image. “We’re very interested and commi@ed to parDcipaDng in this telemedicine market, and are evaluaDng our opDons,” says KaDe Espeseth, Vice President of EPB Product Development. “We’ll soon reach 100,000 subscribers, and having partners that provide innovaDve products and services is how we plan to maintain our compeDDve edge in this market.”

“We funded several telehealth companies with consumer products and they have relied on exisDng broadband networks because they are mostly targeDng ciDes,” says Vic Ga@o, CEO of Jumpstart Foundry, a venture capital fund. “If you want to market to the rural towns, in places where there isn't good broadband, you have to build a network along side of the telemedicine applicaDon.”

Connect the dots between telemedicine, broadband, and economic development. Community broadband networks, telemedicine, and healthcare in general boost a community’s economic health. A hospital or clinic introducing telehealth enables many paDents to remain in the community rather going to a distant hospital. Dollars associated with their treatments stay local. Family that visit might stay in local hotels. Lab work can be done locally. You might be able to retain or recruit healthcare professionals to stay local.

11

Telehealth and community broadband share marke@ng mission

“One prospect’s connecDon was so poor the audio was always out of sync. It was a group of 15 faciliDes and we weren't able to connect with any of them.”

Telehealth apps sell broadband subscripDons

04 Community

broadband and telemedicine

together tackle digital inclusion

12


Broadband is a double edge sword. By providing these networks, communiDes open the door to convenience and a range of benefits such as those offered by telemedicine. But conversely they can slam the digital door on low-‐income rural and urban consDtuents.

Established in the 90s, paDent portals might be considered Telehealth, ver 1.0 or Telehealth Lite. These are private servers that groups of hospitals and/or doctors’ offices build to let paDents perform online some basic level administraDve (e.g. appointment scheduling, bill payment) and clinical (e.g. secure messaging, health monitoring) tasks.

Community broadband and telemedicine together tackle digital inclusion

The Health Care Research and Policy group at MetroHealth Center, a healthcare network covering Cuyahoga County, Ohio, monitored and analyzed urban adult paDents who visited MetroHealth’s outpaDent clinics from 2012 to 2015. 243,248 visited the clinics and 70,835 (29.1%) iniDated portal use.

According to the resulDng research report, “IniDaDon of [portal] use was lower for racial and ethnic minoriDes, persons of lower socioeconomic status, and those without neighborhood broadband Internet access. These results suggest the emergence of a digital divide in paDent portal use.”

Dr. Adam Perzynski is Assistant Professor of Medicine and Sociology in the Center for Health Care Research and Policy, and was a principal researcher for the project. “At the Dme we didn’t draw specific correlaDons between Internet adopDon and telehealth use, but logic infers answers to important quesDons.

For Dr. Perzynski and others who have studied the issue feel, “If adopDon is a problem for paDent portals, it's a worse problem for telemedicine. The telemedicine industry needs to turn to those who’ve been successful increasing digital inclusion. These experts refer to adopDon as a three-‐legged stool that cannot stand if any of the three legs – broadband, devices, and digital literacy – is missing.”

“IniDaDon of use was lower for racial and ethnic minoriDes, persons of lower socioeconomic status, and those without neighborhood broadband Internet access.”

13

CJ Speaks | ConfidenDal 14


In the last two years or so, there’s been a surge of community broadband projects. Ajer watching first pioneering electric co-‐op launch successful networks, dozens of co-‐ops are laying the groundwork to follow suit. Ajer the FCC eliminated net neutrality regulaDons, there’s been a renewed interest among municipaliDes to build networks. WISPs are coming to the broadband table armed with the latest technology that gives their wireless networks significantly more speed and capacity.

Recently, the Cuyahoga County data from the project contributed to the case that community-‐owned broadband – even if it’s older infrastructure – can be a net-‐posiDve for telehealth delivery. Old Brooklyn is a Cleveland neighborhood that built a free Wi-‐Fi network eight years ago.

For the recent research, MetroHealth compared 10,619 Old Brooklyn paDents with the free WiFi coverage with 62,508 City of Cleveland residents without free public WiFi. Dr. Perzynski reports that, “There was a 50% higher portal use with free Wi-‐Fi. 13% were more likely to make an appointment via the portal, and 15% were more likely to check their lab results. We can infer that if you have telehealth set up in areas with free or affordable broadband, you will have more telemedicine usage.”

Old Brooklyn’s Wi-‐Fi is eight years old, which is

seriously old in the technology world. A community today has an array of infrastructure technology opDons at its disposal.

“Fiber will remain the gold standard for a while,” says Lewis-‐Ramirez. However, since it is much cheaper and faster to deploy, fixed wireless can generate revenues to fund some of the cost of a full FTTX build, and can also serve as redundant path to increase wireline network resiliency.”

Here’s just one of my many wriDngs on broadband opDons. Broadband CommuniDes Magazine is a treasure chest of addiDonal recent and archived magazine arDcles that provide a wealth of knowledge regarding broadband buildouts.

“A big concern when telehealth started was, would seniors be comfortable with talking to a face on a screen,” Katrina Heater, a Clinical Household Coordinator at Heartstone. “I have a few who use smartphones who have Facebook, and one used her iPad for church service. Families are good about bring the devices already set up. As we see the generaDons turn over, younger paDents are coming in already using the technology.”

Many vendors design their own sojware and rely on off-‐the-‐shelf devices. A vender named m.Care preinstalls sojware that enables paDents to remotely communicate with customer support rep via video conferencing, text, and other modes just by hieng the “Send” key. m.Care can push medical educaDon back-‐and-‐forth between paDents, or reward and moDvate paDents for good behavior.

The Broadband Leg

CompuDng Devices


Mobile device can present challenges. “Low-‐income residents are likely to have a mobile cellular phone and not likely to have home Internet,” says Angela Seifer, Director of the NaDonal Digital Inclusion Alliance. “Mobile operators such as Sprint and T-‐Mobile offer programs to help these individuals, especially kids, but then the companies put these ridiculous data caps on them. It's a nonstarter.”

A family of four in any month could exceed their data cap with a few doctor consults, sending pictures of a rash, and regular monitoring of a chronic condiDon. Also, venders cannot assume a

paDent can get a free Wi-‐Fi connecDon at the Dme and place they need the app, the only way to beat data caps. Most people will want to use it at home, but the data already shows that home WiFi isn't an opDon for a lot of people.

By and large community networks do not have data caps. Municipal WiFi networks strategically placed in urban areas can drive telehealth and broadband. A fixed wireless network pumping 20-‐40 megabits of data symmetrically (the same upload and download speeds) is great too. And of course, ciDes such as Cha@anooga and Laye@e, LA with their gigabit networks have capacity that keeps subscribers happy.

15


“Surround yourself with others on the same mission as you.” This greeDng welcomes stroke paDents, friends and families, and other customers to Flint RehabilitaDon Device’s Facebook page. Flint’s Facebook and website content includes pictures, videos, and user stories that help customers use their digital products to recover from strokes.

Telemedicine vendors are responsible for customers’ proficiency using these digital products. Flint, for example, uses entertainment, collaboraDon, and simplicity to impart knowledge. Venders and nonprofit organizaDons would do well to help healthcare professionals also become proficient with using their technology.

However, if a community wants telehealth technology to transform their residents and insDtuDons, then they should insist that broadband technology people be involved with the planning, implemenDng, and upgrading community telehealth. Healthcare stakeholders and telehealth vendors manage these projects, but involve input from the broadband team.

MetroHealth is finishing up a pilot program in which they provide digital literacy training to

healthcare professionals who work in primary care clinics. They screen staff to determine if they're using the right digital tools or have literacy those tools, provide brief is educaDon counseling, and provide referrals to community based organizaDons that offer more in-‐depth digital literacy training.

To design the most effecDve digital literacy program, Seifer advises broadband and telehealth teams to consult with those community nonprofits most familiar with the audiences that will use the telehealth programs. “If you’re trying to reach veterans with a telemedicine app, contact local or state organizaDons that service veterans. If you are selling to seniors, talk to groups deals with that populaDon.”

Digital Literacy

05 Telehealth gives general medical

prac@ce an overhaul

16


In 2015, more than 15 million Americans received some kind of medical care remotely last year, with 1 million of those being virtual doctor visits, according to the American Telemedicine AssociaDon. These numbers were expected to grow by 30% in 2016. Just about every person from newborns to seniors may have telehealth influence their lives in some way.

For community broadband owners – municipaliDes, electricity co-‐ops, Wireless ISPs (WISP) and other local providers, telephone co-‐ops – telehealth’s marketability depends on network subscribers’ need for the technology. Specifically, how many people need it, how easily do they understood the technology, does the technology make a difference in the community, and how easily can you package the technology?

This secDon presents three categories of telehealth products and services: 1) general medical services, 2) mental health services, and 3) home health care. The summaries present how or why these are ideal to offer community broadband subscribers.

Docity is a telemedicine vendor that hopes to shake up the world of virtual doctor visits by allowing broadband subscribers to videoconference with their primary care physicians. The alternaDve systems randomly assign paDents to qualified physicians, but physicians that paDents might not see again.

The vendor offers paDents the benefits of telemedicine plus the comfort of the long-‐term ongoing paDent/doctor relaDonship that can’t be easily replicated. PaDents will have their records kept by one physician’ office. Docity makes it easy to sign on doctors and other healthcare provider, handles their payments, and manages/administers the technology elements of the service.

Docity offers community broadband owners a revenue-‐sharing arrangement, markeDng support, Sojware Defined Networking (SDN) capabiliDes, and real Dme analyDcs. PaDents’ on-‐premise equipment (OPE), which includes the router, a laptop or tablet, and an otoscope (diagnosDc device), is easy to install.

The two elements that stand a head and shoulders above the rest, at least for network owners, is the revenue sharing opportunity and the universality of Docity products. The revenue may or may not be

Telehealth gives general medical prac@ce an overhaul

Digital House Calls

17


The revenue may or may not be significant in cash value, but the markeDng value of returning “x” dollars to the network for every telehealth purchase made is high. And the commonality of sore throats, colds, nausea, skin rashes, and sprains should drive subscripDon rates high.

In Good Health is a family pracDce founded in 2006 to provide affordable primary care to individuals and families in the Cha@anooga. In addiDon to the full complement of general medical services, they offer medical home visits for elderly paDents who have difficulty geeng from their assisted living facility.

Dr. Lori Davis was part of a pilot test for Docity products and conducted by EPB, the public uDlity that runs the Cha@anooga, TN public broadband network. She says, “Our paDents who are under 40 were the most enthusiasDc, especially if they have young children. Parents quickly understand that hours spent in the waiDng room full of other sick kids can be painful, whilea video consult is just like being in the room with the doctor.”

Cha@anooga’s gig network and EPB are incredibly popular, and their commitment to telehealth reflects the their devoDon to innovaDon on behalf of subscribers. Dr. Davis and her staff use EPB broadband in the office and their homes. “Our pracDce built its reputaDon on the long-‐term relaDonships we have with our paDents, and telehealth enables us to bring addiDonal value to those relaDonships,” says Dr. Davis.

40% of people in the US don't see a denDst (90% of those 25 to 60 years old), mostly due to cost. Low reimbursement rates, complex forms, and administraDve hassles are why many denDsts don’t accept Medicaid paDents. Medicare rarely covers denDstry, and even regular insurance doesn’t make dental care cheap for individual coverage.

On the other hand, if we eliminated cost barriers tomorrow, there's no way the denDst offices could handle the surge of people, especially in rural where there are fewer denDsts. Healthy Smiles for Kids, a nonprofit, uses teledenDstry to serve 200,000 kids a year but they sDll have a six-‐month backlog.

Besides giving Americans healthier teeth, teledenDstry would benefit communiDes due to the relaDonship between dental health and chronic medical illnesses. “Plenty of research shows the interconnecDon between chronic medical diseases and chronic dental diseases,” Dr. William Jackson, COO at Virtual Dental Care, Inc. “A denDst might see a problem with someone's teeth and suggested they explore the possibility of diabetes or heart condiDon.”

TeledenDstry could open up a new line of consDtuent services for municipaliDes and co-‐ops. The vender combines sojware, teledenDstry devices, pop-‐up denDst chair and mobile cart, the cloud, and broadband to re-‐engineer a typical denDst office into a virtual business ready for urban or rural use. Virtual Dental makes it profitable for denDsts to take on Medicaid paDents and expand their client load.

18

Telehealth gives general medical prac@ce an overhaul

Smile! Tele-‐denDstry rocks

06 Mental health, broadband, and

telehealth

19


The recent suicide deaths of fashion designer Kate Spade and celebrity chef Anthony Bourdain, along with the mountain of news reports on the opiate epidemic, mental health is at the top of a lot of people’s consciousness.

Dr. Edward Kajarian is Chief execuDve of Telepsychiatry for the Statewide California CorrecDonal Healthcare Services. He understands that mental illness, in it’s extreme, can lead to death. “We have 30,000 Americans die every year from opioid addicDons. That’s double the homicide rate in the country. We have over 40,000 suicides every year in the US, many of those as a result mental illness.”

Dr. Kajarian strongly believes broadband and telemedicine are a part of the soluDon to this problem. “There’s no need to delay any broadband projects to rural populaDons that need it the most, whether the networks are owned by communiDes, co-‐ops or whoever.”

To leverage broadband, remember that paDents ojen receive telepsychiatry treatments in their homes. Telepsychiatry requires a good video and audio connecDons with guaranteed security, anywhere between 30 and 100 megabits per second. Slower speeds may be adequate, but doctors may lack enough bandwidth for simultaneously charDng, accessing medical records, or consulDng other informaDon sources.

Mental health, broadband, and telehealth

Telehealth to Fight Opiates Crisis

20

Yes, drug addicDon a mental illness, according to the NaDonal InsDtute on Drug Abuse. “AddicDon changes the brain in fundamental ways, disturbing a person’s normal hierarchy of needs and desires and subsDtuDng new prioriDes connected with procuring and using the drug. The consequences are similar to hallmarks of other mental illnesses.”

The Center for Disease Control has been tracking drug addicDon for many years. They report over 32 million illicit use of prescripDon opioids and illegal opioids like heroin. From 1999 to 2016, more than 630,000 people have died from a drug overdose, with 63,600 of those deaths just in 2016, five Dmes higher than in 1999.

“The opioid epidemic is parDcularly felt in East Tennessee, and where there is street-‐use of opioids, there is also an increase in hepaDDs C and HIV,” says Ma@ McAdoo, COO of Choice Health Network. “Access to quality, competent


healthcare has been a challenge.” Choice Health Network’s Docity telehealth suite is housed in a clinic and interacts with six other telehealth hubs. It took a year to put these professionals into place, and the telehealth program launched in January of 2018.

Choice Health Network’s first-‐year goal is to do 25% of treatments through telehealth, with a higher goal for mental health paDents. Currently they are using these telemedicine hubs for delivering treatment, but it’s also their goal to deliver telemedicine directly to paDent’s homes.

“TreaDng opioid use disorders through telemedicine will likely be a driver as the annual cost of the opioid epidemic in the U.S. has soared to half-‐a-‐trillion dollars.” says Robert Knight, ExecuDve Vice President & COO at Harrison

Edwards -‐ SASHE Group. In Texas, the cost of opioid addicDon and related factors is $21billion. The cost to the state of Michigan is about $20 billion.

MunicipaliDes, co-‐op, and local ISPs/WISPs in every state should team up with telehealth venders with proven mental health success, and make these states an offer. IdenDfy a porDon of the billions of dollars currently spent dealing with opiate addicDon, and redirected some of those fund to community broadband/telehealth hubs focused similarly to Choice Health Network’s hubs.

21


“There are 65 million Americans that have diagnosable mental health illness but we have less than half of the psychiatric providers needed to meet that demand,” says Encounter Telehealth CEO Jennifer Amis. “When you look at many of the rural areas, we may have less than 20% of the number of providers needed.”

Encounter’s naDonal network of board-‐cerDfied psychiatrists teams with long-‐term care faciliDes in rural and underserved areas to provide behavioral and mental health care. There are telehealth companies that provide basic mental health services, such as treaDng minor anxieDes and moderate depression. “But we provide severe mental illness treatments and complicated psychiatric care,” says Amis.

The staff and providers use off-‐the-‐shelf sojware, the Vsee video pla~orm for telehealth encounters,

and a cloud-‐based electronic healthcare records (EHR) system. Encounter also has a clinic that provides services directly to consumer.

Mental healthcare and telepsychiatry


Solid telehealth apps built on strong community broadband networks is key to the vender’s success. “Our pla~orm works well over cellular,” says Amis. “However, if an area has bad broadband they probably have bad cell phone recepDon as well.”

Besides a@racDng broadband subscribers, telehealth can a@ract psychiatrists to a community who are Dred of the administraDve grind, but want to conDnue helping paDents. Amis observes, “Telehealth creates a be@er quality of life for the

provider, gives them be@er flexibility, and they don't have to ‘punch the clock.’” It might not reverse the declining number of psychiatrists, but it could help slow it down.

22


Nancy Hamilton, ExecuDve Director for the Hearthstone senior living buildings in Pella, IA, says, “In 2015 our anD-‐psychotropic medicaDons use was at 15.5% and now it’s at 6.8% even though our acuity of paDents with behaviors has increased. Encounter Telehealth brings constant touch points with psychiatric professionals that we need.

Katrina Heater, a Clinical Household Coordinator at Heartstone adds, “Its experDse that supplements our professionals. Encounter’s staff keeps us informed about state and federal policies, new or changed insurance rules, and medicaDons that cause bad interacDons with other medicaDons.”

Long-‐term care communiDes, including skilled nursing faciliDes, hospitals, and correcDons faciliDes, represent 18 million Americans who have mental illnesses.

Some of these long-‐term paDents plus the millions who can’t afford treatment would be candidates for telemedicine.

There are significant other benefits that telemedicine apps deliver besides treaDng mental health. “Before we had telehealth, it was incredibly difficult geeng paDents to Des Moines, IA for treatments from psychiatric specialists,” says Hamilton. “We don’t have enough psychiatrist and geriatric services in the state, so we were forced to drive over an hour.”

Streamlining LogisDcs

07 Home healthcare

through telehealth and broadband

23


Stephen Morris recalls his father’s ba@le with Parkinson’s disease.

“He was in a rural county where they have general MDs and a hospice within 10 miles,” Morris said. “But specialists were over two hours away. My family would have appreciated telemedicine. Several Dmes my brother or I had to leave work, drive down, and help Mom take Dad to the closest equipped hospital that was an hour from where they lived.”

Morris is a principal of FoothillsNet, a broadband consultant for rural America. He believes telemedicine is incredibly difficult, if not impossible, without broadband. “I envision teleconferences with medical specialists located hours away who give advice in real Dme, and adjust medicaDons to reduce costly ER visits and hospital stays,” he said. Broadband owners need to convene with healthcare professionals to ascertain connecDvity needs on the “Home” end of the home healthcare equaDon. Many hospitals are invesDng in remote paDent monitoring (RPM) projects to cut down on readmissions penalDes, length of stay, and paDent mortality, all of which affect overall hospital costs. With RPM, flagship hospitals also are partnering with rural intensive care units (ICUs) and emergency departments to assist in monitoring.

Home healthcare through telehealth and broadband

Home monitoring applicaDons: the telehealth sojware, equipment, and devices that collecDvely people can buy, rent, install, use, or wear to stay connected to healthcare ajer their hospital stay or a doctor’s diagnosis. Community broadband can be the engine that makes it happen.

The Centers for Disease Control & PrevenDon (CDC) has characterized chronic diseases and condiDons such as heart disease, stroke, cancer, type-‐2 diabetes, obesity, and arthriDs as the leading cause of death and disability in the United States. As of 2012, about half of all adults, or 117 million people, had one or more chronic health condiDons, and one of four adults had two or more chronic health condiDons.

Chronic Illness

24


“The chronic care paDents accounts for over 40% -‐ 50% of the overall healthcare cost. Telemedicine can drive that cost down.”


CriDcally chronically ill paDents in rural areas two or three hours away from a medical facility are prime candidates for telehealth. Travel Dmes issues plague urban areas as well through inadvertent redlining brought on by public transportaDon. “In North Omaha the public transportaDon systems are inadequate, so a person trying to get to the main hospital in downtown Omaha may take two hours or more for what should be a 20 minute car ride,” states Amis.

Steve Hendrix, president of home-‐health monitoring vender m.Care says, “The chronic care paDents accounts for over 40% -‐ 50% of the overall healthcare cost. Telemedicine can drive that cost down. When m.Care paDents are discharged, they receive iPads with our sojware pre-‐installed, Bluetooth-‐enabled devices pre-‐synced to that iPad, and a MiFi mobile WiFi hotspot so the home has internet capabiliDes.

Analysis shows that is paDents are moDvated to do everything they have been instructed because they don’t want to impose on relaDves and friends get them to healthcare a recurring basis. Insurance companies are moDvated by these telemedicine soluDons because it saves them lots of money because paDents aren’t returning to hospitals less than a month ajer their treatments.

Several chronic illnesses such as diabetes, obesity, high blood pressure, and heart disease are the result of people’s bad habits – smoking, drinking, over eaDng. It is much more effecDve and cost-‐efficient to prevent chronic illnesses then treat them ajer they become the problem, the CDC develops programs to address prevenDon, such as its Diabetes NaDonal PrevenDon Program.

Telehealth vender Fruit Street is one of several companies delivering digital therapeuDcs for, in their case, digitally addressing bad habits that have medical consequences. Fruit Street CEO Laurence Girard says, “Digital therapeuDcs may be programs that deal with sleep, stress, and resiliency, others may focus on opiate addicDon or general mental health.

Fruit Street’s Digital Diabetes PrevenDon Program combines group telehealth sessions, wearable devices, and dietary tracking in the vender’s mobile applicaDon. Besides lowering the risk to develop type 2 diabetes, the program can also lower the risk of having a heart a@ack or stroke, improve health overall, and help subscribes feel more energeDc.

“We have a 6 million people who are pre-‐diabeDc, meaning they are at risk for developing diabetes,” says Girard. “You have somewhere between 20 and 30 million people with diabetes. It may not technically be considered an epidemic, but it is a major problem.”

Digital TherapeuDcs



30 years ajer Star Trek, the dream of bloodless surgery sDll exists for some people, but there’s a long way to go before the dream becomes reality. Virgo CEO Ma@ Schwartz believes that surgery and surgical procedures cannot be performed safely and appropriately yet. “When you manipulate a scope that allows the doctor to see inside the colon and possibly remove a polyp, it’s extremely difficult to replicate that.”

Telehealth and broadband can, however, play a role supporDng surgical procedures. Virgo markets a cloud-‐based pla~orm for recording colonoscopies or other endoscopies (exams of the digesDve track). “Need good broadband to get video from endoscopy source to the cloud, and then to the end users,” says Schwartz. “Not only do we need high capacity networks, but also we need them to be stable so we don’t lose video as it’s being transmi@ed off the cloud storage.”

Orthopedic, cardio, and other surgeons can use telemedicine apps to guide paDents through quesDons to assess their injury or problems, examine the injury through video, and explained the diagnosis. Surgeons can make a treatment plan, dispense educaDon material about the surgery from a portal, and order equipment such as braces or walkers for home delivery.

OrthoLive is an orthopedic telemedicine company that provides consumers with a network of orthopedic specialists and physical therapists. The vender also provides a telemedicine pla~orm to manage electronic health record systems and orthopedic provider groups.

Mike Greiwe, OrthoLive’s CEO, says “Only 10% orthopedics work is surgery. We have many paDents who are elderly and need remote monitoring, especially right ajer surgery.

We’ve been working with home-‐health monitoring companies and short-‐tern nursing faciliDes to enable our services that reduce re-‐admissions. We monitor wound care, surgical incisions, and rehab acDviDes.”

Tim Gee, Principal of Medical ConnecDvity ConsulDng suggests that insurance companies direct hospitals’ post-‐surgical staff to work from home via telemedicine to service paDents. “This saves hospitals money because they have any overhead other than the telemedicine equipment, the broadband connecDon and the staff’s Dme. Telemedicine allows the hospital to do things that reduce re-‐admissions that otherwise would not be pracDcal or affordable.”

Pre-‐ and Post-‐surgical Procedures


Physical rehab can be prescribed following strokes, heart a@acks, traumaDc injuries to body limbs, surgery to repair or replace joints, tendons, and ligaments, and host of other injuries and ailments.

Only 35% of physical therapy paDents fully adhere to their plans of care, and 30% of paDents who receive outpaDent physical therapy services a@end all the visits their insurance company authorizes. A good dose of telehealth and broadband can potenDally and dramaDcally these numbers.

Why the low numbers? Rehab acDvity has proven itself beneficial, but it is terminally boring!! Second, except for Dme spent with a therapist, rehab is ojen a solitary endeavor. Third, it is financially and logisDcally impossible to have a physical, occupaDonal, and speech therapists for as many hours as a paDent needs.

Flint RehabilitaDon Devices developed a product called MusicGlove, which incorporates sensors, sojware, the Internet and a Guitar Hero-‐type game that “tricks” a stroke-‐afflicted hand into believing it’s actually moving. Ajer a few weeks, the hand catches on and begins to move on its own. Vendors who marry fun with the addicDve

behavior of computer gaming have a chance increasing rehab success.

Dr. Nizan Friedman, CEO and Co-‐Founder of Flint, believes broadband also adds an extra value to the rehab process because it bridges the gap to knowledge, medical or otherwise. “PaDents can access and use applicaDons such as ours, tap into experDse from medical faciliDes, universiDes, and private-‐sector organizaDons, and join social networks to overcome isolaDon,” he says.

We don’t have to wait for the venders. Surgeons generally do not control what therapists do,” Dr. Stefano Bini, Professor of Orthopedic Surgery at the University of California San Francisco. “But with the telemedicine pla~orms that are out there, can I custom-‐design and prescribe a set of exercises that can be led by an avatar or a video? I may have a staff person monitor your use of the pla~orm.”


27

Rehab to Recovery



Seniors are one of a main demographic target of home healthcare. In both urban and rural communiDes, the concept of “aging in place” is gaining tracDon. Family caretakers, healthcare stakeholders, and community leaders are trying to assemble resources, ameniDes, and technology that enable seniors to remain in their homes rather than enter senior insDtuDons.

The Center for Disease Control provides some stats to put healthcare for this aging populaDon into perspecDve.

•  Fewer than half of adults age 65 years or older are up-‐to-‐date with core prevenDve services despite regular checkups. This includes immunizaDons, screening tests and counseling.

•  There are racial and ethnic dispariDes in the receipt of [healthcare] services. For example, 44 percent of blacks reported not receiving influenza vaccinaDons compared to 29 percent of whites.

•  Rural populaDons have more chronic illnesses to start with, including higher rates of diabetes, stroke, cogniDve impairment, heart arrhythmia, and heart failure.

•  A survey of physicians showed almost one-‐half (46%) report restricDng services to Medicare paDents.

•  In addiDon, 90 percent of seniors recently surveyed by HealthMine said they either don’t have access to telehealth through their Medicare plan or they don’t know if they have it.

“Falling is the number one problem for seniors,” says Anthony Cirillo, President of The Aging Experience. “If a senior falls, many Dmes something will break, which leads to hospital stays, surgeries, and rehabs.

But really, a person in their 70s or older who has any type of a major medical event ojen faces a cycle of greater complicaDons later on. It’s the aging process.”

Hospitals are using telehealth apps to monitor paDents whether they’re dealing with heart failure, diabetes, a broken hip, etc. Community broadband builders should explore “Smart city” applicaDons that include sensors for various occurrences in the home.

Lewis-‐Ramirez says, “We know Nokia is developing a suite of sensors and apps to monitor elderly persons in their homes, thusly empowering them with more freedom, autonomy and comfort than they would have in a tradiDonal nursing home.”

Those sensor-‐enabled products in the “I’ve fallen and I can’t get up” ads years ago have become more sophisDcated. Cirillo says, “Sensors now can tell how long it’s been since a parDcular acDvity occurred which may indicate a person fell. A nurse can determine how long since a person’s been to fridge, a sign an Alzheimer’s paDent maybe forgeeng to eat, or take their medicaDon.”

Seniors and Aging in Place

08 The telehealth pilot –

where we go from here

29


OrganizaDons ojen run pilot tests to determine if the technology works as adverDsed, that end users are comfortable with the technology, and how well the product will adapt to the organizaDons needs. Telemedicine pilots should be conducted with community broadband subscribers to also test various markeDng approaches and messages.

Besides tesDng technology, an effecDve pilot can enable the network’s management. The community can verify the intended telemedicine benefits by providing feedback on different types of telehealth apps and services as well as feedback on the markeDng tacDcs and messages. Just don’t let the test run too long.

Telemedicine pilot tests may require a lean team that consists of a representaDve of the local government, a co-‐op’s or public uDlity’s management team, several healthcare professionals, a member of the community, and a telemedicine vender or consultant. If there’s going to an “unconvenDonal” organizaDon such as a school or a library as part of telemedicine delivery system, a director or administrator should be part of the team.

James Cowan, CEO of Docity, says, “The team should pick the parDcular telemedicine applicaDons to be tested, but there also should be ample input from the community within the geographical area for the pilot test.” The telehealth categories listed in this report are good places to start.

Resources to help facilitate the pilot test could include community nonprofits and funding sources. The team should take into account there likely will be a per-‐person cost associated with the pilot that may or may not be covered by Insurance.

The telehealth pilot – where we go from here

30

Ellumen’s Technology Strategist John Kornak recommend the following checklist of acDviDes to increase the success of the pilot test:

•  Administer a survey to potenDal pilot test parDcipants gauge their expectaDons of the pilot;

•  Include local physicians either as parDcipants or observers;

•  Document how healthcare is being administered currently in the medical disciplines that the pilot addresses;

•  Creates analyDcal engine of some sort to access the data gathered.


The telehealth pilot – where we go from here

MarkeDng Breeds Success

“Telemedicine offers a lot of potenDal revenue because everything related to healthcare is expensive to deliver, but which the Internet makes cheaper.”

MarkeDng is criDcal the success of a telehealth, both in meeDng the healthcare needs of the community, and giving the community’s broadband network extra compeDDve muscle. Subsequently, the pilot has to gauge the marketability of telehealth within the community.

Isak Finer is the Chief MarkeDng Officer at COS Systems, which offers sojware to help communiDes plan and operate broadband networks. “Telemedicine offers a lot of potenDal revenue because everything related to healthcare is expensive to deliver, but which the Internet makes cheaper.

Broadband owners use smart demand aggregaDon (needs assessments) to determine which neighborhoods want telemedicine, educaDon, or the other types of services delivered over the network. Engineers subsequently build networks that “follow the money” and potenDal revenue for the city and service providers.

“If you have good sojware, you can determine that the north side of town has a heavy senior populaDon, for example, and you offer them telehealth monitoring services to check on people's well-‐being within the home,” says Finer. “Or the east side has a populaDon with a tendency for diabetes, so you can recruit telemedicine app

venders that offer video group counseling.”

Any community broadband network delivering telehealth services needs to partner with The Center for Connected Health Policy (CCHP) and Telehealth Resource Centers (TRCs).

“The CCHP is a non-‐parDsan nonprofit policy organizaDon started to form California telemedicine policy,” states ExecuDve Director Mei Kwong. “Now we’re a naDonal telehealth policy resource center” Their responsibiliDes include policy technical assistance to the state TRCs, answering policies quesDons, responding to calls from Congress people, naDonal and state officials.”

Kwong believes “We ask a lot of quesDons to cause people to think and re-‐think their policy decisions, though we are prohibited from lobbying.” Broadband teams will find CCHP to be a good advocacy partner and markeDng ally.

CCHP is responsible for keeping current their Web based interacDve map in which they list all of the telehealth policies, laws, and regulaDons for all 50 states and the District of Columbia. They also do policy analysis and conduct research.

TRCs were established to provide assistance, educaDon, and informaDon to organizaDons and individuals who are acDvely providing or interested in providing healthcare at a distance. Their charter to assist in expanding the availability of healthcare to underserved populaDons, ojen free of charge.

09 Recommenda@ons

32


Many of the people interviewed for this report have offered advice to those building broadband networks and facilitaDng Telehealth deployment. Here’s some of that advice.

Dr. Stefano Bini, Professor of Orthopedic Surgery at the University of California San Francisco

The cost of paDents who use the ER as their primary physicians because they lack insurance, plus the number of needless trips to the ER from the general populaDon put a huge financial burden on ciDes and counDes. Assess how much money they would save by local governments and hospitals by building broadband infrastructure to treat these visits via telemedicine.

Some have found it to be cost-‐effecDve to hire healthcare professionals such as nurses or physicians assistant to go into people's homes on a regular basis to treat people with chronic diseases that otherwise will eventually end up in the ER. Why not use both home visits and telehealth?

Vic Ga[o, CEO of Jumpstart Foundry

Follow the money, specifically venture capital money. Partnering with well-‐financed telehealth startups can be beneficial. Our angel fund targets small startups, maybe three or four people. They have a product that works, but may not have any scale to their operaDon currently. We get involved to help them build a business around that core.

Tiela Chalmers, CEO, Alameda County Bar Associa@on

The local library can be a secret weapon in telehealth deployment. Public libraries ojen are the most well-‐known and trusted local government enDDes. They also can have the fastest broadband speed in town and are centralized meeDng places for local residents.

Libraries can consider doing a variaDon on a program called Lawyers in the Library. There’s no central ‘template’ or mandate for these events, but each community decides on a structure. Typically a local Bar AssociaDon and a library screen lawyers by specialty, then adverDse they schedule. Those who can’t afford lawyers can sign up for specified hours.

Clearly this is not the same as retaining legal counsel, but allows parDcipants to get some basic Dps on how to proceed. In the telehealth world, libraries and local physicians by respecDve specialty can schedule Dmes for library video consults. Many libraries are loaning patrons Mobile Beacon’s mobile hotspots to use in their homes on a limited basis. These units can extend Telehealth in the Library programs.

Recommenda@ons

33


Tim Gee, Principal, Medical Connec@vity Consul@ng

Small companies that aren’t self-‐insured sDll can leverage telehealth for their employees. A community or the community broadband provider should engage with the insurance companies, local or regional healthcare providers, and local businesses, and work out what everyone can do to make telehealthcare cost-‐effecDve and efficient. Everyone has to be willing to make accommodaDons.

Steve Hendrix, President, m.Care

One of our clients in Red Oak Iowa, Montgomery County Memorial Hospital, went to their local business commi@ee and offered them telehealth care services. Even a small company can offer telemedicine services to their employees remote paDent monitoring and virtual care. Establish some sort of telehealth program to moDvate good pracDces for employees to get healthy and stay healthy. You will have accomplished a great deal.

Laurence Girard, CEO, Fruit Street

To address the lack of broadband in underdeveloped areas, the government could facilitate building be@er networks, which would be the ideal. Or maybe insurance companies’ health plans or employers can upgrade employees’ Internet service or build some infrastructure for deploying telehealth. If it only cost $50 a month, maybe there can be a CPT code for ‘Internet upgrade’ for telemedicine services.

Ben Lewis-‐Ramirez, Business Development Manager at Foresite Group

Healthcare faciliDes and by extension telehealth providers, parDcularly in rural areas, can serve as anchor tenants that help solidify business cases in community broadband projects. In big ciDes, funding a network strictly with revenues from telehealth will be a more challenging case to make. You may have to build limited-‐reach networks to serve the un-‐served or underserved communiDes.

Mike Greiwe, CEO, OrthoLive

There’s going to be a globalizaDon of medicine and of experDse in medicine in the next five years. I think we’ll see small offices set up in rural areas, One might have an EKG machine, another one an x-‐ray machine some other small devices. A nursing staff can run these networks of offices, and everything will be connected by telehealth.

The network owners need to contact the owners of telemedicine companies to structure a technology role that facilitates telehealth deployment and adopDon. Those operators have a special feeling of commitment to their communiDes. And they know how to get in touch with the right people and make things happen.

Joe Kochan, COO, US Ignite

Broadband networks will have to keep ahead of that curve in terms of network capacity. Many of the telemedicine apps popular today are basic medical assessments, check-‐in's, or general consults with physicians. Soon, we’ll be able to train students in a new or enhanced medical procedure using virtual reality. Or one person can walk surgeons through procedures using a 3-‐D model of the brain created with CAT scans, while you and I each have a model of a liver as I watch what you do and offer correcDons.

Be watching the CJ Speaks Web site in the weeks ahead for more excerpts from these interviews with Dps and recommendaDons for project teams working to deploy broadband and telehealth infrastructure.

Recommenda@ons

34

About the Sponsors


COS Service Zones is a demand aggregaDon tool enabling the broadband network builder to collect grassroots’ desire for be@er broadband and pre-‐sell Internet connecDons. It splits targeted area into smaller compeDng zones, where the zones show the greatest demand will be connected first.

Craig Se@les helps municipaliDes and co-‐ops build the business and markeDng cases for their community broadband networks. Mr. Se@les’ needs analyses opens up opportuniDes to raise money for networks, as well as increase the financial sustainability of the networks.

About the Author

Craig J. Se@les

35

Docity partners with municipaliDes, co-‐ops, local Internet service providers and others to bundle telehealth access services. PaDents can schedule video consults with their primary doctors and specialists, keep their health records local, and contribute to their community broadband networks.

Encounter Telehealth partners with skilled nursing faciliDes and long-‐term care communiDes to provide behavioral healthcare. Encounter brings the provider to the paDent, parDcularly underserved communiDes, wherever they may be. Its mission is to provide evidence-‐based, quality care to as many as possible and support Encounter’s providers.

Foresite Group is a mulD-‐disciplinary design, planning and engineering firm. It’s Group’s Network Design PracDce Area has built up its Gig-‐City Program that creates “Smart” ciDes. FG works with ciDes and uDlity companies to create networks for their future, and to change communiDes in all aspects of life.

july report 2cjspeaks.com/wp/wp-content/uploads/2018/07/snapshot-7-18.pdfcj)speaks)|)conﬁdendal)...

Documents