Wednesday, September 12, 2012

Geisinger Comments on Broadband

In response to the FCC Wireline Competition Bureau’s request (Public Notice DA-12-1166) seeking comments on the FCC’s “Rural Health Care Pilot Program”, Frank J Trembulak, Executive Vice President and CEO for the Geisinger Health System submitted comments. The comment date opened August 23rd and closed September 7, 2012.

As explained in the comments, when the pilot program was announced, Geisinger briefly considered physically constructing a network. Given the location of the hospital partners, Geisinger planned for a ring network to provide the level of reliability required for healthcare but found that the cost of fiber construction would be $40,000 per mile, the cost of the network would exceeded $6 million, and ongoing maintenance would have been detrimental to sustainability. In addition, funding would not be available for fiber construction to add partners to the network in the future.

In his comments, Trembulak described how broadband can really impact rural healthcare providers. Because broadband connectivity continues to be expensive and/or simply not available in many rural areas, many aspects of the pilot program are critical to the future of telehealth nationwide.

In the case of telemedicine, Trembulak explained how Geisinger’s bandwidth requirements for family practice clinics has grown from 1.5 Mbps several years ago to 10 Mbps. Major clinics are slowly being upgraded from 100 Mbps to gigabit connectivity that is being driven by specialties such as radiology and cardiology.

In regard to connectivity to partner hospitals, the focus of the pilot program bandwidth requirements are more modest. An important outcome of the pilot program was that Geisinger and partner hospitals were able to experiment with various telemedicine technologies. This has helped to determine bandwidth needs.

Community hospitals are not always in a position to fund high-bandwidth connections and the pilot program helped Geisinger determine that a cost-effective alternative would be a T1 line to support diagnostic video combined with a Virtual Private Network (VPN) to transfer studies.

Geisinger will use the additional pilot program funding period to cover the transition to this affordable alternative. However, Geisinger has some concerns since the size of imaging studies will increase in the long term, bandwidth requirement may exceed what can reasonably be expected from a VPN.

Other issues that may affect bandwidth requirements are teleradiology since requirements vary greatly depending on the type of study. For example, in the case of a follow-up X-ray, where the image file is small, the 1.5Mbps connection typically provided at a family practice is adequate. However at the other extreme, when a high-resolution study is done and real-time involvement of a radiologist is needed, a minimum of 10Mbps and preferably 50 Mbps is required.

As Trembulak pointed out in his comments, implementing EMRs can be expensive, so it is likely that many rural physician practices and rural community hospitals will use an EMR hosted off-site. This will increase not only bandwidth requirements but also reliability requirements for rural healthcare.

While a minimum of 10Mbps at physician practices and a minimum of 100 Mbps for a community hospital can be adequate to support the EMR itself, use of an EMR generally includes transition to a paperless environment which implies PACS and business imaging. Depending on how these systems are hosted and integrated into the EMR, bandwidth requirements could be much higher.

Trembulak stressed how urban and for-profit entities should be considered eligible due to the fact that many for-profit community hospitals treat underserved populations and are severely resource constrained.

By including these entities, all patients would be covered regardless of where they receive their healthcare and more telehealth sites should be available in diverse areas. Today, five community hospitals in Geisinger’s region with an average bed size of 178 are for-profit and are currently considered ineligible for FCC funding if they want to participate in telehealth programs. Profit margins at these hospitals preclude them from implementing robust broadband and gaining the advantages of using telehealth.