the slides here - North Carolina Telehealth Network

For ORH HealthNet Group 4/27/2016
Dave Kirby, NCTN Project Manager
dave@kirbyimc.com
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Importance and Value of Broadband Services to typical
clinic.
Broadband Basics for Clinic Managers
How to acquire/manage broadband services
NCTN Concept and History
FCC Discount Program
NCTN Concept, History, Status and Prospects
Exemplars - Rural Clinics, Public health, behavioral health,
FQHCs, Free Clinics, hospitals, data centers, admin offices.
NCTN Value to typical clinic; Contacts – (Laura, Ruthy,
John, Dave)
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Info Sys Importance is Up: information systems have become more important to planning,
operating, and improving the value of care delivered in the typical clinic.
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Electronic Health Records (EHR) – to improve clinic service management
Health Information exchange (HIE)-to support care across the continuum
Telemedicine – to support use of care providers in remote locations to assist in care of local patients; improve
access, lower cost/patient, improve outcomes.
Email, web sites – to support communications with patients, providers, the public
Info Sys Use Incentives are Up: incentives/penalties for valuable use of information
systems is increasing:
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The Meaningful Use of EHRs Program
NC State requirements to use HIE
FCC program for broadband subsidies ; HRSA/USDA program of grants/loans for IT and broadband support
NC State support for telemedicine
Private philanthropy support for programs that include information systems.
Public policy that favors timely communication among providers (ACOs, Patient Home)
Private policy that requires a common information systems available across many sites (e.g. health systems)
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..and Increasing: Info Sys importance and use incentives are continuing to increase over time.
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Why? – When properly used, information systems support better quality of care for more people
at lower costs.
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Info Sys Operations need e-pipes: Most clinic-related
information systems used by the typical clinic require
access to the world outside the clinic. Notably: EHRs,
HIE, email, claims, telemedicine, teleeducation, web site
access, VOIP.
Broadband Services are e-pipes: Broadband services
provide the “pipes” to the outside world.
Typical e-pipe: is a connection that moves all data traffic
across the Internet (to/from all other Internet-connected
services).
Other e-pipes: point-to-point services from one site to
another without using the Internet (e.g. spoke-and-hub for a
larger collection of sites)
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Bad responsiveness for an information system means:
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Clinic providers take more time to process patients.
Patients wait longer or leave – remain in distress longer
Overtime for clinic staff (or continuing backlog of work)
Lowered reputation for the clinic
Provider, staff, and patient frustration.
Pixelated interactive video (as for telemedicine)
Poor voice quality (as on VOIP)
Responsiveness is a consequence of a combination of:
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Speed of local PCs and clinic internal network(not often a problem with networked apps)
Speed of the local site’s (clinic’s) broadband connection (often the weak link)
Speed of the remote site’s (data center) broadband connection (not often the weak link)
Load from users other than the local site’s users on any “shared” parts of the network (e.g.
the Internet or oversubscribed broadband services)
◦ Load on the remote server from other users’ activities.
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So, poor responsiveness might come from many sources but the clinic’s
broadband speed and “Internet traffic clogs” are often the limiting
factors.
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Loss of broadband service (typically) means:
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No more EHR access.
No access to patient records
No access to claims systems
No email
Loss of VOIP (if the clinic uses VOIP)
No web site access
No telemedicine or teleeducation sessions.
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Typically, during a broadband outage:
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Having adequate Broadband Services is essential to minute-tominute operations of the typical clinic.
◦ Clinic operations stop;
◦ Hourly staff go off the clock;
◦ Patients leave the clinic – with no idea when to return because you can’t access
the scheduling features of the EHR.
◦ VOIP phone service is down.
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For the typical clinic obtaining an adequate broadband
service at an affordable cost is critical to meeting its
mission of serving the public.
Let’s explore how to obtain and manage these
services….
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Other User sites
(mobile too)
Clinic Site
Clinic
PC
Data Center
Server
Line A
Router
Line B
Cloud
Line C
Router
Other datacenters
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Line A – Clinic’s Internal Network (i.e. switches cables, WiFi access points)
Line B - Clinic’s Broadband Service
Cloud – Collection of cables, fibers, routers, switches running cross-country
and connecting to other clinics, data centers. Internet; point-to-point
connections don’t have a cloud
Line C - Data Center’s Broadband Service
Data center – physical site with collection of “servers” that deliver the services
invoked at the clinic (e.g. EHR, HIE, email)
Data Center/
Hub site
Clinic Site A
Clinic
PC
Line A
Server
PTP A
Router
Router
Router
Clinic
B
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Clinic
C
Cloud
Line A – Clinic’s Internal Network
PTP x - Clinic’s Broadband Service - connection to hub (no Internet)
Cloud – attached at the data center for use by all clinics to reach Internet
Data center – same as before
TIP: Typically, hub and spoke model is used to lower costs and improve
server access, provide better local access control to the Internet
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Wi-Fi – a wireless short-range network (buildingsized). Typical clinic has a Wi-Fi network available
only in the clinic building.
Asymmetric speeds: Upload/download speed – some
network services are designed to have different
upload/download speeds. Often, this is to provide more
download speed (At the expense of upload speed).
Fiber (vs copper) networks: fiber is the most
common way to provide high speed today; copper
(e.g. DSL) makes use of older wire plant but has
limited speed.
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Speed – usually in megabits per second. Sometimes different
speeds for incoming data (to clinic) vs outgoing. Slower speed of
service often slows the response of a server (EHR, HIE)
Latency – how long it takes for data to move between the clinic
and a server; usually in average milliseconds. Longer latency
delays server response to clinic request. Interactive video and
VOIP may not work well with long latency
Jitter - high variability in data movement time across the
network; often affects real-time apps like VOIP, interactive
video;
Uptime - pattern of network availability/outage; monitoring by
vendor; SLA (Service Level Agreement)
Cost – usually a startup fee and a monthly recurring cost.
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A slowdown or outage of an information service at a
clinic can be caused by one or more of the following:
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Clinic PC- outage or overuse
Line A - clinic internal net – outage or overuse
Line B - clinic broadband service- outage or overuse
Cloud – outages or overuse of cloud resources
Line C – data center internal net- outage or overuse
Server - application server – outage or overuse
Typical clinic staff don’t have a way of determining
which component(s) are causing an outage or slowdown.
TIP: So, having good vendor help desk support is critical to
timely resolution.
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Overload?: Typically, the amount of data traffic that a clinic
presents to its broadband service builds over the day to a peak
“load” at mid day. Load – measured in average megabits per second
across a given time span.
When this load is greater than the speed of the broadband service
(or other IS component), a slowdown occurs.
TIP: So, having your broadband speed be higher than your peak
demand will reduce slowdowns.
A: Max BB Svc
Speed not
overloaded
Load
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B: Max BB Svc
Speed overloaded
5am
8 am
12pm
2pm
5pm 7pm
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Speed – instantaneous data transfer rate (e.g. 10mbps)
Thruput – actual rate at which data can be moved over
a given time frame (e.g. Our thruput at peak time is
often 4 mpbs).
Oversubscribed services vs not - vendors may offer a
service with a “speed” that is much higher than the
actual “thruput” to lower costs while appearing to offer
a better service.
Address speed vs thruput in your contract for service.
TIP: Measure thruput and have vendor do this to
assure delivery during life of service.
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Cable/Fiber cuts (most common)
Software outage in servers (commonly) or network
components
Viruses (on servers, PCs (commonly))
Power outages (to clinic is common); uncommonly
network equipment
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Speed – obtain (contract for) a speed (up and down) that will be
well above your peak load over the life of the contract. Be cautious
of over-subscribed services.
Thruput – actual rate at which data is moved over a given time
frame;
Oversubscribed services vs not - vendors may offer a service with
a “speed” that is much higher than the actual “thruput” to lower
costs while appearing to offer a better service. You really care about
thruput.
Address speed vs thruput in your contract for service.
Measure thruput and have vendor do this to assure delivery during
life of service.
TIP: A lot more speed does not cost much more: Note that,
typically, doubling the speed of a broadband service raises its price
by only 10-20%
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Latency/Jitter – most common management tool is to
get even higher speed to prevent contention for
bandwidth that raises latency/jitter.
TIP: A lot more speed does not cost much more:
Note that, typically, doubling the speed of a broadband
service raises its price by only 10-20%
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Broadband service provider’s network service
structure – how much control over data flow do they
have; how well is net monitoring done; availability of
capable help desk function.
Redundancy- If uptime is super important to you and
your outage is not acceptable, consider getting a second
broadband service at the clinic site whose physical path
and network device set is (as much as feasible) separate
from the primary service. This second service can also
be used to carry traffic load in normal times.
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Compete services where feasible
Be sure to compare apples-to-apples
Consider the “buried” but important costs of provider
time, patient time, etc in balance with saving money on
a slower (or oversubscribed) less reliable broadband
service.
Make use of grants/subsidies where feasible.
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… before I move on to NCTN
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Concept: NCTN is a dedicated non-profit broadband
network with Internet and Internet2 connections to
support health and care in NC for public and non-profit
healthcare providers.
Key design points:
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Low cost (mostly via volume purchase and discounts)
Very high reliability (disaster-resistance)
High bandwidth with no over-subscription
Support key communications among healthcare stakeholders.
High user community collaboration in building and operating
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Statewide Intranet: Traffic among NCTN subscribers does not transit Internet
or Internet2; So, traffic control and security are better.
Managed Network: NCTN has an active monitoring point at each subscriber
site and monitors the service’s operational status 24x7. 24x7 NOC (with real
humans)
Priority on repair: TSP registration
Internal Redundancy: Multiple paths around the net and to/from the Internet
Site Service redundancy (when desired): local loop path diversity
65% Discounts from FCC HCF program: Subscribers pay only 35% of the
service costs.
MCNC - nonprofit provider whose sole mission is to support broadband for
public and non-profit entities in NC (Universities, K-12, Community Colleges,
healthcare, others). DIT is partner. State contract pricing and volume pricing.
Competitive bid.
Focus on Rural Sites: NCTN is 62% rural (according to FCC). NCTN serves
everywhere (not just the easy to reach places).
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Conceived in late 2007 as an NC community project
Phase 1 – NCTN-Public Health
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Phase 2 - NCTN-Hospitals
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Phase 3 – NCTN-EXtension
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◦ Two rounds of recruiting of public health, free clinics, and (a few)
community health centers
◦ Operational – started late 2010
◦ Recruitment of hospitals
◦ Operational - 2011
◦ Extension – more sites (hospitals , CHCs, public health
applicability through 2025).- started 2012
Phase 4 – HCF (started use in 2014)
Contract
◦ Use of permanent subsidy FCC program Healthcare Connect Fund
(HCF) (65%) discounts (i.e. subscribers pay only 35% of service
costs).
◦ About 300 sites now. Growing at about 50 sites per quarter.
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Cabarrus Health Alliance- project administrator
NC Association of Local Health Directors
NC Association of Free Clinics
NC Hospital Association
University Health Systems of Eastern NC(Vidant)
Albemarle Regional Health Services
Western Carolina University
Southwestern Commission
The e-NC Authority (currently NC Broadband)
NC Division of Public Health
NC Institute for Public Health (UNC)
Golden Leaf Foundation
FCC and USAC
NCHICA
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HIE - Health Information Exchange
◦ Needs very high reliability for optimal value
◦ Uses paths between providers and to/from HIE; Internet
connectivity.
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EHR - especially for ASP/remote models
◦ Requires very high reliability; low response time. Business
stops, clinics stop when not available/responsive. Internet
connectivity
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TeleEducation –
◦ With live video/audio needs low jitter/latency, high reliability,
medium bandwidth(minimum 10mbps), to high bandwidth (for
telepresence); Internet connectivity (maybe I2 connection)
◦ Web-based education (enduring materials) – needs
responsiveness, medium reliability. ; Internet connectivity.
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TeleHealth ◦ Live medical imaging (e.g. telepsych, telestroke, echocardio,
orthopedics, ICU monitoring) needs low jitter/latency, medium
bandwidth, high reliability. Internet and (unlikely) I2
connectivity.
◦ Store and Forward (e.g. MRI, radiographs, CAT, Derm) need
high bandwidth, high reliability. Internet and (unlikely) I2
connectivity.
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Voice service
◦ (between sites via VOIP for subscribers with several sites)
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Disaster response –
◦ Most public non-profit healthcare providers have key roles in
responding to community disasters (e.g. hurricanes, tornadoes,
ice storms, earthquakes, bio-events)
◦ requires disaster-resistant level of reliability; high bandwidth;
low MTTR; Internet and perhaps I2 connectivity.
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Sunset the pilot program in 10/2016.
All initial subscribers renewed for phase 4 (permanent
HCF program) except 2.
Mission Statement
MCNC is an independent, non-profit corporation that operates the North Carolina Research
and Education Network (NCREN). NCREN connects all K-12 school districts, community
colleges, universities, and select non-profit health care sites throughout the state to each
other, the Internet, and global research networks at very high speeds.
Vision Statement
Through the provision of value-added services, tools and its operation of NCREN, MCNC
helps improve teaching, learning, research, health care, and collaboration throughout North
Carolina in a cost-effective environment for constituents.
Purpose
Access to broadband and fiber-optic infrastructure is essential for innovation and economic
development everywhere in North Carolina. MCNC enhances the state’s competitive
position in the world by providing high-speed access to Community Anchor Institutions
(CAIs) throughout North Carolina while also offering fiber assets to the private sector to
help meet the broadband demands every citizen needs to succeed in the 21st century.
Tenure
Over 25 years
MCNC greatly values advice and feedback from our constituents. Our
advisory structure provides a mechanism for receiving valuable strategic
advice and engaging in tactical and operational collaborations with the
NCREN community.
MCNC Board of Directors
MCNC is governed by the Board of Directors, who are primarily business
leaders in education and technology arenas. The Board is the only component
of the governance and advisory structure with fiduciary responsibility.
MCNC Advisory Council (MAC)- provides valuable strategic advice to
MCNC. Members of the MAC are primarily technology leaders in the
education and healthcare sectors. These technology leaders understand the
technical needs of the community and brief and advise the board on
opportunities and issues that are strategic in nature.
Working Groups- are open to all constituents, and are formed to advise
MCNC on issues specific to the group's area of expertise.
Focus Groups- are formed to deliver a specific, assigned deliverable to a
working group.
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17 UNC System Institutions
26 of 37 independent colleges and universities
58 Main Community College Campuses & 37 Remote Campuses
115 Local Education Agencies (School Districts)
Over 100 Charter Schools
Non-Profit Healthcare (NCTN)- about 300 sites
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Hospital connections (Non Profit, including data centers)
Hospital Clinics
Mental Health Clinics
Free clinics
FQHCs
Rural Health Clinics
Public Health Sites
RTI, NISS, NHC, Burroughs Wellcome Fund, Bio Tech Center, other research
institutions
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Services available to non-profit healthcare:
◦ Affordable, High Speed Broadband (NCTN)
◦ Videoconferencing Services
◦ Data Center / Hosting Services
◦ Assistance with outreach and training programs
◦ Other Value-add Services as defined by the constituents
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Through partnership with DIT, provide lower cost
broadband.
Buildout of core network (via grant and matching
dollars) in more rural areas of NC to provide
more access and lower costs.
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Issued in late December 2012
◦ Big. The HCF is capped at $400M per year nationwide. We
are not likely to come anywhere close to this cap in the
foreseeable future.
◦ Large discount: Eligible sites can receive a 65% discount
for their NCTN-based broadband leased services.
◦ Funds from USF – not annual allocation from Congress.
◦ Site mix: A consortium (such as NCTN) must have at least
50%+1 rural sites in the consortia to obtain discounts.
Currently, NCTN is 62% rural.
◦ Medical care sites and more get discounts: Rural Clinics,
Public health sites , behavioral health, FQHCs, Free Clinics,
hospitals, data centers, admin offices.
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Public and non-profit healthcare providers:
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(i) "post-secondary educational institutions offering
health care instruction, teaching hospitals, and medical
schools;"
(ii) community health centers or health centers
providing health care to migrants;
(iii) local health departments or agencies;
(iv) community mental health centers;
(v) not-for-profit hospitals;
(vi) rural health clinics; and
(vii) consortia of health care providers consisting of
one or more entities described in clauses (i) through (vi).
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Individual Applicants
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Consortia (e.g. NCTN)
◦ Rural sites only among the categories above.
◦ Rurality is narrower than most in NC used to; based on census tract;
◦ Urban and rural sites (with some limitations on urban sites); more latitude about
specific circumstances
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Individual Applicants:
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NCTN (as a consortia):
◦ For rural sites, individuals can apply for discounts
◦ Some do this directly (with significant admin effort)
◦ Others use for-profit vendors (who usually claim a significant part of
the discount for their efforts).
◦ Non-profit project designed to overcome the limitations of individual
application:
◦ Offers the widest possible coverage of sites/situations/services.
◦ Assumes the admin effort of working with the HCF Program (a
significant amount).
◦ Keeps prices low through volume purchase, use of grants, state
contracts, non-profit vendor use.
◦ Not many in NC have used the individual application and some of
those have converted to using NCTN.
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FQHCs – (approx 190 in NC)
Rural Health Centers (under ORH) – (approx 85)
Additional public health sites (approx 200)
Additional hospitals per se (approx 60)
Non-profit Health system/IDN clinics (approx 1500)
Mental health centers (approx 1000)
State prisons/county jails – (approx 200)
AHEC sites (approx 15)
"post-secondary educational institutions offering health care
instruction, teaching hospitals, and medical schools;” (approx
200)
Site collection implies between $10M-40M per year in HCF
funds to support broadband services.
Note that we use state-wide member orgs and other large group
liaisons to support site development, administration.
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Maintain a broadband network for public and nonprofit healthcare providers in NC with excellent
benefits and low cost (to the subscribers).
Opportunity for major NC HCPs to work together on
this common infrastructure.
Move $10M-$40M per year to the bottom lines of NC
non-profit and public healthcare providers (equivalent
bottom line impact to generating new revenues of
$333M to $1.3B (at 3% operating margin).
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Initial call to see what services/sites might be of interest;
fair share possibility.
Follow-up engineering call or two if the network may be
complicated
Pricing for options provided to subscriber.
Signing subscription agreement and other documents
needed for discount acquisition.
Either wait for discounts and then implement or start
implementation and obtain discounts later.
Service installation with support for any transitional work.
Process usually takes 8-10 months total.
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Dave Kirby – Dave@KirbyIMC.com
See today:
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John Graham
Laura Horne
Ruthy Mabe
Dave Kirby