Wednesday, March 17, 2010

Health IT Broadband Connectivity Gap

Characterizing and Sizing the Gap

Research is scarce on health care providers’ broadband connectivity needs and the ability of the country’s infrastructure to meet those needs. This plan is one of the first attempts to quantify both. A number of challenges that prevented earlier study are relevant to this analysis. Pricing data, for instance, are proprietary and fluctuate widely according to a number of variables, making it difficult to quantify an aggregate price curve. Databases of practice locations bear inconsistent category classifications and often overlap (e.g., a small hospital may also be called a rural health clinic; a small health clinic may also be called a medium-sized physician office). Despite these shortcomings, this analysis is necessary to inform health care policy changes related to broadband, including the effort underway to reform the FCC’s Rural Health Care Program.

Health Care Providers’ Broadband Needs

Health care providers’ broadband needs are largely driven by the rapidly increasing amount of digital health-related data that is collected and exchanged. A single video consultation session can require a symmetric 2 Mbps connection with a good quality of service. There is a wide range of requirements to support EHRs and medical imaging. Exhibit 10-B shows the variation in file sizes for common health care file types. Over the next decade, physicians will need to exchange increasingly large files as new technologies such as 3D imaging become more prevalent.

Exhibit 10-B: Health Data File Sizes

Exhibit 10-B:  Health Data File Sizes

Exhibit 10-C: Required Broadband Connectivity and Quality Metrics (Actual)

Exhibit 10-C: Required Broadband Connectivity and Quality Metrics (Actual)
The connectivity needs of different health delivery settings will vary depending on their type (e.g., tertiary care center versus primary care physician practice) and their size. In addition, applications that integrate real-time image manipulation and live video will stimulate demand for more and better broadband, because these applications have specific requirements for network speeds, delay and jitter. Exhibit 10-C shows an estimate of the required minimum connectivity and quality metrics to support deployment of health IT applications today and in the near future at different types of health delivery settings. Although some delivery settings currently function at lower connectivity and quality, those levels are straining under increasing demand and are unable to support needs likely to emerge in the near future.
Most businesses in the United States, physician offices included, have two choices of broadband service categories: mass-market “small business” solutions or Dedicated Internet Access (DIA), such as T-1 or Gigabit Ethernet service. DIA solutions include broader and stricter Service Level Agreements (SLAs) by network operators. DIA services are substantially more expensive than mass-market packages. For example, in Los Angeles, 10 Mbps Ethernet service with an SLA averages $1,044/month, while Time Warner Cable’s similar mass-market package, Business Class Professional, which offers 10 Mbps download speeds and 2 Mbps upload speeds, is approximately $400/month.

Connectivity Gap: Small Providers (Four or Fewer Physicians)

In general, smaller providers can achieve satisfactory health IT adoption with mass-market “small business” packages of at least 4 Mbps for single physician practices and 10 Mbps for two-to-four physician practices, even though these solutions may not provide business-grade quality-of-service guarantees. Since most small physician offices do not provide acute care services, they do not require the same degree of instant and guaranteed responsiveness that large practices and hospitals require.
Based on the requirements listed above, an estimated 3,600 out of approximately 307,000 small providers face a broadband connectivity gap. The gap is particularly wide among providers in rural areas (See Exhibit 10-D). In locations defined as rural by the FCC, approximately 7% of small physician offices are estimated to face a connectivity gap. In contrast, across all locations, only approximately 1% of physician offices face a connectivity gap.

Exhibit 10-D: Estimate of Small Physician Locations Without Mass-Market Broadband Availability

Exhibit 10-D:  Estimate of Small Physician Locations Without Mass-Market Broadband  Availability

Connectivity Gap: Medium & Large Providers (Five or More Physicians)

Larger physician offices, clinics and hospitals face connectivity barriers of a different nature. Because of their size and service offerings, these providers often cannot rely on mass-market broadband and must usually purchase DIA solutions. DIA pricing is determined on a case-by-case basis depending on factors such as capacity, type and length of the connection; type of service provider; and type of facility used. It often varies significantly by geography. Exhibit 10-E illustrates how widely DIA prices fluctuate in urban areas.

Exhibit 10-E: Wide Fluctuations in Dedicated Internet Access Prices (Monthly Service Cost in Dollars)

Exhibit 10-E:  Wide Fluctuations in Dedicated Internet Access Prices
For two large physician offices seeking to capitalize on meaningful use incentives, a disparity of more than $27,000 per year in broadband costs puts one at a disadvantage to the other, negates a significant portion of the incentives and may prove an insurmountable obstacle to EHR adoption.
Rural and Tribal areas are likely to face even greater price inequities. There are more than 2,000 rural providers participating in the FCC’s Telecommunications Fund, and their broadband prices average three times the price of urban benchmarks

Connectivity Gap: Federally Funded Providers

Several federally funded providers have insufficient connectivity. For example, 92% of IHS sites purchase a DIA connection of 1.5 Mbps or less. These bandwidth constraints prevent IHS providers from achieving full adoption of video consultation, remote image diagnostic and EHR technology. Similarly, federal subsidy recipients such as Federally Qualified Health Centers, Rural Health Clinics and Critical Access Hospitals face challenges in securing broadband solutions relative to the rest of the country. Exhibit 10-F shows the FCC’s estimate of these providers’ mass-market broadband gaps. It is important to note that these gaps in mass-market broadband do not preclude locations from purchasing DIA solutions. Nearly every IHS location purchases DIA broadband. However, the fact that such high percentages of federally funded providers are located outside the mass-market footprint means that they face significantly higher prices.
Federally funded providers have a direct impact on the government’s costs and serve health care populations for whom the government assumes responsibility; the federal government should improve their connectivity and make them models of harnessing health IT to ensure better health (see Recommendation 10.10).

Exhibit 10-F: Health Care Locations Without Mass-Market Broadband Availability

Exhibit 10-F:  Health Care Locations Without Mass-Market Broadband Availability


Connectivity Gap: Next Phase of Analysis

Understanding the state of broadband connectivity for health care providers is a new but important area of analysis. There is more to be done, especially as the need for better data continues to grow. As nascent health IT applications become more prevalent and the importance of wireless connectivity grows, an up-to-date understanding of broadband use cases and connectivity levels will be invaluable. Immediate efforts should be made to quantify the price disparity problem on a more granular level. Similarly, the levelsand costsof broadband that providers purchase warrant further analysis.
The FCC should play an ongoing role in serving this knowledge base via the Health Care Broadband Status Report proposed in Recommendation 10.11. This information is important not only to policymakers and regulators, but to the health IT industry and the health care provider community. These groups are also invested in understanding the role broadband plays in health care delivery and should participate in shaping this body of research.

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