Monthly Archives: March 2023

Quantifying the Benefits of Telemedicine

There was a recent article in JAMA Network Open, part of the monthly journals of the American Medical Association, that reported on a large study to quantify the benefits of using telemedicine with cancer patients. The study was conducted at National Cancer Institute – Designated Comprehensive Cancer Center in Florida from April 2020 through June 2021.

The study wanted to quantify the cost savings for patents that were able to conduct visits via telehealth rather than drive to the cancer center. This is a particularly interesting study because one of the most important claimed benefits of telemedicine is the ability to see specialists who don’t reside in a local community or a rural area. The savings from seeing a doctor by telemedicine includes patient savings for travel and lost productive work time.

The study was launched after it came clear that the number of telemedicine visits increased after the beginning of the pandemic. The Cancer Institute started encouraging telemedicine visits starting in April 2020, soon after the onset of the pandemic. Protecting cancer patients from Covid was a major concern at the time.

The study looked at 25,496 telehealth visits made by 11,688 patients. The median age was 55 with 46% of the patents younger than 65. 61% of the patients were women.

The savings for patients to use telemedicine was significant. The average patient drove 148.6 round trip miles per visit. It was estimated that eliminating the drive to and from the Center eliminated almost 3.8 million miles of driving. There was also a significant savings in lost time. Patients with a job, or those driving a patient to the Cancer Center lost a lot of time for the round-trip visit. Lost time was calculated in two components – the driving time and the extra time at the Cancer Center waiting to see a doctor.

The total savings per visit was significant. The average savings for vehicle costs ranged $80 to $176 depending upon the make and model of the vehicle. The total savings for a visit averaged between $141 and $223 per visit. That’s a significant savings for a patient to see a doctor since a cancer patient typically sees a doctor multiple times during the course of cancer treatment.

This study did not try to calculate the savings for the caregivers of cancer patients. Caregivers for cancer patients spend substantial time coordinating appointments. 18% of the caregivers in the study expressed high financial stress related to the cancer.

One of the points made in the study was that these savings were not available to all patients due to the digital divide. Rural patients, or those without broadband were unable to participate in the telemedicine visits.

The study notes that the savings per visit are higher in this case since patients are likelier to travel to see a specialist – the savings would not be as large for seeing local doctors.

Benefits of Peering

Peering is the process of exchanging Internet traffic directly between networks instead of passing calls through the open Internet. That probably requires a little explanation and an example. Let’s say that you’re at home and you request to look at a website for a bookstore. You do this by typing in a web URL (the name of the website). Regardless of where that bookstore is located – in your town or across the country – your request is routed by your ISP to the open Internet. Every ISP has connections to reach the web that we generically call backhaul in the industry. In plain English, that means a fiber route from the ISP to the Internet.

Some ISPs buy connections directly at the major Internet hubs in places like Kansas City, Washington DC, Atlanta, etc. Many ISPs instead send traffic to a closer point of presence, and the request gets passed on by somebody else to the primary Internet hubs. The major Internet hubs then route the request to the region of the country where the website for the bookstore is hosted. The closest hub to the final destination will hand the request to the ISP that hosts the website. Once your request reaches the website of the bookstore, the process is then duplicated in the reverse direction so that the signal is sent back to you to interact with the website.

Peering is a process that bypasses this normal routing. If your ISP has a peering arrangement with the ISP that hosts the bookstore website, your request would be handed from your ISP directly to that ISP without the intermediate steps of passing through Internet hubs.

There are two major benefits of the peering arrangement. First, it’s faster. There is extra time required to pass through intermediate hubs. In a peering arrangement, the request would go to the ISP that hosts the bookstore website. The bigger advantage is that peering saves money for both ISPs. ISPs must pay to transport traffic to and from the Internet and also pay for the usage at the major Internet hub. When this particular request is sent through a peering arrangement, your ISP avoids paying to use the major Internet hubs.

Peering makes the most sense and saves the most money when it can bypass Internet hubs with large amounts of traffic, so the most common peering arrangements connect with companies that generate a lot of web traffic. The three largest users of bandwidth for residential ISPs are Google, Netflix, and Facebook. All three of those companies are willing to enter into a peering arrangement with an ISP if it saves money. These companies also like peering because it improves performance for users.

Large ISPs probably all peer directly with these large web companies and others. It’s unusual for big web companies to peer directly with a small ISP. However, there are a number of places around the country where small ISPs pool their traffic to peer with the large web companies. These regional peering hubs might be owned by one of the ISPs or perhaps by a third-party.

Peering can save a lot of money. I talked to several of my clients who take advantage of peering, and they claim that peering saves them from sending from 30% to 65% of their traffic through the open Internet – depending on the specific nature of the peering arrangement.

Peering with the large web companies is not free, and an ISP must provide the transport to meet the peering partner. But this still can save a lot of money compared to paying for broadband usage at the major Internet hubs.

There is another kind of peering that is talked about less, but is widely used, which is private peering. Another name for this is creating a private network that bypasses the Internet. One of the biggest examples of this is the Internet2 network, where universities pass large volumes of usage directly between each other without going through the Internet. The federal government has a huge private network for government and military traffic. Many companies pay a for private network between different branches of the company. It’s common for schools in a region to be networked together in a private network.

If an ISP isn’t peering today, it’s worth asking around to see if any peering opportunities are available to you. If you are in a region where none of the small ISPs are peering, it might make sense to work together to create a peering arrangement for the region. All that’s generally needed to justify a peering point is to aggregate enough traffic volume to make it worthwhile to the big web services.

Corporate Broadband at Home

One of the broadband products that quietly emerged during the pandemic is a suite of products that enable corporate broadband to safely be used at home. IT Directors of large companies were aghast when a large percentage of staff were sent home to work and instantly wanted full access to the same systems and functionality that they used in the office.

One of the key linchpins of corporate data security has always been to limit access to corporate networks from outside the physical confines of the office. Corporations have always had employees working remotely while out of the office sick or on travel. But remote employees were usually given limited access and often didn’t get full access to sensitive databases and systems. But suddenly, everybody from the CEO down to the lowest-level office workers needed access to the systems that they had been using in the office every day. Employees wanted access to everyday proprietary systems, collaboration software, unified messaging, and everything that let them operate as if they were in the office. This was a nightmare scenario for IT departments that were tasked with protecting proprietary corporate data while somehow opening the portals for large numbers of remote works.

Some of the largest ISPs eventually stepped in to put the IT departments at ease with a suite of products that added the needed access security so that remote users were fully verified to be a real employee and not a hacker. The first thing these products offered was a broadband connection controlled by the company, not by the employee. These new connections were intended to be separate from an employee’s existing home broadband to create a clear demarcation between corporate data and personal data.

I may not remember these in the right order, but the earliest such products I can recall after the onset of the pandemic were from AT&T and Comcast. The AT&T Home Office Connectivity product was only available in homes connected to any AT&T broadband product, but touted fiber connections as the best. This was a challenging sale to companies due to the hit-and-miss deployment of AT&T fiber that has been deployed in small neighborhood clusters rather than citywide. The original AT&T product offered speeds up to a gigabit, static IP addresses, and priority customer care for employees. These first products let a company have some control over the type of home connection being used to access corporate systems. Over time, AT&T rolled out the kinds of features that IT departments wanted – multilayer safe logins, compatibility with SD-WAN, encrypted transmissions, deep packet inspection, and a secondary connection on cellular if the primary link fails.

The Comcast Business at Home product was similar, but with the ability to offer relatively fast speeds in any Comcast market on the coaxial/fiber networks.

Over time, these products have gotten more sophisticated. Some of the products today offer redundant connections from home to multiple cloud data centers. The latest versions of corporate-at-home connections offer a suite of collaboration tools that are more sophisticated than what an employee might have been using at work.

As might be expected, corporate-quality connections are considerably more expensive than normal home broadband and are nearer in cost to broadband products sold to sophisticated small businesses like law firms.

It seems likely that these products are here to stay since a lot of workers are never going back to the office. The latest reports I’ve seen about downtown business occupancy show that most downtown business districts are barely back to 50% of the number of daily workers pre-pandemic. While we hear of the occasional large company that is forcing people back to the office, there are far more quiet examples where companies have decided that remote employees are going to be permanent. Companies are realizing the benefits that come from the ability to attract the best employees from anywhere and the expansion of the business from having employees in all time zones. Younger workers are demanding the ability to work at home at least part-time as a condition for taking jobs.

I would expect over time there will arise an industry selling suites of these products that are not associated with an ISP. Just as the VoIP industry grew outside of telephone companies, it’s not hard to imagine companies springing up that specialize in the software needed to create the safest and most seamless corporate broadband connection at home.