Is Telemedicine Here to Stay?

It’s going to be interesting to see if telemedicine stays after the end of the pandemic. In the past months, telemedicine visits have skyrocketed. During March and April, the billings for telemedicine were almost $4 billion, compared to only $60 million for the same months a year earlier.

As soon as Medicare and other insurance plans agreed to cover telemedicine, a lot of doctors insisted on remote visits during the first few months of the pandemic. In those early months, we didn’t know a lot about the virus and doctor offices were exercising extreme caution about seeing patients. But now, only four months later a lot of doctor’s offices are back to somewhat normal patient volumes, all done using screening patients at the door for temperature and symptoms.

I had two telemedicine visits during April and the experience felt familiar since I was was spending a lot of my day on Zoom meetings that month. These were zoom-like connections using specialized software to protect patient confidentiality, but with a clearly higher resolution camera (and more bandwidth used) at the doctor’s end. I was put on hold waiting for the doctor just as I would have been in the doctor’s office. One of my two sessions dropped in the middle when the doctor’s office experienced a ‘glitch’ in bandwidth. That particular doctor office buys broadband from the local cable incumbent, and I wasn’t surprised to hear that they were having trouble maintaining multiple simultaneous telemedicine connections. It’s the same problem lots of homes were having during the pandemic when multiple family members have been trying to connect to school and work servers at the same time.

One of my two telemedicine sessions was a little less than fully satisfactory. I got an infected finger from digging in the dirt, something many gardeners get occasionally. The visit would have been easier with a live doctor who could have physically looked at my finger. It was not easy trying to define the degree of the problem to the doctor over a computer connection. The second visit was to talk with a doctor about test results, and during the telemedicine visit I was wondering why all such doctor meetings aren’t done remotely. It seems unnecessary to march patients through waiting rooms with sick patents to just have a chat with a doctor.

There was a recent article about the topic in Forbes that postulates that the future of telemedicine will be determined by a combination of the acceptance by doctors and insurance companies. Many doctors have now had a taste of the technology. The doctors that saw me said that the technology was so new to them at the time that they hadn’t yet formed an opinion of the experience. It also seems likely that the telemedicine platforms in place now will get a lot of feedback from doctors and will improve in the next round of software upgrades.

The recent experience is also going to lead a lot of doctor’s offices to look harder at their broadband provider. Like most of us, a doctor’s office historically relied a lot more on download speed than upload speed. I think many doctor’s offices are going to find themselves unhappy with cable modem service or DSL broadband that has been satisfactory in the past. Doctor’s will join the chorus of those advocating for faster broadband speeds – particularly upload speeds.

Telemedicine also means a change for patients. In the two sessions, the doctor wanted to know my basic metrics – blood pressure, temperature, and oxygen levels. It so happens that we already had the devices t home needed to answer those questions, but I have to think that most households do not.

I don’t think anybody is in a position to predict how insurance companies will deal with telemedicine. Most of them now allow it and some have already expanded the use of telemedicine visits through the end of the year. The Forbes articles suggest that insurance companies might want to compensate doctors at a lower rate for telemedicine visits, and if so, that’s probably not a good sign for doctor’s continuing the practice.

My prediction is that telemedicine visits will not stay at the current high level, but that they will be here to stay. I think when somebody books a visit to a doctor that they’ll be given a telemedicine option when the reason for the visit doesn’t require an examination. The big issue that will continue to arise is the number of homes without adequate bandwidth to hold a telemedicine session. We know there are millions of people in rural America who can’t make and maintain a secure connection for this purpose. There are likely equal millions in cities that either don’t have a home computer or a home broadband connection. And there will be many homes with so-so broadband that will have trouble maintaining a telemedicine connection. Telemedicine is going to lay bare all of our broadband shortcomings.

Telemedicine and Broadband Access

North Carolina’s Broadband Infrastructure Office and the NC Department of Health and Human Services published a 77-page report that compares the state of healthcare and broadband access in Western North Carolina. I expect to soon see similar reports from around the country as States are taking a hard look at broadband access and related issues.

Western North Carolina is in Appalachia and has higher rates of poverty than the rest of the state. Many of the counties in the region had economies driven by coal extraction and related supply chains. These areas were already seeing economic devastation before the pandemic.

As might be expected, the report shows that deaths from diabetes, stroke, heart disease, opioid use, COPD, and unintentional injuries are higher in western North Carolina than in the state’s metropolitan areas. The region has far fewer doctors per 10,000 population than the rest of the state.

There had already been a start for bringing telemedicine to the region. For example, Mission Health, a large health care provider in Asheville had already been working with rural hospitals in a few western counties to bring access to specialists. But like everywhere else in the country, the need for telemedicine has exploded since the advent of the pandemic.

As might be expected, broadband access is low in many of these counties. Western North Carolina is like the rest of Appalachia, with hilly and mountainous terrain, a lot of woods, narrow and winding country roads, and scattered rural populations. The counties in the region have already identified the lack of broadband as a major problem before the pandemic and have been taking steps to try to attract ISPs to the region.

This study is the first step attempt in correlating broadband access to the availability of health care. One of the first steps taken in the study was to equate the broadband adoption rate in counties to the degree to which a county has higher death rates than the rest of the state. Interestingly, there were no counties with high broadband adoptions that rated below average for health statistics. However, only 3 or the 20 counties were rated as having high broadband adoption rates.

The study surveyed what the report called safety net sites – locations that provide health care to low-income people. They found that 70% of these locations were already using telemedicine before the pandemic. However, most of these health care providers said they were underutilizing telemedicine. The study showed that many of the health care facilities don’t have an affordable or reliable broadband connection, making it hard for them to reliably conduct telemedicine.

The State Broadband Office had identified almost 72,000 homes in these rural counties that don’t have access to broadband at home, meaning there is no ISP able to provide a broadband connection capable of delivering telemedicine. Telemedicine platforms differ, but I’ve been told that most telemedicine connections require both a download and an upload connection of between 3 Mbps and 4 Mbps. Anybody living in a rural area knows that an upload speed of that magnitude is a rarity.

The study also showed that even where broadband is available that 17 of the 20 counties have lower than average rates of computer ownership and broadband adoption. The study correlates this with the level of poverty, which is also lower in these areas than average for the State.

This study is an important step in understanding the broadband gaps in Western North Carolina, and telemedicine is only one of the many ways that lack of broadband is hurting the region. If any good has come out of the pandemic, it’s that state government has turned its attention to the huge problems caused by poor broadband in rural areas. Hopefully, this will translate into finding broadband solutions – which is going to be a huge challenge in Appalachia.

Bandwidth Needed to Work from Home

The pandemic made it clear that the millions of homes with no broadband or poor broadband were cut off from taking the office or the school home. But the pandemic also showed many additional millions of homes that their current ISP connection isn’t up to snuff for working or doing schoolwork from home. Families often found that multiple adults and students couldn’t share the bandwidth at the same time.

The simplest explanation for this is that homes were suddenly expected to connect to a school or work servers, use new services like Zoom, or make telemedicine connections to talk to doctors. These new requirements have significantly different bandwidth needs when a home’s big bandwidth need was watching multiple video streams at the same time.  Consider the following bandwidth needs listed by Zoom:

Zoom says that a home should have a 2 Mbps connection, both upload and download to sustain a Zoom session between just two people. The amount of download bandwidth increases with each person connected to the call, meaning Zoom recommends 6 Mbps download for a meeting with three other people.

Telemedicine connections tend to be even larger than this and also require the simultaneous use of both upload and download bandwidth. Connections to work and schools servers vary in size depending upon the specific software being used, but the VPNs from these connections are typically as large or larger than the requirements for the Zoom.

Straight math shows fairly large requirements if three or four people are trying to do make these same kinds of 2-way simultaneous connections at the same time. But houses are also using traditional bandwidth during the pandemic like watching video, gaming, web browsing, and downloading large work files.

The simplistic way to look at bandwidth needs is to add up the various uses. For instance, if four people in a home wanted to have a Zoom conversation with another person the home would need a simultaneous connection of 8 Mbps both up and down. But bandwidth use in a house is not that simple, and a lot of other factors contribute to the quality of bandwidth connections within a home. Consider all of the following:

  • WiFi Collisions. WiFi networks can be extremely inefficient when multiple people are trying to use the same WiFi channels at the same time. Today’s version of WiFi only has a few channels to choose from, and so the multiple connections on the WiFi network interfere with each other. It’s not unusual for the WiFi network to add a 20% to 30% overhead, meaning that collisions of WiFi signals effectively waste usable bandwidth. A lot of this problem is going to be fixed with WiFi 6 and 6 GHz bandwidth which together will add a lot of new channels inside the home.
  • Lack of Quality of Service (QoS). Home broadband networks don’t provide quality of service, which means that homes are unable to prioritize data streams. If you were able to prioritize a school connection, then any problems inside the network would affect other connections first and would maintain a steady connection to a school. Without QoS, a degraded bandwidth signal is likely to affect everybody using the Internet. This is easily demonstrated if somebody in a home tries to upload a giant data file while somebody else is using Zoom – the Zoom connection can easily drop temporarily below the needed bandwidth threshold and either freeze or drop the connection.
  • Share Neighborhood Bandwidth. Unfortunately, a home using DSL or cable modems doesn’t only have to worry about how other in the home are using the bandwidth, because these services used shared networks within neighborhoods, and as the demand needs for the whole neighborhood increase, the quality of the bandwidth available to everybody degrades.
  • Physical Issues. ISPs don’t want to talk about it, but events like drop wires swinging in the wind can affect a DSL or cable modem connection. Cable broadband networks are also susceptible to radio interference – your connection will get a little worse when your neighbor is operating a blender or microwave oven.
  • ISP Limitations. All bandwidth is not the same. For example, the upload bandwidth in a cable company network uses the worse spectrum inside the cable network – the part that is most susceptible to interference. This never mattered in the past when everybody cared about download bandwidth, but an interference-laden 10 Mbps upload stream is not going to deliver a reliable 10 Mbps connection. There are a half dozen similar limitations that ISPs never talk about that affect available bandwidth.

The average home experiencing problems when working at home during the pandemic is unlikely to be able to fully diagnose the reasons for the poor bandwidth. It is fairly obvious if you are having problems with having multiple zoom connections if the home upload speed isn’t fast enough to accommodate all of the connections. But beyond the lack of broadband capacity, it is not easy for a homeowner to understand any other local problems affecting their broadband experience. The easiest fix for home broadband problems is for an ISP to offer and deliver faster speed, since excess capacity can overcome many of the other problems that might be plaguing a given home.

Predictions for a Post-COVID-19 World

While it might still be too early to make predictions, there are dozens of articles on the web predicting how the COVID-19 pandemic might change our long-term behavior. Here are some of the more interesting predictions I’ve seen that involve broadband and telecom:

An Outcry for Better Home Broadband. Millions of people were sent home for work or school to homes that didn’t have good broadband. These folks have been telling the world for years that they don’t have good broadband. When this crisis is over these people are going to insist on being heard, and they are going to take out their anger on politicians who don’t help to find broadband solutions. This means Mayors and City Councils that are not pro-broadband. This means County Boards and Commissions that don’t offer matching grants to attract ISPs. This means any state politician who votes against significant state broadband grants or who votes against municipal participation in broadband. And this means federal Senators and Representatives that support the big cable companies and telcos over their constituents. Folks are not likely to be fooled any longer by false legislation that supposedly is pro-broadband but which is the exact opposite – because folks are going to be paying attention to any news concerning their home broadband.

Digital Meetings Are Here to Stay. We are all seeing how effective it can be to meet online. People are going to be a lot less willing to travel for a one or two-hour meeting. I know my days of doing that kind of traveling are over. This means airline business travel is likely never coming back to former levels, but it means a lot more. I was talking to somebody in local government the other day who told me that they spend over 10 hours of every workweek driving between meetings around a large county. He said he thinks the day or required live attendance at such meetings is likely over.

Demand for Faster Upload Speeds. The permanent uptick in more video meetings means there will be an increased demand for faster upload broadband speeds. The FCC still talks about 25/3 Mbps as acceptable broadband, but a home or office getting only 3 Mbps upload is not able to hold multiple simultaneous video calls. Homes and businesses are going to favor technologies willing to meet that upload speed demand.

Telemedicine has Arrived. I have been watching the glacial acceptance of telemedicine for fifteen years. The biggest hurdles have been the reluctance of doctors to try telemedicine and the willingness of insurance companies to pay for it. We’ve broken both of those barriers and telemedicine is here to stay. There are numerous routine doctor visits that don’t require an office visit. It’s never made sense to force patients who aren’t sick to march through a waiting room that has been filled all day with those with colds, the flu, or worse.

Expect Contactless Payments. I can remember being promised twenty years ago that we’d be able to pay for things by waving a cellphone. Nobody wants to hand a credit card to a clerk or even pass a credit card through a device that other people have used all day – so stores that install touchless payment systems are quickly going to become preferred. Expect an expansion of telephone, voice, and vision interface at checkout locations and a phase-out of credit card swiping. Also, expect an increased reluctance to take cash. There were already stores in New York City last year that made headlines by refusing to accept cash – expect a lot more of that.

More Telecommuting. Businesses have seen that people can be effective when working from home. Expect to see businesses more easily allowing for working from home at least part-time. This likely means a downturn in business real estate. For example, my neighbor is an architect who works at a small local branch of a larger firm. They’ve already seen the effectiveness of working from home and have already discussed not reopening the local office when the crisis is over. More telecommuting means more daytime use of neighborhood bandwidth and an increased expectation of residential broadband signal quality.

A Reboot for Corporate Security. We just spent a decade moving corporate data behind firewalls and restricting access to data from outside the business. Many businesses scrambled to find ways to allow employees to work from home, and in doing so undid many of their security protocols. Expect a major reboot as companies implement security solutions that support telecommuting.

Congress Ignores Rural Broadband

One of the biggest topics in rural America right now is the inability of employees to work from home and students to stay connected to schools from home due to the lack of broadband. Rural homes have struggled with poor broadband for many years, but the Covid-19 pandemic has brought the issue into a focus as rural residents are told to shelter in place, but don’t have the broadband needed to stay employed or to keep up with schoolwork.

I expected Congress to tackle this issue to some significant extent in the stimulus package that was just passed. However, the level of funding for broadband is disappointingly small in terms of finding any meaningful broadband solutions. The Senate bill contains the following:

  • $25 million to the RUS Distance Learning, Telemedicine & Broadband Program for the ‘‘Distance Learning, Telemedicine, and Broadband Program” (page 617).
  • $100 million for the USDA Reconnect program. This is a grant program administered by the USDA that provides grants and loans for bringing broadband to areas where at last 90% of households don’t have access to broadband of at least 10/1 Mbps. The money is to be prioritized to previous recipients of this grant (pages 622/623)
  • $50 million to the Institute of Museum and Library Services to prevent, prepare for, and respond to the coronavirus, including grants to States, territories, and tribes to expand digital network access (page 773).
  • Secretary of Veterans Affairs may enter into short-term agreements with telecommunications companies to provide temporary, fixed or mobile broadband service to provide mental health services to isolated veterans (page 807).

There is no such thing as bad grant money that brings better broadband, and all of the above allocations are welcome. However, none of this money is going to make more than a miniscule dent in the rural broadband issue. The only award that is likely to construct new broadband facilities is the $100 million for the ReConnect grant program. I’ve seen estimates over the years that it will take $100 billion to bring fiber to everybody in rural America. While a $100 million grant program might sound huge, if the need is $100 billion, then Congress just allocated one-tenths of one percent (0.1%) of the money needed to solve the rural broadband issue. It would take 1,000 years of grants at that level to bring fiber broadband to rural America.

Don’t get me wrong – the ReConnect grants have been going to independent telcos, electric cooperatives, and independent ISPs and any ISP that gets this extra money will be glad to get it. But when we map out the areas covered by this extra money you won’t be able to see it on a map of the US.

I think Congress is misreading rural America. My consulting firm does surveys and interviews in rural America and we have continued to do this during the pandemic. Rural America is pissed. They aren’t annoyed, they aren’t just sore – they are fuming mad that the government has been ignoring them for a decade by not bringing them broadband. They are mad at everybody – local politicians, state politicians, and federal politicians. Broadband isn’t a partisan issue, and I’m getting the sense that folks without broadband are ready to vote out anybody who is not bringing them a broadband solution, regardless of party.

You can’t blame them for being mad. One of the counties I’m working with right now is typical of much of rural America. We’ve done speed tests across the county and found almost nobody getting speeds faster than 5 Mbps, with many getting only a fraction of that. These homes mostly have DSL or fixed wireless broadband. These slow speeds are for the homes that can get at least some broadband – many homes have nothing. A large percentage of residents have tried satellite broadband and found it to be worthless. That’s understandable since we’re seeing latency of 700 to 900 milliseconds for satellite households – too much latency to connect to a corporate server or to connect to a school for remote classes or to do homework.

Almost every home we talk to has a story about how a lack of broadband costs them money when they have to drive 30 minutes each way to sit outside for a WiFi connection so their kids can complete their homework. Residents tell us of the inability to work from home or to start a home-based business. These folks are frantic and angry now that they are cut off from their jobs and schools.

It’s impossible not to sympathize with these rural residents. I am sitting in an office with good broadband. Sheltering in place is, at worst, a hassle for my wife and me. We’re able to work all day and we’re able to spend as much time on the Internet as we want when we’re not working. But what about people who have lost their paycheck because they are unable to work from home? What about students who feel they are losing a school year and are fearful they’ll have to repeat a grade? I find it impossible to believe that members of Congress aren’t hearing these same stories and I can’t understand how Congress ignored the millions of Americans without broadband in the stimulus plan.

The Explosive Growth of M2M Traffic

The Cisco Annual Internet Report for 2018 – 2023 is full of interesting predictions this year. One of the more intriguing predictions is that Machine-to-Machine (M2M) traffic (which they also refer to as Internet of Things (IoT) traffic) will become a little more than half all of the traffic on the web by 2023. That’s an amazing prediction until you stop and think about all of the devices that communicate with the Internet without needing a human interface.

Cisco forecasts several reasons why M2M traffic will grow so much in the next few years. The primary way is through the proliferation of M2M devices. They predict over the 5-year period there will be a 2.4 times growth in connected devices from 6.1 billion in 2018 to 14.7 billion in 2023. That’s a 19% compounded growth rate and by 2023 equals 1.8 connected devices for every person on earth.

The second reason for the growth is that we are using M2M devices for a lot more functions than just a few years ago. Cisco is predicting fast growth in the following categories of M2M

  • They predict the number of worldwide connected home devices will grow by 20% per year. This is the largest category of devices and will represent just under 50% of connected devices by 2023. This category includes things like home automation, home security and video surveillance, connected white goods (the new term for connected appliances), and our communications and entertainment devices like smart TVs, laptops, desktops, and smartphones.
  • They predict that connected car applications will be the fastest-growing sector, growing at 30% per year. This includes connections made for things like fleet management, in-vehicle entertainment, emergency calling systems, vehicle diagnostics, and vehicle navigation.
  • Cisco predicted that connected city applications will be the second fastest-growing M2M category with a 26% compounded growth. This includes things like smart traffic systems, surveillance cameras, weather and environmental monitors, smart parking systems, gunshot monitors, etc.
  • They predict that connected health will grow 19% annually. This category mostly consists of telemedicine monitors used for outpatient monitoring.
  • Connected energy applications are predicted to grow by 24%. This includes smart grid monitors that track utility usage and loads, and pinpoint network outages quickly. It includes energy monitors, which can turn off air conditioners during times of heavy peak usage. In includes sensors in water systems that track pressure and usage and that predict underground leak locations.
  • Cisco predicts connected work will grow by 15%. This is used for things like inventory tracking, surveillance and security monitoring, and tracking and connecting to employees working in the field.
  • They predict that connected retail will grow by 11% annually. M2M traffic is being used to track inventory. Big chain stores are starting to track the shopping pattern of individual shoppers to see how they traverse the various departments.
  • Connected Manufacturing and Supply Chain will grow by 8% annually. Supply chain monitoring tracks the status of delivery for components needed in the manufacturing process. This also includes smart warehousing that automates packing and shipping or orders. Smart manufacturing supports monitors that track the performance of machinery and manufacturing processes.
  • They predict all other M2M traffic will grow by 19%. This would include things like smart agriculture where monitors are tracking individual herd animals and are just starting to be deployed to monitor crop conditions. This would include other things like sports monitors.

The volume of traffic generated by M2M traffic surprises people. So much of what we do happens in the background and we either forget about it or don’t even know it’s happening. For example, there was an article in the Washington Post last year by a reporter that left the country for a month and left his cellphone in his home. During his absence, the phone used a significant portion of his monthly data plan by updating apps and communicating regularly with remote web sites. My wife’s car connects to the web through or WiFi every time she pulls into the driveway and uploads diagnostics of the various monitors and checks for and downloads needed software updates. Whether for good or bad, our machines and electronics are connecting to the web and using broadband.

CoBank Supports Telemedicine

For those who don’t know CoBank, it’s a bank that specializes in loans to telecom and electric cooperative but which also has funded numerous rural fiber projects for other borrowers over the years. In August CoBank filed comments In FCC Docket 18-213 in support of expanded use of the Universal Service Fund for rural telemedicine. CoBank is a huge supporter of telemedicine and has made substantial grants to telemedicine projects dealing with diabetes management, opioid abuse, prenatal maternity care, and veteran care.

As part of that filing, CoBank discussed a telemedicine trial they had sponsored in rural Georgia. The trial was conducted in conjunction with Perry Health, a software provider and Navicent Health, a healthcare provider in Macon, Georgia.  The trial was for 100 low-income patients with uncontrolled Type 2 diabetes. These patients were on a path towards kidney failure, amputation, loss of vision, and numerous other major related health problems. These are patients who would normally be making numerous emergency room visits and needing other costly medical procedures.

In the trial, the patients were provided with tablets containing Perry Health software that provided for daily interaction between patients and Navicent. Patients were asked to provide daily feedback on how they were sticking to the treatment regimen and provided information like the results of blood sugar tests, the food they ate each day, the amount of daily exercise, etc. The tablet portal also provided for communication from Navicent asking patients how they generally felt and providing recommendations when there was a perceived need.

The results of the trial were hugely positive. In the trial of 100 patents, 75% of the patients in the trial showed a marked improvement in their condition compared to the average diabetes patient. The improvements for these patients equated to reduced health care costs of $3,855 per patient per year through reduced doctor visits and reduced needs to make emergency room visits. The American Diabetes Association says that patients with Type 2 diabetes have 2-3 times the normally expected medical costs, which they estimate totals to $327 billion per year.

Patients in the trial liked the daily interaction which forced them to concentrate on following treatment plans. They felt like their health care provider cared about how they were doing, and that led them to do better. After the trial, Navicent Health expanded the telemedicine plan to hundreds of other patients with Type 2 diabetes, heart failure, and Chronic Obstructive Pulmonary Disease (COPD).

One of the interesting outcomes of the trial was that patents preferred to use cellphones rather than the special tablets. The trial also showed the need for better broadband. One of the challenges of the trial was the effort required by Navicent Health to make sure that a patient had the needed access to broadband. To some degree using cellphones gives patients easier access to broadband. However, there are plenty of rural areas with poor cellular data coverage, and even where patients can use cellular data, the cost of cellular data can be prohibitive if heavily used. Landline broadband is still the preferred connection to take advantage of unlimited WiFi connections to the healthcare portal.

One thing that struck me about this study is that this sounds like it would be equally useful in urban areas. I’ve read that a lot of healthcare costs are due to patients who don’t follow through on a treatment plan after they go home after a procedure. The Navicent Health process could be applied to patients anywhere since the biggest benefit of the trial looks to be due to the daily interface between patient and doctor.

The FCC has already pledged to increase funding for the rural medicine component of the Universal Service Fund. However, that funding is restricted. For example, funding can only be granted to rural non-profit health care providers.

Telemedicine has been picking up steam and is seeing exponential growth. But telemedicine still only represents just a few percentages of rural healthcare visits. The primary barrier seems to be acceptance of the process and the willingness of health care providers to tackle telemedicine.

The Slow Growth of Telemedicine

One of the most hoped-for benefits of rural broadband has been the use of telemedicine to conduct routine doctor visits via a broadband connection rather than requiring rural patients to drive to cities for a doctor’s visit. However, the use of telemedicine hasn’t grown as fast as once predicted.

A recent study was published in JAMA, the Journal of the American Medical Association that looked at telemedicine use from 2005 through 2017. The study gathered records of telemedicine claims that were reimbursed through insurance. In 2005 there were only 206 telemedicine claims. By 2017 that had grown to 202,000 – but that is still only a tiny fraction of total medical visits. When looked at statistically it’s an annual growth rate of over 50% annually, but the overall number of visits are still a tiny blip in the industry.

The analysis showed that 53% of telemedicine visits were for mental health treatment, followed by 39% of telemedicine visits with a primary care physician. The average age of a telemedicine patient was 38. As expected, 83% live n rural areas, although telemedicine is also valuable for patients in cities with limited mobility.

The use of telemedicine has been bolstered by having 32 states pass laws that require insurance companies to treat telemedicine visits on parity with in-person visits. This provides the ability for Health Delivery Organizations (HDOs) like hospitals and clinics to treat patients remotely if the choose to do so.

I don’t want to sound negative because there is also good news in the study statistics. Most of the growth in telemedicine visits have occurred in just the last few years. A recent study was done by Vidyo, a company that provides the telemedicine equipment for hospitals and clinics. Vidyo surveyed 300 HDO organizations and asked about their telemedicine plans. Vidyo reported the following:

  • 75% of HDOs are now using or planning to soon use telemedicine.
  • Of the HDOs already using telemedicine, 47% report a savings for the medical practice; 51% report improved efficiency for the HDO; 58% report that doctors are satisfied with the results from telemedicine; 67% say that telemedicine is easy for staff to use, and 67% say that patients are receptive to telemedicine.
  • HBOs report the primary benefits of telemedicine as: patients get to ask questions which stops little problems into becoming big ones; telemedicine lets patients build a bond with a doctor; cellular video provides the ability for patients to get access to healthcare from anywhere; and video connections allows for collaboration among multiple doctors for complex health issues.
  • One of the holdups of telemedicine deployment has been the need for HDOs to invest in new technology. There are a number of practices waiting to see more proof of the benefits of telemedicine before implementing.

I’m sure that one of the hold-ups for more deployment of telemedicine is that that a lot of rural places don’t yet have the broadband to support it. Telemedicine requires a 2-way video conference, like Skype. It also often requires a good broadband connection for ongoing 24/7 monitoring of devices for outpatients from surgery or other procedures. Homes without a good broadband connection cannot participate in telemedicine. There are rural health clinics that initiate telemedicine visits from their site to specialists in nearby cities – but this still requires the patient to travel.

It looks like telemedicine is poised for rapid growth. This has taken longer to get going than what I would have guessed when looking at the discussion of telemedicine a decade ago. But like many industries it’s taken a while for the technology to get perfected and for doctors to trust using it. Now that many HDOs are starting to  use telemedicine it looks like we are finally poised for gigantic growth of the practice.

Quantifying the Benefits of Broadband

Economic development staff in almost every community I’ve ever worked with want to be able to quantify the benefits of broadband. It’s not hard to list the many benefits such as providing the ability for rural students to do homework, or the ability to start a home-based business after getting broadband. However, there has never been any way to put a dollar value to the community for these benefits.

Three economists from Purdue University have tackled the problem and took a stab at quantifying the benefits of bringing broadband to all of the areas served by Rural Electric Member Cooperatives (REMCs) in the state of Indiana. The work was done by looking in detail at the public benefits that would be generated at the Tipmont Cooperative and then extrapolating those results to the six other REMCs in the state.

The results are eye-catching and the study calculates a net present value of $24,293 to every cooperative household. I think most people’s first reaction is that amount seem too large, but when you look at the assumptions behind each component of that number, each assumption seems to be conservative.

Here are a few of the benefits measured by the study:

Medical. The study relied on recent studies that quantified the benefits of telemedicine. Several studies have shown that there is a significant decrease in Medicare costs once a region begins using telemedicine. The biggest savings comes from significantly reduced hospital stays and emergency room costs that come as a result of using telemedicine for preventive medicine – by checking up on patients regularly, resulting in small problems not escalating to severe ones.

Education. Numerous recent studies have shown that students without access to broadband don’t perform as well as students with broadband. Adults also benefit from online education through the ability to pursue college degrees online or to get training for new careers. It’s challenging to quantify the benefit of more education at the macro level, but it’s really easy to understand at the microlevel. We know that those who complete high school degree earn more over a lifetime than those who don’t. There have been numerous studies that quantify the increased lifetime earnings from various levels of post-high school education.

Economic Development. Recent studies have shown that there is a direct positive correlation between broadband adoption and economic development. The old economic model of communities thriving by attracting large employers is crumbling as the US continues to lose factories and factory jobs. But broadband helps existing businesses do better and can help keep an existing business to flee a market due to lack of broadband.

At the local level, better home broadband allows people to work at home, many of them finding higher-paying jobs than are available in the local economy. Good broadband also let’s some households bolster full-time earnings by engaging in ecommerce such as opening Etsy web stores. Numerous studies over the years have shown that anything that increases local wages benefits the local community with a multiplier effect as those extra earnings are spent on local goods and services.

Shopping. If you read my blog from last Monday, I discussed surveys we’ve done at CCG that listed the ability to shop online as one of the things most wanted in areas that have no broadband.

A recent Price Waterhouse Cooper study in England calculated the advantages of online shopping at US $754 per household annually – a combination of being able to buy goods at lower prices and the savings from not having to drive to buy things. That number has to be conservative when compared to rural areas in the US where households have longer drive times to reach retail shopping.

Farming Benefits. Much of the area covered by the study are agricultural and several studies have shown that good broadband can bolster farm incomes by as much as 6% annually – a number that is bound to increase as the benefits or smart-farming and outdoor IoT sensors improve crops and herd management.

Why the Study is Conservative. There are some obvious economic benefits that aren’t even included in the study. For example, there are several studies that show that lack of broadband depresses housing value. Anecdotally, I’ve been told in the last few years by rural real estate agents that they are starting to have trouble selling houses with no broadband – and it’s hard to put a value on the inability to sell a house.

The study pulls together studies done by others paint an overall picture of broadband benefits. looking at specific benefits of broadband – anybody that wants to understand this more should read the links to other studies. They step that made this study relevant to me was layering these impacts onto the specific area served by the Tipton Cooperative. One only has to travel to rural America these days to be able to see the differences between areas with and without broadband. Areas without broadband are unable to take part in things the rest of us take for granted like online shopping, easy access to do homework or pursue advanced degrees and the ability work from home and start new businesses. This is the first study I’ve seen that has tried to quantify all of these benefits for rural America, and the results are startling.

Broadband and Rural Population

Rural counties in total in the US gained 33,000 people in 2017, the first overall increase in rural population since 2011. But the gains came entirely to rural counties adjacent to metropolitan areas and highlights that remote rural counties continue a long-term trend of losing population. Nationwide, counties not next to metropolitan areas lost 24,000 people in 2017.

Further, within that global number, there is a different by the primary economic drivers in each county. Farming counties lost the most population, rural counties with manufacturing only lost a little population, and counties that rely on recreation and tourism gained population, attributed mostly to in-migration of retirees.

The loss of population is one of the primary reasons that rural counties are looking for better broadband. Rural counties don’t have to peer to far into the future to see a bleak picture. Their counties are often rapidly aging as young people move away to find employment. They are already seeing houses abandoned and foresee a shrinking property tax base. Farm counties continue to see the consolidation of farms and the loss of the family farmer.

Rural counties have different goals from broadband than more urban areas. They foremost hope that better broadband can mean more jobs and more employment. Many rural counties are not naïve enough any more to think they are going to attract factories or other businesses to their county. Some get lucky occasionally, but the country as a whole has lost an astonishing 60,000 factories since 2001. And even when new factories arise, they are largely automated and support far fewer jobs than factories in the past.

Rural counties care more about finding ways for residents to supplement incomes, and better broadband brings the chance to work from home. I was working with a rural county in Minnesota last year where I noticed that almost every farm in the county was operating a non-farming business along with farming as a way to supplement income – and this was in a county where the farms had practically no broadband at all and many homes relies on their cellular data for extremely expensive broadband connections. These counties want broadband so that the people living there can make enough money to stay.

Rural counties also need broadband for education. I rarely visit a rural county where there are not a few places in the county where rural residents drive their kids a few night each week to use WiFi in order to do their homework. It’s disheartening to see a parking lot full of cars at a library after it’s closed sitting and doing homework on the slow WiFi leaking out through the library walls.

Earlier I mentioned counties that rely on recreation for their economy. These counties desperately want broadband because they are finding that urban tourists don’t want to visit places that don’t have good internet connectivity and cellphone coverage. And businesses in these counties who rely on tourism have a hard time making it without broadband. Something as simple as offering on-line reservations requires a decent broadband connection, and lack of broadband puts counties at a disadvantage compared to similar areas with broadband.

Finally, rural counties want broadband to help keep the elderly in their homes longer. As hard as it is to be elderly in an urban area it’s much harder in a rural area where something as simple as seeing a doctor can mean a long trip. Rural areas also have a hard time attracting doctors and as rural clinics and hospitals continue to close it will become even harder to get basic healthcare. So rural counties are relying more and more on telemedicine and providers like the Mayo Clinic are embracing the technology to help rural America – but telemedicine require decent broadband including good upload speeds.

The skeptics of any government push to improve broadband often use the excuse that people just want broadband to watch TV, and that broadband is just for entertainment. And when people get broadband they take advantage of the wonderful world of entertainment now available on the Internet. But I can’t recall ever having seen entertainment on the list of reasons why rural counties want better broadband – they want it so that their counties survive as viable communities.