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OBI TECHNICAL PAPER NO. 5: HEALTH CARE BROADBAND IN AMERICA

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Released: August 27, 2010
o B i t e C h n i C a l P a P e r n o . 5
HealtH care
BroadBand in
america
Early analysis and a path forward
august 2010

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o B i t e C h n i C a l P a P e r n o . 5
tablE of ContEnts
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4
I. Health Care Providers’ Broadband Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
II. Broadband Connectivity Options . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
III. Gaps and Barriers Preventing Sufficient Broadband Levels . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Small Providers (Four or Fewer Physicians) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
Medium & Large Providers (Five or More Physicians) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Federally Funded Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
IV. Next Phase of Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

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h e a l t h C a r e B r o a d B a n d i n a m e r i C a
introduCtion
The National Broadband Plan lays out a bold roadmap to America’s future . “Chapter 10: Health Care” highlights how health infor-
mation technology (IT) offers the potential to improve health care outcomes while simultaneously controlling costs and extending
the reach of a limited pool of health care professionals .
Section 10 .5, “Closing the Health IT Broadband Connectivity Gap” presents an analysis of health care providers’ connectivity
requirements and the ability of the country’s infrastructure to meet those needs . The analysis is discussed here in more detail, with
a full explanation of assumptions and methodology used . However, this analysis is just the starting point . The goal in publishing this
paper is to solicit feedback and new ideas for furthering the country’s understanding of health care connectivity issues .
The health care connectivity analysis encompasses four sections:
1 . Health Care Providers’ Broadband Needs
2 . Broadband Connectivity Options
3 . Gaps and Barriers Preventing Sufficient Broadband Levels
4 . Next Phase of Analysis
4

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o B i t e C h n i C a l P a P e r n o . 5
i. hEalth CarE
leverages consumer devices such as smartphones, allowing
health care to travel with the patient and clinician .
providErs’
All of these solutions require broadband . Although some
analysis has been performed by vendors and health care provid-
broadband nEEds
ers on the broadband requirements of individual applications,
little has been published on the aggregate broadband demands
of adopting a robust suite of health IT solutions . The National
Today, health information technology (IT) plays an important
Broadband Plan estimates required broadband levels from the
role in the practice of medicine . Over the next 10 years1
bottom up, starting with demands of individual applications . The
this role will grow more prominent as technologies includ-
analysis then defines use cases that calculate the network needs
ing electronic health records, e-care technologies2 and mobile
of various types of health care providers based on their size and
health technologies become more critical to expanding ac-
the combination of applications that they will likely utilize .
cess to primary, acute and preventive care, lowering costs and
Estimates of the demands of individual applications range
reforming reimbursement incentives .
widely . To address this challenge, the National Broadband
Electronic health records enable efficient exchange of
Plan began with an understanding of common health care data
patient and treatment information by allowing providers
file sizes and their requirements for different download times
to access patients’ information from on-site or hosted loca-
using actual bandwidths (see Exhibit A) . Over the next decade,
tions . Video consultation and remote monitoring applications
physicians will need to exchange increasingly large files as new
remove geography and time as barriers to care, enabling instant technologies such as 3D imaging become more prevalent .
contact with health care professionals and real-time track-
The connectivity demands for specific applications were
ing of patient vitals from outside the hospital . Mobile health
then extrapolated, based on the size, type and duration of
Exhibit A:
Health Data

X-Ray Download Times

Text of single clinical doc

0.025
Mbps Needed
File Sizes and
(HL7 CDA format)
Seconds
(actual)

Text of single clinical doc

Bandwidth
0.050
5
16 Mbps
(PDF)
to Support
30
3 Mbps

Ultrasound

0.200
60
1 Mbps
Download

Standard chart

300
< 1 Mbps
Times3
(healthy patient)
5
MRI Download Times

X-Ray

10
Mbps Needed

Chest radiography

Seconds
(actual)
16
5
72 Mbps

MRI

45
30
12 Mbps
60
6 Mbps
64 - Slice CT Scan Download Times

PET scan

100
300
1 Mbps
Mbps Needed
Seconds
(actual)

Mammography study

(4 images)
160
5
4800 Mbps
30
800 Mbps
64-slice CT scan
3,000
60
400 Mbps

Human genome

300
80 Mbps
(sequence data only)
3,000

Cellular pathology study

(6 slides)
25,000

Megabytes (not to scale)

Exhibit B:

Basic email

Bandwidth
+

Text-only EHR

Remote

SD Video

HD Video

Image Transfer

Web browsing

Monitoring

Conferencing

Conferencing

(PACS)
Requirements to Achieve
1.0
0.025
0.5
2.0
>10
100
Full Functionality of
Health IT Applications
(Mbps)4

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h e a l t h C a r e B r o a d B a n d i n a m e r i C a
Exhibit C: Health IT Use Cases and
Associated Actual Broadband Requirements

Rec.


Bandwidth


Delivery Setting


Use Profile


Key Assumptions


(Mbps)
• Supports practice management functions (billing,
scheduling, etc.), email and web browsing
• Three total users per doctor for EHR and
Solo Primary
• Allows simultaneous use of EHR and high-quality
other general web-based activities
Care Practice
SD video consultations
≥ 4
• Image files (~10MB) should download in
• Enables non real-time image downloads
less than 30 seconds
• Enables remote monitoring
• Supports practice management functions (billing,
scheduling, etc.), email and web browsing
• Three total users per doctor for EHR and
Small Primary
other general web-based activities
• Allows simultaneous use of EHR and high-quality
Care Practice
SD video consultations
• Two simultaneous high-quality SD video
(2–4 physicians)
consultations
≥ 10
• Enables non real-time image downloads
• Enables remote monitoring
• Image files (~10MB) should download in
less than 30 seconds
• Makes possible use of HD video consultations
• Supports facility management functions, email and
• Five simultaneous users of general
web browsing
facility management and web-based
• Enables remote monitoring of resident population
activities
Nursing Home
• Allows simultaneous use of EHR and high-quality
• Two simultaneous high-quality SD video
≥ 10
SD video consultations
consultations
• Enables non real-time image downloads
• Image files (~10MB) should download in
• Makes possible use of HD video consultations
less than 30 seconds
• Supports clinic management functions (billing,
• Three total users per practitioner for
scheduling, etc.), email and web browsing
EHR and other general web-based
Rural Health Clinic
• Allows simultaneous use of EHR and high-quality
activities
(~5 practitioners)
SD video consultations
• Two simultaneous high-quality SD video
≥ 10
• Enables non real-time image downloads
consultations
• Enables remote monitoring
• Image files (~10MB) should download in
• Makes possible use of HD video consultations
less than 30 seconds
• Specialty services (e.g., radiology,
• Supports clinic management functions (billing,
orthopaedics, dermatology) provided
scheduling, etc.), email and web browsing
• Three total users per practitioner for
Clinic / Large
• Enables real-time image transfer
EHR and other general web-based
Physician Practice
• Allows simultaneous use of EHR and high-quality
activities
(5–25 physicians)
≥ 25
SD video consultations
• Large image files (~20MB) should
• Enables remote monitoring
transfer in less than 10 seconds
• Makes possible use of HD video consultations
• Five simultaneous high-quality SD video
consultations
• Supports hospital management functions (billing,
scheduling, etc.), email and web browsing
• PACS in place for real-time diagnostic
• Enables real-time image transfer
imaging
Hospital
• Allows simultaneous use of EHR and high-quality
• Very large image files (~50MB) should
≥ 100
SD video consultations
transfer in less than 5 seconds
• Enables continuous remote monitoring
• Mulitple simultaneous high-quality SD
video consultations
• Makes possible use of HD video consultations
Academic / Large
• Same as hospital, but scale of demands
Medical Center
• Same as hospital
on largest medical centers drives
≥ 1 Gbps
exponential bandwidth needs
6

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o B i t e C h n i C a l P a P e r n o . 5
data transmission associated with each . Extensive input from
these different institutions, the use cases profile technologies
industry experts and health care professionals validated actual
each type of provider utilizes and the number of concurrent
connectivity required to enable full functionality of health IT
users to be supported, which translate into minimum actual
applications . Basic email plus web browsing, text-based EHRs,
broadband requirements .
remote monitoring, standard definition videoconferencing, high
Quality-of-service metrics are also crucial to health IT uti-
definition videoconferencing and image transfer were evaluated lization . Latency, reliability, packet loss, and jitter can be even
(see Exhibit B) .
more important than bandwidth in supporting applications .
Health care institutions, depending on the type of facility,
Certain remote monitoring technologies, for instance, may
concurrently use a range of applications . The plan developed
require very low latency in order to pass through high priority
use cases to determine real-life guidelines of required actual
events like alarms . Although the plan uses input from indus-
bandwidths . The use cases examine seven common types of
try experts, health care practitioners and vendors to establish
health care institutions: Solo Primary Care Practices, Small
these quality-of-service requirements, further analysis is need-
Primary Care Practices, Nursing Homes, Rural Health Clinics,
ed to refine them for specific provider types . General guidelines
Clinics/Large Physician Practices, Hospitals and Large
for quality-of-service metrics are shown in Exhibit D .
Medical Centers . Based on the size and clinical practices of
Exhibit D:

Quality Metric

Recommended Target*

Quality-of-Service
Reliability (uptime)
99.9%
Requirements
Latency
<50 ms primary
<120 ms back-up
Jitter
<20 ms
Packet loss
<1%
* Recommended targets reflect findings from
interviews and submissions to the public record.

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h e a l t h C a r e B r o a d B a n d i n a m e r i C a
ii. broadband
It is important to note that bandwidth is just one metric
affected by these different technologies . Latency, reliability,
ConnECtivity
packet loss, and jitter also vary for each of the network tech-
nologies listed in Exhibit E, independent of the bandwidth
options
levels . Low latency, for instance, does not perfectly correlate
with high bandwidth . DIA services offer a solution to this
challenge by guaranteeing quality-of-service levels as well as
Most businesses in the United States, health care institutions
bandwidth levels .
included, have two choices of broadband service categories:
Unfortunately, DIA services are substantially more expen-
mass-market “small business” solutions or Dedicated Internet
sive than mass-market packages . For example, in Los Angeles,
Access (DIA), such as DS3 or Gigabit Ethernet service . DIA
10 Mbps Ethernet service with an SLA averages $1,044/
solutions often offer higher bandwidth, and include broader and month, while Time Warner Cable’s similar mass-market
stricter Service Level Agreements (SLAs) by network operators . package, Business Class Professional, which offers 10 Mbps
According to the estimated actual broadband needs listed
download speeds and 2 Mbps upload speeds, is approximately
above, only smaller delivery settings can consistently adopt
$400/month .5
health IT using mass-market solutions . As mass-market solu-
tions increasingly bring a reliable 50–100 Mbps to institutions,
this may change . However, most larger practices currently must
purchase Dedicated Internet Access . Within DIA options, T1s
and most bonded T1s will not provide sufficient bandwidth
levels; providers have to adopt more robust, often fiber-based,
technologies .
Exhibit E:

Protocols

Common Broadband Access/

Common Broadband

Circuit Types

Common Associated Bandwidths

Access Options for
ISDN
Mass Market
Health Care Providers6
Broadband (Consumer Fixed Wireless Access
or Business Class
Speeds range greatly according to package
DSL
Internet Service)
Cable (DOCSIS)
Fractional T1
< 1.5 Mbps
T1
1.5 Mbps
Bonded T1
3–6 Mbps
Fractional DS3
6–45 Mbps
Dedicated Internet
Access
Fast Ethernet
10–100 Mbps
DS3
45 Mbps
OC3
155 Mbps
Gig Ethernet
100–1,000 Mbps
Satellite
Speeds range
8

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o B i t e C h n i C a l P a P e r n o . 5
iii. gaps and

Small ProviderS (Four or Fewer Physicians)

In general, smaller providers can achieve satisfactory health IT
barriErs
adoption with mass-market “small business” packages of at least
4 Mbps for single physician practices and 10 Mbps for two-to-
prEvEnting
four physician practices, even though these solutions may not
provide business-grade quality-of-service guarantees .10 Since
suffiCiEnt
most small physician offices do not provide acute care services,
they do not require the same degree of instant and guaranteed
broadband lEvEls
responsiveness that large practices and hospitals require .
For small providers, the key connectivity consideration is
whether or not they can access mass-market solutions of suf-
Because broadband options vary greatly according to the type
ficient bandwidth . As long as they are within the mass-market
and size of a health care institution, the barriers associated
infrastructure footprint, they are likely to have a more conve-
with acquiring broadband also differ according to type and size . nient and affordable option than the Dedicated Internet Access
The National Broadband Plan analyzes connectivity barriers
necessary for their larger peers (see pricing example for Los
for three different segments of providers: Small Practices (one
Angeles above) .
to four physicians, includes nursing homes), Large Practices
The National Broadband Plan completed the first estimate
(five physicians and more) and Federally Funded Providers .
of how many small providers are located outside the mass-
Exhibit F approximates the health care landscape for those
market infrastructure footprint . All AMA locations with four
three segments . The overall count of physicians was gained
physicians or fewer were inputted into a new model developed
courtesy of the American Medical Association’s “Physician
by the Omnibus Broadband Initiative (OBI) . The model pre-
Masterfile Database (2009) .” This one-of-a-kind database
dicts the availability of wired and wireless technologies at the
tracks the address of every location where physicians practice
census block level throughout the country .11 Please see working
in the United States; it can also provide a count of the number
paper “The Broadband Availability Gap” (http://download .
of physicians practicing at each location . The federally funded
broadband .gov/plan/the-broadband-availability-gap-obi-
provider segment that the National Broadband Plan considered technical-paper-no-1 .pdf ) for further discussion of this model .
included every Federally Qualified Health Center (FQHC),7
Based on the requirements listed above, an estimated 3,600
Rural Health Clinic (RHC),8 Critical Access Hospital (CAH)9
out of approximately 307,000 small providers face a broadband
and Indian Health Service (IHS) location in the country . The
connectivity gap (adequate mass-market broadband is not
count does not include Veterans Health Administration, Public available to them) . The gap is particularly wide among provid-
Health Departments and federally funded mental health facili-
ers in rural areas . In rural areas, approximately seven percent of
ties due to the dificulty in obtaining their locations . These
small physician offices are estimated to face a connectivity gap .
facilities should be included in future analyses .
In contrast, across all locations, only approximately one percent
of physician offices face a connectivity gap (see Exhibit G) .12
Exhibit F:
~346,000 Locations with Practicing Physicians
Approximate Count of
* Federally Funded
Health Care Locations

Providers is not a discrete

category. Overlaps completely
in the United States
307,000
with the other two categories.
39,000
13,000

Small Providers

Medium & Large Providers

Federally Funded Providers*

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h e a l t h C a r e B r o a d B a n d i n a m e r i C a
Exhibit G:

Approx. Number

Estimate of Small
of Locations
Physician Locations
5,000
Without Mass-
30% of
4,000
Market Broadband
70% of

Total

3,000
Availability
1,100
13

Total

2,000
3,600
1,000
2,500
0

Small Physician

Small Physician

All Small Physicians

Offices (rural)

Offices (non-rural)

medium & large ProviderS (Five or more
other, possibly negates a significant portion of the incentives,

PhySicianS)

and may prove an insurmountable obstacle to EHR adoption .
Larger physician offices, clinics and hospitals face connectivity
Moreover, rural and tribal areas are likely to face even great-
barriers of a different nature . Because of their size and service
er price inequities . There are more than 2,000 rural providers
offerings, these providers often cannot rely on mass-market
participating in the FCC’s Telecommunications Fund, and their
broadband and must usually purchase DIA solutions .
broadband prices average two and a half times the price of ur-
One major difference between mass-market and DIA solutions ban benchmarks .17 This analysis indicates that rural providers
is that DIA is available everywhere . Broadband service providers
receive an average 60 percent discount on their cost of service,
offer customized solutions for customers who are willing to pay
which reflects the rural/urban cost differential .18
for them, no matter where they are located . For instance, even in
In order to gain a more developed understanding of the price
rural Alaska where no broadband infrastructure exists, clinics are
barriers for medium and large practices in various regions of
able to pay for satellite connections equivalent to multi-bonded
the country, there must be better data19 on the nature of those
T1s, but these cost $10,000 or more per month .14
barriers . These data would not only provide a more representa-
Therefore, the major barrier for medium and large providers tive picture of actual adoption rates of broadband services (as
is not access—it is price . As noted in the Los Angeles example
opposed to availability), but could show how wide and severe
above, DIA solutions are often significantly more expensive
price disparities are across the country .
than mass-market solutions with similar bandwidths . Within
DIA service offerings, prices jump substantially between T1

Federally Funded ProviderS

connections and higher levels of service such as DS3s . As a
The National Broadband Plan took a closer look at the feder-
result, anecdotal data indicate that providers who purchase
ally funded provider segment because it has a direct impact on
DIA solutions often buy connections that are too slow to meet
the government’s costs and serves health care populations for
their health IT needs . For instance, 92% of IHS sites and over
whom the government assumes responsibility .
80% of institutions in the FCC’s Rural Health Care Program
The Plan entered databases of Rural Health Clinics (RHC),
are purchasing T1s (1 .5 Mbps) when, ideally, they need 4–1,000 Federally Qualified Health Centers (FQHC), Critical Access
Mbps to meet their operational needs .15
Hospitals (CAH) and Indian Health Service (IHS) locations into
DIA pricing also varies significantly by geography . Prices are the predictive broadband availability model discussed above .
determined on a case-by-case basis depending on factors such
This allowed a comparison between mass-market broadband
as capacity, type and length of the connection, type of service
availability for these locations and mass-market availability for
provider, and type of facility used . Exhibit H illustrates how
all locations in the country . The analysis demonstrates that the
widely DIA prices fluctuate in urban areas alone .
four groups of providers analyzed face relatively greater chal-
For two large physician offices seeking to capitalize on mean-
lenges in securing broadband (see Exhibit I) . This conclusion is
ingful use incentives, a disparity of more than $27,000 per year16 not surprising, as these providers serve patient populations lo-
in broadband costs could put one at a major disadvantage to the
cated in some of the most rural and economically disadvantaged
1 0

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Exhibit H:

Monthly service cost ($)

Wide Fluctuations in
Dedicated Internet

1.8x
$
Access Prices20
5,082
6,000

DS3

4,290
3,680
(45 Mbps)
4,000
2,800
2,000
0

Wyoming

Mississippi

Kansas

Vermont

$
6,000

DS1

(1.5 Mbps)
2.6x
4,000
2,000

225
336
390
586
0

Wyoming

Mississippi

Kansas

Vermont

Exhibit I:

Federally Funded Providers

Health Care Locations

Total Number

Without Mass-
346,000
7,800
1,300
3,700
670
of Locations
Market Broadband

With Mass

Availability
99%
91%
74%
71%
67%

Market

21

Broadband

(Estimated %)
1%
9%

Without Mass

26%
29%
33%

Market

Broadband

All locations with

FQHCs

Critical Access

Rural Health Clinics

IHS Locations

(Estimated %)

Physicians

Hospitals

areas of the country . These challenges materialize in terms of ac- achieved for each of its sites . Its database shows that 92% of
cess for small providers, and higher costs relative to their peers
locations are purchasing T1 (1 .5 Mbps) connections or slower,
for medium and large providers . Importantly, providers in areas
and that it would cost $29 million to upgrade these ~630 sites
without mass-market broadband can still access connectivity via to sufficient levels of connectivity .22 The same information
DIA solutions, albeit at a greater price .
is currently not available for FQHCs, RHCs or CAHs, but
A more precise analysis will be grounded in an under-
it should be collected . The analysis should also be widened
standing of actual levels and cost of broadband purchased by
to included VHA, BOP, NASA, and federally funded mental
federally funded providers . Indian Health Service, for instance, health facilities .
tracks the broadband type purchased and bandwidth levels

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h e a l t h C a r e B r o a d B a n d i n a m e r i C a
iv. nExt phasE of
analysis
Understanding the state of broadband connectivity for health
care providers is a relatively new, but important area of analy-
sis . 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 con-
nectivity grows, an up-to-date understanding of broadband use
cases and connectivity levels will be invaluable . Specific data
needs and analyses are suggested in each of the sections above .
1 2

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o B i t e C h n i C a l P a P e r n o . 5
E n d n o t E s
1
The National Broadband Plan set a goal for 2020 of 100 Mbps to over 100 million house-
11
Please see working paper “The Broadband Availability Gap” (http://download .broad-
holds and 1 Gbps to at least one anchor institution in each community, such as a hospital .
band .gov/plan/the-broadband-availability-gap-obi-technical-paper-no-1 .pdf) for
Omnibus Broadband Initiative, Federal Communications Commission, Connected
further discussion of this model .
America: The National Broadband Plan (2010), available at http://www.broadband.gov/
12
Access to mass-market broadband is used here to mean passed by terrestrial broadband
plan/, at Chapter 2 . By then the health IT requirements outlined here will be out-of-date
access facilities such as those used to deliver DSL or cable modem service . This analysis
and likely too low . This paper’s primary concern is the needs of health care providers now
does not predict how many of the 307,000 small providers purchase the appropriate
and in the immediate future .
level of broadband; only the mass-market broadband available to them . The analysis is
2
As used herein, “e-care technologies” includes remote monitoring, video consultations
a predictive estimate combining the FCC’s statistical network model and provider data-
and remote image diagnostics .
bases, as shown below . Gap is calculated based on connectivity requirement threshold
3
GE Healthcare Comments in re NBP PN #17 (Comment Sought On Health Care Delivery
of 4 Mbps for Single Physician Practices and 10 Mbps for all other practices . AMA small
Elements of National Broadband Plan – NBP Public Notice #17, GN Docket Nos . 09-47,
provider locations (four physicians or less) were assigned to an appropriate census block,
09-51, 09-137, WCB Docket No 02-60, Public Notice, 24 FCC Red 13728 (WCB 2009)
based on their street address, and then reconciled with the model showing connectivity
(NBP PN #17)), filed Dec . 4, 2009, at 8; Euclid Seeram, Digital Image Compression,
availability for that census block . About 24,000 (or 7%) of the health care locations in
Radiologic Tech ., July–Aug . 2005, http://www .entrepreneur .com/tradejournals/article/
the AMA database had addresses that were impossible to convert accurately to census
134676840 .html; Human Genome Project Information, Frequently Asked Questions,
blocks; results for these locations were modeled to complete the analysis . A small
http://www .ornl .gov/sci/techresources/Human_Genome/faq/faqs1 .shtml (last visited
percentage of the records (less than 1 .5%) were geographically located outside of the
Jan . 31, 2010); Ichiro Mori et al ., Issues for Application of Virtual Microscopy to Cyto-
Master Broadband Availability data (e .g ., Puerto Rico), and therefore were dropped from
screening, Perspectives Based on Questionnaire to Japanese Cytotechnologists, diagnosTic
consideration in the connectivity analysis . The analysis does not take into account other
PaThology, July 15, 2008, http://www .diagnosticpathology .org/content/pdf/1746-1596-
network quality requirements . Some of these locations may have alternative networks or
3-S1-S15 .pdf . See, e.g., DICOM sample image sets, http://pubimage .hcuge .ch:8080/ (last
commercial services, where residential broadband is unavailable .
visited Jan . 31, 2010) .
• FCC Deployment Baseline Analysis: See omnibus bRoadband iniTiaTive, The
4
Mbps recommendations reflect a compilation of the record . Numbers are guidelines, not
bRoadband availabiliTy gaP (http://download .broadband .gov/plan/the-broadband-
precise measures . See Record in response to NBP PN #17 and ex parte filings (see, e.g.,
availability-gap-obi-technical-paper-no-1 .pdf) . The OBI deployment team created
Letter from Alice Borelli, Director, Global Health Care and Workforce Policy, Intel Cor-
a nationwide model for broadband availability from wired and wireless technologies .
poration, to Marlene H . Dortch, Secretary, FCC, GN Docket Nos . 09-47, 09-51, 09-137
• Database of all locations in the United States with practicing physicians: Am . Med .
WCB Docket No 02-60 (Dec . 16, 2009)) . See also, e.g., FibeRuTiliTies gRouP, a PRacTical
Ass’n, AMA Physician Masterfile Database (2009) (on file with the FCC) . The
Review oF bRoadband RequiRemenTs FoR healThcaRe clinical aPPlicaTions 6–7 (2009),
Physician Masterfile includes current and historical data for more than 940,000
available at http://www .fiberutilities .com/documents/FG_Press_Release_FCC_Brief-
residents and physicians and approximately 77,000 students in the United States .
ing_Healthcare_Application_Requirements_for_Broadband_110609 .pdf .
Includes all active practicing physicians in the US (655,630) and the addresses
5
TimeWarner Business Class Professional 10 x 2, listed at $399 .95 / month on TimeWar-
where they practice . Sorting by address sorts 655,630 physicians into 351,172
ner Los Angeles website . Taxes and other surcharges not factored in . See Time Warner
locations, with a size metric for each one based on how many physician entries are
Cable Business Class, https://www .twcbc .com/LA/buyflow/buyflow .ashx (last visited
associated with each location entry . Removed 5,077 locations in Puerto Rico and
Feb . 27, 2010) (requires providing additional information to access) .
other locations that were not included in the Statistical Model, leaving 346,095 loca-
6
For requirements, see Exhibit D and note 1 .
tions for our analysis . Detailed information on this database is available from the
7
“FQHCs are ‘safety net’ providers such as community health centers, public housing cen-
AMA . AMA Physician Masterfile, http://www .ama-assn .org/ama/pub/about-ama/
ters, and programs serving migrants and the homeless . The main purpose of the FQHC
physician-data-resources/physician-masterfile .shtml (last visited Feb . 27, 2010) .
Program is to enhance the provision of primary care services in underserved urban and
• FCC’s Rural definition, 47 C .F .R . § 54 .5: “For purposes of the rural health care
rural communities .” Cms, FedeRally qualiFied healTh cenTeR FacT sheeT 1 (2009),
universal service support mechanism, a ‘rural area’ is an area that is entirely outside
http://www .cms .hhs .gov/MLNProducts/downloads/fqhcfactsheet .pdf . FQHCs qualify
of a Core Based Statistical Area; is within a Core Based Statistical Area that does not
for cost-based CMS reimbursement and other benefits .
have any Urban Area with a population of 25,000 or greater; or is in a Core Based
8
“The Rural Health Clinic Program was established in 1977 to address an inadequate sup-
Statistical Area that contains an Urban Area with a population of 25,000 or greater,
ply of physicians who serve Medicare and Medicaid beneficiaries in rural areas .” CMS,
but is within a specific census tract that itself does not contain any part of a Place or
RuRal healTh clinic FacT sheeT 1 (2007), http://www .cms .hhs .gov/MLNProducts/
Urban Area with a population of greater than 25,000 . ‘Core Based Statistical Area’
Downloads/rhcfactsheet .pdf . Clinics must meet criteria established by HHS, includ-
and ‘Urban Area’ are as defined by the Census Bureau and ‘Place’ is as identified by
ing being located in rural area and in a Health Provider Shortage Area or a Medically
the Census Bureau .”
Underserved Area . RHC institutions qualify for cost-based CMS reimbursement and
13
Ibid .
other benefits .
14
Letter from Ellen Satterwhite, Policy Analyst, Omnibus Broadband Initiative to Marlene
9
Critical Access Hospitals are hospitals qualified to receive cost-based reimbursement
H . Dortch, Secretary, FCC, GN Docket No . 09-51 (August 16, 2010) .
from Medicare and are important components of states’ rural health networks . See gener-
15
Letter from Theresa Cullen, MD, MS, RADM, U .S . Public Health Service Chief Information
ally cms, cRiTical access hosPiTals FacT sheeT (2009) (discussing what qualifies as a
Officer and Director, to Marlene H . Dortch, Secretary, FCC, GN Docket Nos . 09-47, 09-51,
Critical Access Hospital), available at http://www .cms .hhs .gov/MLNProducts/down-
09-137, WC Docket No . 02-60 (Feb . 23, 2010) Attach . (IHS Ex Parte) Indian Health Service
loads/CritAccessHospfctsht .pdf .
calculated the annual cost to upgrade its broadband networks to the minimum require-
10
Statement reflects compilation of the record and is a guideline, not a comprehensive re-
ments in Exhibit C, supra . Estimates were made using median prices paid across its 600+
quirement . Record in response to NBP PN #17 and ex parte filings (see, e.g., Letter from
location system . Competitive bidding and selective network deployment similar to the
Winifred Wu, MD, MPH, Director, Public Health Informatics, New York City Depart-
FCC’s universal service programs will likely reduce prices . Also, as ARRA funding through
ment of Health and Mental Hygiene, to Marlene H . Dortch, Secretary, FCC, GN Docket
BIP and BTOP is spent on Tribal lands, the prices for service may decline .
Nos . 09-47, 09-51, 09-137 WCB Docket No 02-60 (Feb . 26, 2010)) .

F e d e r a l C o m m u n i C a t i o n s C o m m i s s i o n | h e a l t h C a r e B r o a d B a n d i n a m e r i C a

1 3

h e a l t h C a r e B r o a d B a n d i n a m e r i C a
16
Difference between DS3 purchased in Wyoming versus Vermont for one year of service,
• FCC Deployment Baseline Analysis: see discussion ch . 3 endnotes, supra . The OBI
according to rates listed in Exhibit H, supra, is $27,384 .
deployment team created a nationwide model for broadband availability from wired
17
Letter from William England, Vice President, Rural Health Care Division, Universal
and wireless technologies . Database of all locations in the United States with prac-
Service Administrative Company, to Marlene H . Dortch, Secretary, FCC, GN Docket Nos .
ticing physicians: AMA, AMA Physician Masterfile Database (2009) (on file with
09-47, 09-51, 09-137 (Feb . 23, 2010) (USAC Feb . 23, 2010 Ex Parte) at 1 . If locations in
the FCC), “The Physician Masterfile includes current and historical data for more
Alaska are excluded, the participants’ broadband price still averages 3x the price of their
than 940,000 residents and physicians and approximately 77,000 students in the
urban benchmarks .
United States .” Includes all active practicing physicians in the US and the addresses
18
See id .
where they practice . Sorting by address sorts 655,630 physicians into 346,095
19
Specifically: 1) what type of broadband such providers are purchasing, 2) what actual
locations, with a size metric for each one based on how many physician entries are
bandwidths and quality metrics they are realizing from their broadband, and 3) how
associated with each location entry . Removed 5,077 locations in Puerto Rico and
much they are paying in overall broadband costs .
other locations that were not included in the Statistical Model, leaving 346,095 loca-
20 Wyoming, Mississippi, Kansas, and Vermont prices: USAC, Urban Rate Search Tool,
tions for our analysis . Detailed information on this database is available from the
http://www .usac .org/rhc/tools/rhcdb/UrbanRates/search .asp (last visited Feb . 8, 2010)
AMA . AMA Physician Masterfile, http://www .ama-assn .org/ama/pub/about-ama/
(use 2009 data) .
physician-data-resources/physician-masterfile .shtml (last visited Feb . 27, 2010) .
21
Access to mass-market broadband is used here to mean passed by terrestrial broadband
• Federally Qualified Health Center Database: HRSA Electronic Handbooks,
access facilities such as those used to deliver DSL or cable modem service . This analysis
Bureau of Primary Health Care Management Information System, Scope Reposi-
does not predict how many of the providers purchase the appropriate level of broadband;
tory retrieved via the HRSA Geospatial Data Warehouse’s Health Care Service
only the mass-market broadband available to them . The analysis is a predictive estimate
Delivery Sites report at http://datawarehouse .hrsa .gov/HGDWReports/RT_App .
combining the FCC’s statistical network model and provider databases as shown below .
aspx?rpt=HS, retrieved on Oct . 24, 2009 .
Gap is calculated based on connectivity requirement threshold of 4 Mbps for Single
• Rural Health Clinic Database: CMS, Name and Address Listing For Rural Health
Physician Practices and 10 Mbps for all other practices . Health care locations were as-
Clinic Database (accessed Oct . 6, 2009) . Updated versions are available at http://
signed to an appropriate census block, based on their street address, and then reconciled
www .cms .hhs .gov/MLNProducts/downloads/rhclistbyprovidername .pdf .
with the model showing connectivity availability for that census block . For each database,
• Critical Access Hospitals Database: HHS, Health Resources and Services Admin-
a percentage of the health care locations had addresses that were impossible to convert
istration, HRSA Geospatial Data Warehouse—Report Tool, http://datawarehouse .
accurately to census blocks; results for these locations were modeled to complete the
hrsa .gov/HGDWReports/RT_App .aspx?rpt=P2 (providing data snapshot from
analysis . For the AMA, this accounted for ~24,000 (or 7%) of total entries . For IHS, this
Sept . 30, 2009) .
accounted for ~350 (or 52%) of entries . Additionally, the FQHC database contained
• IHS Database: IHS Ex Parte, Attach .
duplicate location records, which were excluded from the connectivity analysis . A small
22 IHS Ex Parte, Attach . Indian Health Service calculated the annual cost to upgrade its
percentage of the records (less than 1 .5%) were geographically located outside of the
broadband networks to the minimum requirements in Exhibit C, supra . Estimates were
Master Broadband Availability data (e .g ., Puerto Rico), and therefore were dropped from
made using median prices paid across its 600+ location system . Competitive bidding and
consideration in the connectivity analysis . The analysis does not take into account other
selective network deployment similar to the FCC’s universal service programs will likely
network quality requirements . Some of these locations may have alternative networks or
reduce prices . Also, as ARRA funding through BIP and BTOP is spent on Tribal lands, the
commercial services, where residential broadband is unavailable .
prices for service may decline .
1 4

F e d e r a l C o m m u n i C a t i o n s C o m m i s s i o n | W W W . B r o a d B a n d . g o V




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