the slides here - North Carolina Telehealth Network
Transcription
the slides here - North Carolina Telehealth Network
For ORH HealthNet Group 4/27/2016 Dave Kirby, NCTN Project Manager [email protected] 1 Importance and Value of Broadband Services to typical clinic. Broadband Basics for Clinic Managers How to acquire/manage broadband services NCTN Concept and History FCC Discount Program NCTN Concept, History, Status and Prospects Exemplars - Rural Clinics, Public health, behavioral health, FQHCs, Free Clinics, hospitals, data centers, admin offices. NCTN Value to typical clinic; Contacts – (Laura, Ruthy, John, Dave) Info Sys Importance is Up: information systems have become more important to planning, operating, and improving the value of care delivered in the typical clinic. ◦ ◦ ◦ ◦ Electronic Health Records (EHR) – to improve clinic service management Health Information exchange (HIE)-to support care across the continuum Telemedicine – to support use of care providers in remote locations to assist in care of local patients; improve access, lower cost/patient, improve outcomes. Email, web sites – to support communications with patients, providers, the public Info Sys Use Incentives are Up: incentives/penalties for valuable use of information systems is increasing: ◦ ◦ ◦ ◦ ◦ ◦ ◦ The Meaningful Use of EHRs Program NC State requirements to use HIE FCC program for broadband subsidies ; HRSA/USDA program of grants/loans for IT and broadband support NC State support for telemedicine Private philanthropy support for programs that include information systems. Public policy that favors timely communication among providers (ACOs, Patient Home) Private policy that requires a common information systems available across many sites (e.g. health systems) ..and Increasing: Info Sys importance and use incentives are continuing to increase over time. Why? – When properly used, information systems support better quality of care for more people at lower costs. Info Sys Operations need e-pipes: Most clinic-related information systems used by the typical clinic require access to the world outside the clinic. Notably: EHRs, HIE, email, claims, telemedicine, teleeducation, web site access, VOIP. Broadband Services are e-pipes: Broadband services provide the “pipes” to the outside world. Typical e-pipe: is a connection that moves all data traffic across the Internet (to/from all other Internet-connected services). Other e-pipes: point-to-point services from one site to another without using the Internet (e.g. spoke-and-hub for a larger collection of sites) Bad responsiveness for an information system means: ◦ ◦ ◦ ◦ ◦ ◦ ◦ Clinic providers take more time to process patients. Patients wait longer or leave – remain in distress longer Overtime for clinic staff (or continuing backlog of work) Lowered reputation for the clinic Provider, staff, and patient frustration. Pixelated interactive video (as for telemedicine) Poor voice quality (as on VOIP) Responsiveness is a consequence of a combination of: ◦ ◦ ◦ ◦ Speed of local PCs and clinic internal network(not often a problem with networked apps) Speed of the local site’s (clinic’s) broadband connection (often the weak link) Speed of the remote site’s (data center) broadband connection (not often the weak link) Load from users other than the local site’s users on any “shared” parts of the network (e.g. the Internet or oversubscribed broadband services) ◦ Load on the remote server from other users’ activities. So, poor responsiveness might come from many sources but the clinic’s broadband speed and “Internet traffic clogs” are often the limiting factors. Se cti on 15 Loss of broadband service (typically) means: ◦ ◦ ◦ ◦ ◦ ◦ ◦ No more EHR access. No access to patient records No access to claims systems No email Loss of VOIP (if the clinic uses VOIP) No web site access No telemedicine or teleeducation sessions. Typically, during a broadband outage: Having adequate Broadband Services is essential to minute-tominute operations of the typical clinic. ◦ Clinic operations stop; ◦ Hourly staff go off the clock; ◦ Patients leave the clinic – with no idea when to return because you can’t access the scheduling features of the EHR. ◦ VOIP phone service is down. Se cti on 16 For the typical clinic obtaining an adequate broadband service at an affordable cost is critical to meeting its mission of serving the public. Let’s explore how to obtain and manage these services…. Se cti on 17 Other User sites (mobile too) Clinic Site Clinic PC Data Center Server Line A Router Line B Cloud Line C Router Other datacenters Line A – Clinic’s Internal Network (i.e. switches cables, WiFi access points) Line B - Clinic’s Broadband Service Cloud – Collection of cables, fibers, routers, switches running cross-country and connecting to other clinics, data centers. Internet; point-to-point connections don’t have a cloud Line C - Data Center’s Broadband Service Data center – physical site with collection of “servers” that deliver the services invoked at the clinic (e.g. EHR, HIE, email) Data Center/ Hub site Clinic Site A Clinic PC Line A Server PTP A Router Router Router Clinic B Clinic C Cloud Line A – Clinic’s Internal Network PTP x - Clinic’s Broadband Service - connection to hub (no Internet) Cloud – attached at the data center for use by all clinics to reach Internet Data center – same as before TIP: Typically, hub and spoke model is used to lower costs and improve server access, provide better local access control to the Internet Wi-Fi – a wireless short-range network (buildingsized). Typical clinic has a Wi-Fi network available only in the clinic building. Asymmetric speeds: Upload/download speed – some network services are designed to have different upload/download speeds. Often, this is to provide more download speed (At the expense of upload speed). Fiber (vs copper) networks: fiber is the most common way to provide high speed today; copper (e.g. DSL) makes use of older wire plant but has limited speed. Speed – usually in megabits per second. Sometimes different speeds for incoming data (to clinic) vs outgoing. Slower speed of service often slows the response of a server (EHR, HIE) Latency – how long it takes for data to move between the clinic and a server; usually in average milliseconds. Longer latency delays server response to clinic request. Interactive video and VOIP may not work well with long latency Jitter - high variability in data movement time across the network; often affects real-time apps like VOIP, interactive video; Uptime - pattern of network availability/outage; monitoring by vendor; SLA (Service Level Agreement) Cost – usually a startup fee and a monthly recurring cost. A slowdown or outage of an information service at a clinic can be caused by one or more of the following: ◦ ◦ ◦ ◦ ◦ ◦ Clinic PC- outage or overuse Line A - clinic internal net – outage or overuse Line B - clinic broadband service- outage or overuse Cloud – outages or overuse of cloud resources Line C – data center internal net- outage or overuse Server - application server – outage or overuse Typical clinic staff don’t have a way of determining which component(s) are causing an outage or slowdown. TIP: So, having good vendor help desk support is critical to timely resolution. Overload?: Typically, the amount of data traffic that a clinic presents to its broadband service builds over the day to a peak “load” at mid day. Load – measured in average megabits per second across a given time span. When this load is greater than the speed of the broadband service (or other IS component), a slowdown occurs. TIP: So, having your broadband speed be higher than your peak demand will reduce slowdowns. A: Max BB Svc Speed not overloaded Load B: Max BB Svc Speed overloaded 5am 8 am 12pm 2pm 5pm 7pm Speed – instantaneous data transfer rate (e.g. 10mbps) Thruput – actual rate at which data can be moved over a given time frame (e.g. Our thruput at peak time is often 4 mpbs). Oversubscribed services vs not - vendors may offer a service with a “speed” that is much higher than the actual “thruput” to lower costs while appearing to offer a better service. Address speed vs thruput in your contract for service. TIP: Measure thruput and have vendor do this to assure delivery during life of service. Se cti on 114 Cable/Fiber cuts (most common) Software outage in servers (commonly) or network components Viruses (on servers, PCs (commonly)) Power outages (to clinic is common); uncommonly network equipment Se cti on 115 Se cti on 116 Speed – obtain (contract for) a speed (up and down) that will be well above your peak load over the life of the contract. Be cautious of over-subscribed services. Thruput – actual rate at which data is moved over a given time frame; Oversubscribed services vs not - vendors may offer a service with a “speed” that is much higher than the actual “thruput” to lower costs while appearing to offer a better service. You really care about thruput. Address speed vs thruput in your contract for service. Measure thruput and have vendor do this to assure delivery during life of service. TIP: A lot more speed does not cost much more: Note that, typically, doubling the speed of a broadband service raises its price by only 10-20% Se cti on 117 Latency/Jitter – most common management tool is to get even higher speed to prevent contention for bandwidth that raises latency/jitter. TIP: A lot more speed does not cost much more: Note that, typically, doubling the speed of a broadband service raises its price by only 10-20% Se cti on 118 Broadband service provider’s network service structure – how much control over data flow do they have; how well is net monitoring done; availability of capable help desk function. Redundancy- If uptime is super important to you and your outage is not acceptable, consider getting a second broadband service at the clinic site whose physical path and network device set is (as much as feasible) separate from the primary service. This second service can also be used to carry traffic load in normal times. Se cti on 119 Compete services where feasible Be sure to compare apples-to-apples Consider the “buried” but important costs of provider time, patient time, etc in balance with saving money on a slower (or oversubscribed) less reliable broadband service. Make use of grants/subsidies where feasible. Se cti on 120 … before I move on to NCTN Se cti on 121 Concept: NCTN is a dedicated non-profit broadband network with Internet and Internet2 connections to support health and care in NC for public and non-profit healthcare providers. Key design points: ◦ ◦ ◦ ◦ ◦ Low cost (mostly via volume purchase and discounts) Very high reliability (disaster-resistance) High bandwidth with no over-subscription Support key communications among healthcare stakeholders. High user community collaboration in building and operating Statewide Intranet: Traffic among NCTN subscribers does not transit Internet or Internet2; So, traffic control and security are better. Managed Network: NCTN has an active monitoring point at each subscriber site and monitors the service’s operational status 24x7. 24x7 NOC (with real humans) Priority on repair: TSP registration Internal Redundancy: Multiple paths around the net and to/from the Internet Site Service redundancy (when desired): local loop path diversity 65% Discounts from FCC HCF program: Subscribers pay only 35% of the service costs. MCNC - nonprofit provider whose sole mission is to support broadband for public and non-profit entities in NC (Universities, K-12, Community Colleges, healthcare, others). DIT is partner. State contract pricing and volume pricing. Competitive bid. Focus on Rural Sites: NCTN is 62% rural (according to FCC). NCTN serves everywhere (not just the easy to reach places). Se cti on 124 Conceived in late 2007 as an NC community project Phase 1 – NCTN-Public Health Phase 2 - NCTN-Hospitals Phase 3 – NCTN-EXtension ◦ Two rounds of recruiting of public health, free clinics, and (a few) community health centers ◦ Operational – started late 2010 ◦ Recruitment of hospitals ◦ Operational - 2011 ◦ Extension – more sites (hospitals , CHCs, public health applicability through 2025).- started 2012 Phase 4 – HCF (started use in 2014) Contract ◦ Use of permanent subsidy FCC program Healthcare Connect Fund (HCF) (65%) discounts (i.e. subscribers pay only 35% of service costs). ◦ About 300 sites now. Growing at about 50 sites per quarter. Cabarrus Health Alliance- project administrator NC Association of Local Health Directors NC Association of Free Clinics NC Hospital Association University Health Systems of Eastern NC(Vidant) Albemarle Regional Health Services Western Carolina University Southwestern Commission The e-NC Authority (currently NC Broadband) NC Division of Public Health NC Institute for Public Health (UNC) Golden Leaf Foundation FCC and USAC NCHICA Se cti on 127 HIE - Health Information Exchange ◦ Needs very high reliability for optimal value ◦ Uses paths between providers and to/from HIE; Internet connectivity. EHR - especially for ASP/remote models ◦ Requires very high reliability; low response time. Business stops, clinics stop when not available/responsive. Internet connectivity TeleEducation – ◦ With live video/audio needs low jitter/latency, high reliability, medium bandwidth(minimum 10mbps), to high bandwidth (for telepresence); Internet connectivity (maybe I2 connection) ◦ Web-based education (enduring materials) – needs responsiveness, medium reliability. ; Internet connectivity. TeleHealth ◦ Live medical imaging (e.g. telepsych, telestroke, echocardio, orthopedics, ICU monitoring) needs low jitter/latency, medium bandwidth, high reliability. Internet and (unlikely) I2 connectivity. ◦ Store and Forward (e.g. MRI, radiographs, CAT, Derm) need high bandwidth, high reliability. Internet and (unlikely) I2 connectivity. Voice service ◦ (between sites via VOIP for subscribers with several sites) Disaster response – ◦ Most public non-profit healthcare providers have key roles in responding to community disasters (e.g. hurricanes, tornadoes, ice storms, earthquakes, bio-events) ◦ requires disaster-resistant level of reliability; high bandwidth; low MTTR; Internet and perhaps I2 connectivity. Sunset the pilot program in 10/2016. All initial subscribers renewed for phase 4 (permanent HCF program) except 2. Mission Statement MCNC is an independent, non-profit corporation that operates the North Carolina Research and Education Network (NCREN). NCREN connects all K-12 school districts, community colleges, universities, and select non-profit health care sites throughout the state to each other, the Internet, and global research networks at very high speeds. Vision Statement Through the provision of value-added services, tools and its operation of NCREN, MCNC helps improve teaching, learning, research, health care, and collaboration throughout North Carolina in a cost-effective environment for constituents. Purpose Access to broadband and fiber-optic infrastructure is essential for innovation and economic development everywhere in North Carolina. MCNC enhances the state’s competitive position in the world by providing high-speed access to Community Anchor Institutions (CAIs) throughout North Carolina while also offering fiber assets to the private sector to help meet the broadband demands every citizen needs to succeed in the 21st century. Tenure Over 25 years MCNC greatly values advice and feedback from our constituents. Our advisory structure provides a mechanism for receiving valuable strategic advice and engaging in tactical and operational collaborations with the NCREN community. MCNC Board of Directors MCNC is governed by the Board of Directors, who are primarily business leaders in education and technology arenas. The Board is the only component of the governance and advisory structure with fiduciary responsibility. MCNC Advisory Council (MAC)- provides valuable strategic advice to MCNC. Members of the MAC are primarily technology leaders in the education and healthcare sectors. These technology leaders understand the technical needs of the community and brief and advise the board on opportunities and issues that are strategic in nature. Working Groups- are open to all constituents, and are formed to advise MCNC on issues specific to the group's area of expertise. Focus Groups- are formed to deliver a specific, assigned deliverable to a working group. 17 UNC System Institutions 26 of 37 independent colleges and universities 58 Main Community College Campuses & 37 Remote Campuses 115 Local Education Agencies (School Districts) Over 100 Charter Schools Non-Profit Healthcare (NCTN)- about 300 sites ◦ ◦ ◦ ◦ ◦ ◦ ◦ Hospital connections (Non Profit, including data centers) Hospital Clinics Mental Health Clinics Free clinics FQHCs Rural Health Clinics Public Health Sites RTI, NISS, NHC, Burroughs Wellcome Fund, Bio Tech Center, other research institutions Services available to non-profit healthcare: ◦ Affordable, High Speed Broadband (NCTN) ◦ Videoconferencing Services ◦ Data Center / Hosting Services ◦ Assistance with outreach and training programs ◦ Other Value-add Services as defined by the constituents Through partnership with DIT, provide lower cost broadband. Buildout of core network (via grant and matching dollars) in more rural areas of NC to provide more access and lower costs. Issued in late December 2012 ◦ Big. The HCF is capped at $400M per year nationwide. We are not likely to come anywhere close to this cap in the foreseeable future. ◦ Large discount: Eligible sites can receive a 65% discount for their NCTN-based broadband leased services. ◦ Funds from USF – not annual allocation from Congress. ◦ Site mix: A consortium (such as NCTN) must have at least 50%+1 rural sites in the consortia to obtain discounts. Currently, NCTN is 62% rural. ◦ Medical care sites and more get discounts: Rural Clinics, Public health sites , behavioral health, FQHCs, Free Clinics, hospitals, data centers, admin offices. Public and non-profit healthcare providers: ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ ◦ (i) "post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools;" (ii) community health centers or health centers providing health care to migrants; (iii) local health departments or agencies; (iv) community mental health centers; (v) not-for-profit hospitals; (vi) rural health clinics; and (vii) consortia of health care providers consisting of one or more entities described in clauses (i) through (vi). Individual Applicants Consortia (e.g. NCTN) ◦ Rural sites only among the categories above. ◦ Rurality is narrower than most in NC used to; based on census tract; ◦ Urban and rural sites (with some limitations on urban sites); more latitude about specific circumstances Individual Applicants: NCTN (as a consortia): ◦ For rural sites, individuals can apply for discounts ◦ Some do this directly (with significant admin effort) ◦ Others use for-profit vendors (who usually claim a significant part of the discount for their efforts). ◦ Non-profit project designed to overcome the limitations of individual application: ◦ Offers the widest possible coverage of sites/situations/services. ◦ Assumes the admin effort of working with the HCF Program (a significant amount). ◦ Keeps prices low through volume purchase, use of grants, state contracts, non-profit vendor use. ◦ Not many in NC have used the individual application and some of those have converted to using NCTN. FQHCs – (approx 190 in NC) Rural Health Centers (under ORH) – (approx 85) Additional public health sites (approx 200) Additional hospitals per se (approx 60) Non-profit Health system/IDN clinics (approx 1500) Mental health centers (approx 1000) State prisons/county jails – (approx 200) AHEC sites (approx 15) "post-secondary educational institutions offering health care instruction, teaching hospitals, and medical schools;” (approx 200) Site collection implies between $10M-40M per year in HCF funds to support broadband services. Note that we use state-wide member orgs and other large group liaisons to support site development, administration. Maintain a broadband network for public and nonprofit healthcare providers in NC with excellent benefits and low cost (to the subscribers). Opportunity for major NC HCPs to work together on this common infrastructure. Move $10M-$40M per year to the bottom lines of NC non-profit and public healthcare providers (equivalent bottom line impact to generating new revenues of $333M to $1.3B (at 3% operating margin). Initial call to see what services/sites might be of interest; fair share possibility. Follow-up engineering call or two if the network may be complicated Pricing for options provided to subscriber. Signing subscription agreement and other documents needed for discount acquisition. Either wait for discounts and then implement or start implementation and obtain discounts later. Service installation with support for any transitional work. Process usually takes 8-10 months total. Se cti on 144 Dave Kirby – [email protected] See today: ◦ ◦ ◦ ◦ John Graham Laura Horne Ruthy Mabe Dave Kirby
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