Today’s meeting felt collegial. The healthcare folks did a great job. I think the afternoon speaker (who presented variations on the Connect Minnesota maps) spurred a lot of good conversation relating to the maps. From the outside it seem like people were really in synch and that compromises were being made in an effort to really start working together. Or maybe it’s not right to say that there were compromises – but that everyone was able to rise above their individual concerns to start building a plan together.

Here are the regular notes from the Broadband Task Force meeting…

Approve Agenda – done

Approve minutes Feb 20 meeting – done

Status of Stimulus funding – letter to US Department of Commerce from Pawlenty and Congressional Research Service report…

We’re looking the stimulus funding like every other state. Department of Commerce and DEED will be working on the Stimulus packages. There’s a bill out to have Department of Commerce handle stimulus issues (HF 1914); the Senate is looking at the same.

The TF Board is no longer taking project ideas/proposals for stimulus funding. Projects should go to the appropriate agencies. Commerce or DEED might come back to get involvement from TF to look at projects. That’s not part of the charge of the TF so we would need to get explicit directions.

In other states such as New Mexico Virginia and maybe NY they are trying to take a coordinated approach to the projects. Maybe that’s something MN wants to consider.

It’s not part of our charge but our charge can be modified – especially since the money is a motivator.

There is money for innovative projects libraries and community colleges as well as deployment.

General Concerns

Concerns on the TF web site, we are accepting things for posting but we need to tag those items by submitter. – Agreed

We’re about half way through the process and haven’t finalized any definitions. We need to do that.

Public Comments – None

Panel on Health Care

• Stuart Speedie, Professor, U of M Medical School, Health Informatics
• Karen Welle, Asst Director, MN Dept of Health, Office of Rural Health & Primary Care
• Maureen Ideker, Rice Memorial Hospital, Chief Nursing Officer
• Steve Mulder, Hutchinson Area Health Care Director of Quality and Clinical Services
• Joe Schindler, MN Hospital Association
• Mark Schmidt, SISU Chief Information Officer
• Dr Eduard Michel, Emergency Physician for Virtual Radiologic

Here is a compilation of their PPTs – with scattered notes following…

Basic of Telehealth – Stuart Speedie

One of the most difficult things about health care is getting the patient and the specialist in the same place at the same time. Technology bridges that need with techniques such as store and forward teledermatology.

Questions:

Do the rural providers get paid through insurance?

Yes – but the subsidies do not cover expense.

How much broadband does it take to do telehealth applications?

To be answered individually.

The big benefits for telehealth are seen by the patient. What are nonmedical benefits to the provider?

The business case for the providers is less clear. It allows them to develop a larger population base from which to work. With an emphasis on telemedicine it allows you to reduce local facilities (might not need as much space). It might broaden your customer base. (If someone needs an operation, you’d be their first choice.

There’s interest in county facilities in using telehealth applications

What does health care need in terms of broadband?

• We need ubiquitous connectivity.
• We need seamless (interoperable) connectivity. Interoperability for transferring data – especially for electronic records.
• Capacity – the minimum capacity we use 350+Kbps bi-directional – but we need better BB to access high definition photos, which are becoming a must.
• Need quality of services. Audio is critical!!
• Security
• Reliability is essential. A lost connection is potentially a lost patient.

Do you know your volume of data transfer?

No but we should. We know we need a T1 for each interactive session – for live interaction. Store and forward requirements are much less.

A full on T1 turned on full time is a huge amount of data.

Knowing peak periods is important too.

What about tele-surgeries?

That’s a bigger issue. It’s going to require very big pipes. You need symmetrical connectivity. You also need staff at the remote site to handle post-op care. The navy is doing a lot of access.

Are the point-to-point connections reliable?

Yes but even those can be problematic. The problems are more frequent when you need to traverse multiple networks.

MN Telehealth Network – Maureen Ideker

Psychiatry is a big field because of the shortage of psychiatrists and the fact that it works so well with youth.

Triage in the jails has saved many trips to the emergency rooms.

Residents in nursing homes cannot get reimbursed for telemedicine.

Telehealth is often based on a need in one area and a surplus in another. Often telehealth visits seem to stem from an initial in-person consultation followed up with telehealth monitoring. Or the telehealth session might both precede and follow an in-person procedure.

Steve Mulder

The Leap From Group recommended that ICU folks all see specialists but that’s not practical in small towns and rural areas. eICU offered an opportunity to make this possible. Hutchinson sign on to a system out of Sioux Falls.

eICU includes monitoring through video and other means of remote patients. From an eICU station a doctor can see video, electronic records, all other bedside monitoring. Also there is software monitoring vital signs and other aspects and will flag irregularities.

Benefits

Sioux Fall saw a 50% reduction in mortality compared to predicted
Hutchinson saw 32% increase in ICU (keeping more patients)
8.5% increase in CM (keeping sicker patients)

What is the incentive to get specialist involved?
Meeting the needs of people in MN.

Broadband involved?

Point to Point T1 at a cost of about $2000/month – just for ICU. The hospital has 7-8 T1 lines. They have had no unscheduled downtimes.

What do you think will happen in the future?

The technology is ahead of the culture. The doctors and nurses are somewhat apprehensive. They are used to hands on interaction.

Speed has been an issue when we’ve wanted to keep people in their homes.

Three years ago eICU was an experiment. Now it’s established – hospitals in Minnesota are looking at it.

The TF needs to think about what homes need to take advantage of telehealth applications. What do you think people at home are going to need?

In a perfect world there’d be an Internet for health care – but where we could control reliability. So we end up building our own networks with Pt-to-Pt T1s, unfortunately there is no redundancy with those connections.

We’re going to have the same issues with homes where quality of service and reliability will be an issue. In rural areas it’s difficult to get the resiliency you need because the connections all go into the same door. So building a redundant connection is tough.

That’s the issue in Cook County – as opposed to Scott County where they are been busy building redundancy. (Alluding to last month’s TF presentations.)

Another issue is that this is being built on a an ad hoc basis and that’s not cost effective. Maybe we do need a second Internet.

It’s the same problem that education had 10 years ago and the impetus for the Learning Network, which is a WAN that supports MNSCU and U of M videoconferencing. With the school there was an economy of scale. Ideally, however, we wouldn’t have to do that.

Quality of service is a big issue – and a really reliable way to do that is to have way more broadband than you need.

So the schools were able to pull together. Should the hospitals build their own, should they join (Steve Kelley had a bill to merge hospitals with schools in 2001 (or so). It didn’t pass. Hosptials then tried to use T1s to jump onto the edu-funded network but the legislature said no way – that’s for education.)

Karen Welle

The goal of the Office of Rural Helath and Primary Care is to maintain access to healthcare in rural communities. Rural hospitals HAVE to get technologically connected. We want to keep primary care in these areas – these areas that the aging and declining in population. If we don’t have technology – whiz bang applications are the least of our concerns.

The potential for rural communities isn’t high right now. Provider to patient is most important in mental health areas. Videoconferencing is our main tool, especially for mental health services – but we need reliability.

The need for BB is accumulative – we transfer electronic records, we videoconference…

What’s happening now is that providers don’t have a lot of resources to go through bureaucracy. They can’t be re-inventing things that are already there and yet they don’t’ have time to learn about what’s out there. They need to be part of a larger organization.

Questions

Are there other examples where is you can make money on some applications to subsidize projects that don’t?

Dr Eduard Michel

Trauma Outcomes are sometimes a matter of minutes or seconds.

Typical Transmission Times
CT Brain (100 images)
DSL takes 8.65 minutes
T1 takes 4.43 minutes
3MB cable takes 2.22 minutes
T3 line takes 1.33 minutes

Radiology there are 2 payments – facility payment and doctor payment; no one pays for transmission.

We have 140 radiologists.

The speeds required here aren’t remarkable; but the amount of data transferred is remarkable. And we need to make sure that the volume of data won’t be an issue. (They product/transfer 400 Gig in 24 hours.)

Are most facilities hospitals?

Yes but some are clinics.

It seems as if much of the delivery as night – perhaps there are facilities with a radiologist but not at night. Do you see facilities without radiologists dring the day too?

Yes.

Some procedures can be done by nursing staff but a specialist will always be needed for diagnosis.

What will you need for the future?

Limiting volumes of traffic would be an issue for us.

Your main facility is in Minnetonka? And you have 4 providers in your area that meet your needs?

Yes – there is a disparity between what’s available in the Cities and what’s available in rural areas.

Maureen Ideker

We need to keep as much care in rural areas as possible. The slides are available.

Why is it important to be on this?

Maintaining congestive care potentials in their homes makes economic sense – especially when 60% of patients are served by Medicare.

Mark Schmidt

Current/Future BB Opportunities

Remotely hosted advanced clinical applications (e.g. e-Medication Admin Record, patient care plans and documentation, bedside medication verification)
Remote patient monitoring (ICU, ER, etc) allows patients to stay local which is easier on patent and family

Tele-video / telehealth applications (e.g. mental health evaluations, dermatologist consults)

Note: unlike the initial applications we offered in the late 1990s the applications above require VERY high availability.

Questions:

What do you think the network of the future should look like?

Right now one issue is that some towns have only one provider and it’s tough to get redundancy with only one provider.

Resiliency

Over high bandwidth

Everything seems to be going the way of Pt-to-Pt T1s and that doesn’t make sense. We need something that is more secure and more robust.

When you see outages – how much is in the building, operator error, versus network error?

In the past the SISU data center, we had outages in 2006. So we’ve worked hard to mitigate that risk. (Backup, cooling systems, better UPS…) But the WAN is what we’re working on now. The data center is as rock solid as we can be – so most of the errors are in the WAN.

Hutchinson has 4 T1s coming to us. SO there is redundancy built in – but some towns can’t do that. Everything runs on the same fiber. Last year the segment from the local phone company and the hospital went down twice; once for 8 hours and once for 20 minutes.

Could SISU use the Internet?

Sometimes we can use it for redundancy – but there’s a difference in radiology and the applications we run. We have a low latency need.

The issue isn’t how can we build for this individual but how can we build the costs into the infrastructure?

Economies of scale comes in. Hutchison has a 6-bed ICU so there is a volume to build from; some clinics don’t have that volume. So it’s hard to make a case in those smaller towns.

The infrastructure doesn’t exist to reach out to some communities – such as in SE MN. Crossing borders is another issue.

People aren’t rolling in telecommunications like they should.

With Pt to Pt, is it possible that lots of the info you need.

Economic Development Factors Related to Broadband Penetration
Bob Isaacson, Director of Analysis and Research for the Dept of Employment and Economic Development (DEED)

Bob took the Connect Minnesota maps and overlaid other demographic data.

About job map – if we took a look at job growth before broadband, would the dots look different?

That’s a map we can create later.

Can we take the info to a more granular level?

Yes – down to the street level. Connect Minnesota seems to have that data. In fact they created the maps that we are looking at today. The legislature asked only for county level – but more granular is available. We just need to work with Connect Minnesota to get the info we need/want.

What about take rates and issues of consumer making a choice for BB?

There is a digital divide and there is a geographic component – by geography was a lesser issue than age, economic status, ethnic makeup, education level… Computer penetration is a bigger issue.

So what should we ask for next in terms of maps?

Can we come up with a couple of profiles of counties on both ends, and can we dig down for more data on each? (Grand Rapids, Fergus Falls, and Mankato would be a good place to start since we’re going there.)

Can we get housing value?

There are businesses would relocate but need to know that access is available. But you need to make the call to find out that infrastructure – can we make sure people know this?

Yes – and we’re now updating MNPRO and could get that info added to the profile.

To lose businesses because of a lack of communication (as opposed to telecommunications) would be terrible.

Can we see the communities that are taking advantage of highest speeds? We think that maybe it isn’t the most affluent and that we might have some surprises.

Right now speeds often surpasses need. And most providers will step up if they can meet the needs of a commercial customer.

There is money out there to get better maps. There is money in the stimulus package to create better maps. Let’s make a play for that money. There’s $350 million from the feds available.

Let’s build a stage II request.

Can we see the layers of the maps – one that shows only fiber, only DSL, only cables?

Will Connect Minnesota give us the granular level info?

They have it and they’ll make maps for us. So maybe we can ask for individual layers. Maybe we can work with DEED to get this info.

There may be disclosure issues. But why not ask.

The biggest problem might be that we only paid for certain maps.

Would the providers in the room be comfortable at the census tract level?

Well there needs to be some disclosure. Comcast provided more granular info; Qwest provided more granular info. We’re OK with it being made available. Sjoberg’s just provided that info to the FCC – the 470 forms? – but the census tracks for rural areas are not that helpful. They are larger than zip codes.

[Thanks for Joanne Johnson for updating me with some info that eluded me. CPNI (Customer proprietary number info) is info that can’t be shared by providers info by law. There are also restrictions from homeland security about how much info they can provide about their main communication lines/routes.]

What does unserved and underserved mean? That’s a big topic. Rumor has it that states with maps will have a foot up with the funding so, heck out maps are pretty good – especially if it moves us to the front of the line.

Maybe we can take the maps we have – and use it to define unserved areas.

Suggestion for Bob – greater BB and greater economic growth seem to go hand in hand – but which came first?

We look at areas with technological jobs – but heck aren’t all jobs (or most) technology-enhanced? Think of realtors.

Do we have any data how BB is being used at consumer level?

Jack Geller has some – but it’s crude. Let’s remember that the consumer of the future is a completely different animal.

Will Connected Nation provide data to DEED? If so it would be great to have DEED go through their info at census level and go wild.

Another problem is that the census info is 9 years old.

So – to recap – we want to endorse looking at getting more money for mapping to get to the second level we need.

Working Business…

We will be getting some definitions of unserved and underserved from Feds.

May meeting is dedicated to actual writing in smaller groups. A big question has been – how are we going to get into this given commonalities and differences? The following 3 meetings are all on the road. Then we have 2 more meeting entirely about the report.

Bernadine Joselyn will be here next month. We’ll still be hearing from suepr high tech folks.

Writing assignment – each TF member is going to try to write 5 paragraphs for the report. There may be overlap. There may be conflicts but that should lead to good discussion. Need to be done by April 17.

We do need to look at values statements – those will be important. The values that we can agree on will shape the report.

Maybe someone can do that instead of their 5 paragraphs. We need goals based on values. There has been a coming together of values as we have worked together. Our conversation has given us a clearer view.

It’s time we start that conversation. We’ve gotten good info and fact finding has been good – but it’s time to get to the hard work of writing.

Here are the values that were most popular last time:

Ubiquity of service

1. Businesses & citizens can get BB capability they need.
2. Level of service by type of users/tiers. By use and need (not one size fits all).
3. Defining different levels of usage and service that is necessary for those levels.
4. Today if people are willing to pay, they can get the service.
5. Specific minimum speed to all Minnesotans. (Think far into the future.)
6. Neutrality (We are not picking a technology)
7. Focus on both the demand side and supply side of the issue.
8. Look forward
9. Public/private partnership
10. Cooperation across all players
11. The public good

Should we forget about panels in May?

Yes!

Recap of potential business talk: Big business can get what they want. Small business can’t. Location also matters. Maybe we don’t’ need to hear it now.

Maybe we should use remote meetings to write.

Maybe we should have some panel discussions in rural areas.

Maybe we should start writing and request panels as we need them.

Let’s still try to get Vint Cerf and Robert Stevens (Geek Squad) on video. And let’s try to think about the really hard questions to ask.

So – the recap – we’ll see the video in May of Vint Cerf and Robert Stevens. And we really need to start writing.

Mike will be the scribe of the report.

Greater Minnesota visits – it is important to have all of us there or at least as many of us as usual.