Connectivity for Telemedicine and Remote Work

By: John Shepler

The sudden onset of the Coronavirus pandemic is accelerating a couple of trends that were already in progress. One is telemedicine. The other is remote work. Both have a common critical path, which is broadband Internet bandwidth. Let’s look at what’s available to get connected.

Connecting the User
Most remote workers and patients accessing telemedicine will be connecting at home, perhaps using a desktop PC or Mac, or on the move through their smartphones, laptops and tablets. The most popular option at home is cable broadband, with bandwidths of 30 to 100 Mbps. Remotely, the most popular options are public WiFi and 4G & 5G cellular broadband.

The individual user who is an employee or patient seldom has the budget for business grade connections such as private lines, fiber optic bandwidth or point to point microwave. Their connection is to the Internet through whatever last mile connection they can afford. That’s almost always a cable or cellular connection which is shared bandwidth and asymmetric, with download speed perhaps 10x upload speed.

These connections generally work fine for remote log-in, video chat and website access. They’re pretty reliable and budget friendly.

Special Cases
Certain medical equipment doesn’t work well over home Internet. The patient may need a classic analog landline (yes, even today) or built-in proprietary wireless access.

A business needing higher performance than consumer broadband offers may have to pay the cost of a dedicated leased line. This might be a T1 line, Ethernet over Copper, or Fiber to the Premises, if available. Dedicated Internet Access generally offers a performance improvement over shared consumer broadband first-mile connections. You also have the option of setting up a dedicated private line, although higher bandwidths are often not available to consumers.

If broadcast quality live video is required, you may need to set up a small remote studio near your talent. A Metro Ethernet private line will support the quality you need to avoid the distorted audio and video glitches common with consumer Internet video chat services.

Business Bandwidth Options

If you are the provider rather than the user, your connectivity needs are likely more demanding. As the company or medical organization you will probably be supporting more than one simultaneous employee or patient. That could be dozens, hundreds or even thousands of users connecting into your central system, which might be cloud-based.

There are two types of connectivity you’ll want to consider. First is connection to those outside users, mostly likely through Internet broadband. Second is connections within your own organization. Your internal connectivity will be by Local Area Network and either Metropolitan or Wide Area Networking to include more than one business location. You may also want a dedicated high bandwidth cloud connection to make your cloud applications perform as if they were hosted in a local data center.

You’ll need enough Internet bandwidth to support the maximum number of simultaneous users that will commonly be connected, plus some surge ability to support additional users when things get busy. A dedicated broadband Internet connection using scalable Ethernet over Fiber bandwidth can handle heavy demands. Gigabit and 10 Gig E services are readily available.

Within the organization, you may wish to stay off the Internet both for higher performance and better security. Point to Point dedicated private lines can be nearly transparent to your network. If multiple locations are involved scattered over a wide geographical area, an MPLS network can save cost while still preserving high performance and excellent security.

The performance of the last-mile Internet connection can also be improved by using an SD-WAN connection. SD-WAN or Software Defined Wide Area Network combines several types of Internet connections, including wired, fiber optic and wireless. The SD-WAN software constantly monitors the various connections and chooses the most appropriate for each packet. This helps ensure that more demanding applications have priority over activities that can be run in the background.

Is your company planning or already engaged in remote work or telemedicine? If so, we can help you find the right type of connectivity at the best price.

Bandwidth Options for Healthcare Providers

By: John Shepler

Electronic health records, medical imaging and telemedicine are making broadband connections an essential part of healthcare operations. Let’s take a look at what’s needed for today’s EHR environment.

There are two types of bandwidth services that you’ll want to consider. These are private lines and the public Internet. Both have their place.

Private lines are used by all sizes of businesses and organizations for internal communications. The fact that these lines are “private” means that they are not used for communication with the public at large or anyone not directly connected into the network.

Physician and hospital groups may well have large amounts of electronic data that they want to keep in-house under strict access control. Think of private lines as a way to extend your network.

Point to point private lines include such familiar options as T1, DS3, SONET OC3, OC12 and OC48, Ethernet over Copper and Ethernet over Fiber. Each of these options gives you a fixed amount of bandwidth that is dedicated to your use only and is inaccessible by anyone else. They differ in the technology to implement the service and the amount of bandwidth available.

For instance, T1 lines have been around forever, are available just about anywhere you can get a phone line installed, are highly reliable and are very reasonably priced. What’s not to love? The bandwidth is their limitation. While 1.5 Mbps was considered high speed in the days of dial-up modems, 1.5 Mbps is entry level broadband today. You probably won’t want to wait around for the time it takes to transfer large files with both text and images.

You’ll find a good discussion on healthcare provider bandwidth needs on the Health IT. gov site. The minimum bandwidth recommend for a single physician practice is 4 Mbps. That’s enough to support practice management functions including email and web browsing, plus simultaneous use of electronic health records (EHR) and high quality video consultations. It also is enough for non real-time image downloads and remote monitoring.

A small physician practice with 2 to 4 physicians will want to move up to 10 Mbps for the same functions. The extra bandwidth assumes more than one physician using the service at a time. The 10 Mbps level is also considered suitable for nursing homes and rural health clinics.

When you consider the needs of a clinic or large physician practice with 5 to 15 physicians, the bandwidth requirements increases to 25 Mbps. A hospital will need 100 Mbps and a large or academic medical center really needs 1000 Mbps.

The FCC publication “Health Care Broadband in America” goes into more detail about what drives bandwidth requirements. An Xray is about 10 MB and needs 60 seconds to download at 1 Mbps or 5 seconds at 16 Mbps. An MRI at 45 MB needs 72 Mbps to download in the same 5 sends or 300 seconds or a full 5 minutes at 1 Mbps. A 64 slice CT scan at 3 GB needs 4800 Mbps for a 5 second download or 80 Mbps for a 5 minute download time.

As you can see, there is a tradeoff between the amount of bandwidth you have and how long it takes to transfer files of various sizes. I’d suggest taking these requirements as a minimum, as the report was published in 2010 and technology is only getting more sophisticated with larger file sizes.

In addition to the bandwidth of the line, there are other technical parameters to consider. These include whether the service is symmetrical (same upload and download speeds), dedicated to your use only or shared between your practice and other users, the latency or time delay in transmission, and the amount of jitter and packet loss. All of these are quality of service metrics.

Dedicated private lines are almost always symmetrical, with low values of latency, jitter and packet loss. You can bond T1 lines together to increase bandwidth from 3 Mbps up to about 12 Mbps. That’s important for rural practices where there may be few other options. In metro areas, DS3 offers 45 Mbps, OC3 is 155 Mbps, OC12 gives you 622 Mbps and OC48 is 2.4 Gbps. These are all delivered over SONET fiber optic carriers.

Alternative landline services include Ethernet over Copper with bandwidth from about 3 to 50 Mbps, depending on location. Ethernet over Fiber service starts at 10 Mbps and goes up to 10 Gbps, with service to 40 or 100 Mbps in select areas.

Dedicated lines are also popular for connecting to the Internet to get the highest performance available. You don’t have the same level of control of what’s actually traversing the Internet, but it does have offer nearly universal connectivity.

For Internet access, you also have the option of option of connecting via shared bandwidth services. Popular options are DSL, Cable, satellite and 3G/4G wireless. Generally, these are asymmetrical, with higher speeds on download than upload. Also, they are offered on an “as available” basis without any service level agreement regarding availability, bandwidth, latency, jitter and packet loss.

The tradeoff in performance between the dedicated and shared services is that the shared services are for using the Internet and they are considerably less expensive. Internet security doesn’t begin to measure up to dedicated private lines, but it can be made workable using encryption such as VPN and SSL at each end.

The best solution for many practices may be a combination of private lines and Internet service. The Internet is valuable for communication with patients at home and using mobile apps, and also to establish WiFi service for visitor use. Private lines are beneficial for high speed communication between medical facilities and physician offices.

Is your medical practice running out of bandwidth in today’s EHR environment? You may be able to afford much more than you think with multiple bandwidth options and providers available at your location.

Can Ethernet Enable Electronic Health Care?

It’s no secret that there is ample opportunity to improve service and cut costs in the health care field. Much of the “low hanging fruit” involves digitizing, storing & transporting medical records and automating what remains of clerical processes. Beyond that, there are new applications such as remote diagnostics that can bring medical services to remote areas and emergency scenes like auto accidents. Sounds good, so what’s stopping us?

One big bottleneck is the lack of universal broadband infrastructure, both wired and wireless. Until recently, the best connection that many doctor’s offices, clinics and medical centers could afford was the venerable T1 line running at 1.5 Mbps. The sheer size of high resolution medical images, especially when bundled into complete electronic medical records, makes the once speedy T1 line a potential bottleneck to productivity.

The FCC has identified barriers to e-care caused by limited adoption of high speed digital connections and has proposed remedies in its National Broadband Plan. Bringing broadband connections to rural areas for the first time is the focus of stimulus funding. There are also licensing, privileging, and credentialing standards that need to be modernized to enable physicians to practice remotely. Additionally, structures need to be put in place to ensure patient privacy in an insecure online world.

The private sector hasn’t been sleeping through all this. There’s a quiet revolution going on in the telecommunications industry that will be a major factor in enabling the efficiencies of e-health care. The FCC estimates that over $700 billion could be saved over 15-25 years through electronic health records and remote monitoring technology alone. What will be the primary transport technology for these wide band applications? It’s almost surely going to be Metro Ethernet, Carrier Ethernet and Multi-Protocol Label Switching (MPLS) networks.

The thing these communications technologies have in common is a core based on packet switching or IP networking. MPLS adds privacy and efficiency for connecting multiple locations in a single mesh network. That could include hospitals, clinics, physicians offices and insurance companies.

One reason why Ethernet will play such an important role in the medical networks to come is cost. Metro Ethernet over both fiber and copper has proven to be less expensive per Mbps than traditional circuit switched telecom technologies. MPLS networks have all but taken over the role of multipoint to multipoint secure networks from Frame Relay. In some cases, Ethernet connections are even cheaper than T1 lines on an absolute cost basis.

There’s no need to wait if you need more bandwidth to improve the efficiency of your operation, or simply want to save money during this challenging economy. See how much you could save with Metro Ethernet services for your business location.