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Craig Settles and Sean Gonsalves: Telehealth For All is a ‘Stroke of Genius’

Without access to a secure broadband connection, the co-author of this Expert Opinion would have died.

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Craig Settles (left) and Sean Gonsalves are the authors of this Expert Opinion.

My colleague Craig Settles likes to say he had a “stroke of genius” when writing his last book about building the gigabit city. “I literally had an ischemic stroke at 10:30 p.m. on a Saturday night,” he recalls. “If I had been in a low-income urban community with poor communication infrastructure, or in a rural area with bad broadband, I’d probably be dead.”

The “genius” part was realizing broadband is magic that directly or indirectly enables us to perform minor and major miracles that we could not do before, but faster and easier.

When Craig moved to Alameda, California, situated less than five miles from the heart of Silicon Valley, he could not get cell service without a signal booster, and even then it was sketchy. Several years later the service was better, which allowed him to speed-dial his best friend who called 9-1-1.

The neurologist who set up the stroke center in Alameda Hospital had mirrored much of its technology and servers in her home so she could see everything the ER staff was seeing as they administered life-saving procedures within 25 minutes of Craig’s gurney hitting the ER door.

While Craig counts his blessings, over 14 million urban households do not have broadband in their home – 75 percent of whom are African American and other people of color. Millions more technically have home Internet service but don’t have the connection speeds and capacity to use the applications needed for remote work and school, or telehealth.

And don’t forget the 4 million rural homes that do not have broadband subscriptions.

Broadband as Social Determinant of Health

The essential nature of broadband came to the fore with the onset of the pandemic. And it compelled states and local communities across the nation to take the connectivity crisis far more seriously, especially with the influx of federal funds from the American Rescue Plan Act and the Infrastructure Investment and Jobs Act.

Although advocates commonly, and understandably, tout the importance of broadband access in the context of remote work and schooling, what often gets overlooked are the transformative powers of telehealth and its potential to drive broadband adoption.

It’s no exaggeration to say that broadband is a major social determinant of individual health as it enables access to virtual healthcare and facilitates a host of other things critical to health, such as education, employment, housing, and social services, all of which require broadband, most especially for telehealth applications.

More than video chats with your doctor, telehealth uses high-speed Internet connectivity to observe, diagnose, initiate or otherwise medically intervene, administer, monitor, record, and/or report on the continuum of care. Public health, in particular, can leverage telehealth to a great advantage.

Yes, healthcare providers are increasingly integrating telehealth into the delivery of care. But, if the patients most in need of better access to healthcare do not have access to broadband, as well as computing devices and digital skills, tremendous healthcare benefits and cost-savings will be needlessly missed.

This suggests that “fiscally conservative” elected officials, many of whom claim to support universal access to broadband while lamenting the high cost of healthcare, have been thinking about this whole thing backwards. Instead of wailing about the cost of building universal robust broadband infrastructure that could be used for telehealth, why not flip the script?

Achieving universal broadband infrastructure that would last a lifetime would cost on the order of $100 billion, which is just two and a half percent of what we spend on healthcare in this country every single year. Hundreds of academic and industry studies say that even the most conservative telehealth initiatives save more than two and a half percent of system costs.

Talk about a return-on-investment! A hint of this can be seen in a study done by the National Center for Biotechnology Information which found there were as many as 3.5 million potential preventable adult inpatient hospital stays in 2017 alone. That amounted to $33.7 billion in health care costs just for that year.

Telehealth can eliminate many of those stays. And in terms of improving health outcomes, the study further found that the elderly, men, Black communities, and those insured with Medicaid would reap the biggest benefits.

So why not exploit the math, and pay for broadband using healthcare savings? Let’s connect every home, hospital, and community anchor institution in the country to robust broadband, and transform healthcare while bringing it into the 21st century. The municipal broadband model in which local communities build and own the infrastructure is ideal.

Telehealth Can Drive Broadband Adoption

Looking at it this way, universal access to telehealth has the potential to simultaneously solve the connectivity crisis and ensure that millions of families can lead healthier lives.

Here are six tactical ways of using telehealth to maximize public health in a community along with increasing broadband adoption.

  1. Re-inventing the doctor’s office visit for a variety of healthcare practices

Understanding telehealth, all you need are four walls, an Internet connection, a computer, a healthcare partner, and a healthy imagination to create a range of practical telehealth solutions.

Transform barbershops and hair salons into Covid vaccination and hypertension screening centers. The school nurse’s office can now become school telehealth centers. Libraries are starting to add telehealth kiosks.

Libraries Without Borders uses interactive Web health content, laptops, and wireless gear to outfit intercity laundromats on Saturdays. Tucson used ARPA funds to build out a wireless network on top of the city’s fiber infrastructure and gave 5,000 low-income homes the ability to have telehealth resources.

  1.  Telehealth can marry chronic healthcare, home care, and public health

Frederick Memorial now distributes hundreds of tablet computers for remote patient monitoring  in patients homes to check their vital signs, changing medical conditions and treatments, with data that goes to the hospital daily.

Urban hospitals should partner with ISPs to leverage the FCC’s Affordable Connectivity Program subsidy of up to $30 per month for Internet service and up to $75/month for households on Tribal lands. ACP also offers a $100 discount on computing devices.

  1. Enhance the emergency response and Emergency Department to save more lives and money.

African Americans and other populations of color have the highest rates of strokes, heart attacks, and other medical trauma. We could reverse the trend of hospitals that abandon poor urban communities and replace them with city telestroke or telehealth critical care “broadband subnetworks” that are hosted by major hospitals and linked to Federally Qualified Health Center, clinics, and other facilities.

  1. Expand efficiency of mental healthcare delivery

Mental health professionals getting to see patients in their homes and therefore providing an alternative to needing to go to a therapist’s office can not only eliminate no-show appointments but can provide those most in need of therapy with broader access to a variety of specialists.

Leveraging telehealth can be especially empowering for underserved communities in which approximately 30% of African American adults with mental illness receive treatment each year, compared to the U.S. average of 43%, according to the National Alliance on Mental Illness.

But as Carly McCord, Director of Clinical Services at the Texas A&M Telehealth Counseling Clinic, rightly points out: “Often we’re talking about intensive therapy, like treating PTSD, which you can’t do with crappy Internet connections. When your patient’s disclosing a trauma and your connection glitches, or you miss a word and have to say, ‘I’m sorry. Can you repeat that? ‘This is a huge problem.”

  1. Improving senior care and facilitating aging in place for our nearly 60 million seniors

Three-in-four older Americans want to stay in their homes and age in place, according to a AARP survey. And, if offered a choice, about 53 percent of respondents say they would prefer to have their health care needs managed by a mix of medical staff and healthcare technology.

A key broadband element in this telehealth equation is “smart home” technologies that include wirelessly-controlled sensors. Some sensors now can determine whether a person sat up in bed or actually fell on the floor, if patients are eating regularly, or if they are taking their medications on time.

  1. Re-imagining what hospital care can be

In areas prone to natural disasters, make prior arrangements with hotels, college dorms, warehouses, and other facilities where you can bring in generators, computers, telehealth equipment, and wireless intranets.

Use these buildings for seniors with health conditions who have been displaced: people with chronic illnesses and patients with non-serious injuries from the disaster should those people not have easy access to other residential or healthcare facilities.

Building and subsidizing access to robust community-owned broadband networks is a wise investment because it will improve health outcomes and return significant community savings for decades to come.

And with a flood of federal funds available to build broadband infrastructure and advance digital equity, we have a once-in-a-life opportunity to stitch this all together and deliver telehealth for all.

Sean Gonsalves is a Senior Reporter, Editor and Communication Team Lead for the Institute for Local Self Reliance’s Community Broadband Networks Initiative. Saved from a stroke by telehealth, Craig Settles pays it forward by uniting community broadband teams and healthcare stakeholders through telehealth-broadband integration initiatives. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views reflected in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

Broadband's Impact

Dianne Crocker: Recession Fears Have Real Estate Market Forecasters Hitting the Reset Button

Growing fears of recession trigger pullback on previous rosy forecasts.

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The author of this Expert Opinion is Dianne Crocker, Principal Analyst for LightBox

The lyrics to “Same As It Ever Was” by the Talking Heads certainly don’t apply to how 2022 is playing out in the commercial real estate market. Two quarters of negative economic growth has put a damper on market sentiment and triggered fears that the U.S. economy is heading for a recession. By midyear, market analysts were taking a good, hard look at their rosy forecasts from the start of the New Year and redrawing the lines.

Once upon a time…

At the start of 2022, forecasters were bullishly predicting that commercial real estate investment and lending levels would be nearly as good as 2021. This was significant, considering that 2021 set new records for deal-making and lending volume as the debt and equity capital amassed during the pandemic while looking for a home in U.S. commercial real estate.

What a difference a few quarters have made. Virtually, all the predictions that started the New Year were obsolete by mid-summer. The abrupt shift in market conditions is palpable and surprised just about everyone. Now, markets are reaching an inflection point that is in sharp contrast with the strong rebound of last year.

The two I’s: Inflation and interest rates

At the core of the recent upset in market sentiment is the persistence of high inflation, which seems to be ignoring all attempts by the Federal Reserve to raise interest rates and bring prices down. Higher inflation is having a ripple effect throughout the economy, pushing up the costs of construction materials, energy, and consumer goods. Among the notable economic indicators showing stress at mid-year was the GDP, which fell for the second consecutive quarter, and the Consumer Price Index, which jumped 9.1% year-over-year in June – the highest increase in about four decades.

In July, the CPI fell to 8.5%, an encouraging sign that inflation was beginning to stabilize. By the latest August report from LightBox, however, hopes were dashed when the CPI showed little improvement, holding firm at a still high of 8.3%.

The market is responding to a higher cost of capital as lenders tap the brakes. As the cost of capital rises with each interest rate hike and concerns of a recession intensify, many large U.S. financial institutions are pulling back on their loan originations for the rest of 2022 and into 2023. This change in tenor is a significant shift, given that 2021 was a record-breaking year for commercial real estate lending. Many lenders have already shifted to a more defensive underwriting position as they look to mitigate risks.

The Mortgage Bankers Association, which had previously predicted that lending levels in 2022 would break the $1 trillion mark for the first time revised their forecast downward in mid-July. By year-end, the MBA now expects volume to be a significant 18% below 2021 levels—and one-third lower than the bullish forecast made in February. Now, investment activity is cooling as higher borrowing costs drive some buyers from the market.

In the investment world, transactions were down by 29% at midyear due to a thinning buyer pool as higher rates impact access to debt capital. Market volatility is causing investors, lenders, and owners to rethink strategies, reconsider assumptions, and prepare for possible disruption.

Looking ahead to year-end and 2023

The rapid and diverse shifts in the market make for an uncertain forecast and certainly a more cautious investment environment. The battle between inflation and interest rates will continue over the near term. As LightBox’s investor, lender, valuation, and environmental due diligence clients move toward the 4th quarter—typically the busiest quarter of the year–unprecedented volatility is driving them to recalibrate and reforecast given recent market developments.

Continued softness in transaction volume is likely to continue as rates and valuations establish a new equilibrium. If property prices begin to level out, there will be more pressure on buyers to consider how to improve a property to get their return on investment. The next chapter of the commercial real estate market will be defined by how long inflation sticks around, how high interest rates go, and whether the economy slips into a recession (and how deeply). The greatest areas of opportunity will be found in asset classes like office and retail that are evolving away from traditional uses and morphing to meet the needs of today’s market. Until barometers stabilize, it’s important to rethink assumptions, watch developments, and recalibrate as necessary.

Dianne Crocker is the Principal Analyst for LightBox, delivering strategic analytics, best practices in risk management, market intelligence reports, educational seminars, and customized research for stakeholders in commercial real estate deals. She is a highly respected expert on commercial real estate market trends. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views reflected in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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Jeff Pulver and Noah Rafalko: A Humble Request to the FCC on Robocalls

Blocking bad actors requires a whole new way of thinking, the authors say in this ExpertOp exclusive to Broadband Breakfast.

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The authors of this Expert Opinion are Jeff Pulver (left), innovator in VoIP and Noah Rafalko, is a pioneer in TNID

Should the Federal Communications Commission seek out alternative platforms to solve their 2022 spam, scam and robocall issues? Yes! Does Blockchain offer valuable solutions? Yes! We would like to ask the FCC to increase the width of their lens when it comes to deploying solutions to solve their growing number of systemic challenges.

Any action to stop robocall insanity and tech-driven scams would be welcome. While Americans deal with the linger pandemic, mass shootings, an uncertain economy and war in Europe, the constant annoyance from scammers and 4.1 billion robocalls a month is just too much. Most people have responded by literally giving up voice communications all together.

Recently implemented legislation called STIR/SHAKEN is a step in the right direction, but it is not a long-term solution. The FCC  is simply taking old standards and applying them to new technologies. New thinking is needed; the next generation of technology must be explored. And the most promising of the new tools to protect our telecommunications system from fraudulent players lies in blockchain.

The key to stopping these nefarious acts lies in a digital identity solution powered by blockchain – a shard database or ledger. An identity solution enables customers to be confident that the communication is truly from enterprises they know and trust.

With blockchain, only authorized and verified messages get through. Spam and robocalls are virtually eliminated in one shot. All that’s required is a slight change in how we approach communications.

In a world where consumers are already doing whatever they can to self-manage their identity, it isn’t a large leap of faith to imagine adding a certified, digital ID to our telephone numbers.

Consumers freely use their telephone numbers to attest and manage their identity – even more than they use their Social Security numbers, birthdays, mother’s maiden name and secret questions. In our current digital universe, consumers use their phone numbers to register for store discounts, receive health and safety alerts and even transfer money to others.

And in their effort to stop spam and robocalls, consumers willingly add apps such as Hiya, paying over $300 million a year to these intermediaries.

The FCC needs to evolve and embrace the technology that allows consumers and mobile carriers who have a shared stake in attesting their identities. They need to recognize that blockchain technology offers an elegant, all-encompassing solution to the $40 billion in fraud that consumers fall victim to every year.

It’s time we leveraged a solution that’s already being used in other countries such as India, where blockchain technology helps protect over 600 million citizens from spam and robocalls.

Back in 2004, when the future of telecommunications was being written, the FCC was challenged with laying down rules governing Voice over Internet Protocol (VoIP). At that time, we hosted brown-bag lunches for Congress, and held open demonstration days at the FCC as well as a mini-trade show on the Hill in our effort to inform and educate Congress, staffers and other government employees on the latest and greatest innovations in Internet communications technology.

The FCC would be wise to revisit this practice of show and tell where they hear from the innovators of new game-changing technologies that can solve their biggest concerns. It certainly is wiser than simply taking advice handed down from lobbyists and relying on legislation that’s severely limited and unenforceable.

When the FCC uses its influence to investigate and embrace new and innovative technologies, they can finally make significant headway in restoring trust in the quality of service associated with our communications.

Jeff Pulver is an innovator in the field of Voice over Internet Protocol (VoIP). He was instrumental in changing how the FCC classified VoIP in 2004, paving the way for the development of video and voice internet communications. The co-founder of Vonage, Jeff has invested in over 400 start-ups. 

Noah Rafalko is a pioneer in TNID (Telephone Number ID), a blockchain solution that restores trust in communications. Noah is founder and CEO of TSG Global, Inc. which provides voice, messaging and identity management services for SaaS companies and large enterprises. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views reflected in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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Jay Anderson: Is Texas the New Home for Robust Internet Access?

Cost of doing business is driving companies into markets with favorable tax rates and fewer regulations. Here’s how they’re prioritizing.

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The author of this Expert Opinion is Jay Anderson, chief technology officer, FiberLight

It is hard to ignore how the COVID-19 pandemic has impacted our lives––namely, how we work and live. Many people emerged from the pandemic with a request to employers: Continue to allow flexible work arrangements. Thanks to digital transformations across industries, Americans are embracing flexible work arrangements, and they want more of it.

In fact, according to McKinsey’s American Opportunity Survey, 58 percent of U.S. job holders—equivalent to 92 million people—report that their employers are still offering the option to work from home for all or part of the week. The survey also showed that when given the opportunity to work flexibly, 87 percent of workers embrace it.

Because of the shift toward remote work, people are relocating to cities that better suit their needs. New data by Upwork reports that 2.4 percent of Americans–– about 5 million people––have relocated since 2020. And, 9.3 percent of Americans––around 20 million people––are planning to relocate.

Companies also are considering relocation. According to FiberLight’s 2022 Business Relocation Expansion Survey, 70 percent of IT and corporate decision makers say they are considering relocating their business or adding more locations within the next 3-5 years. Executives cited market saturation and availability, followed by the expense of doing business in major metropolitan areas, and expanding their operations, as factors driving the change.

Notably, of these respondents, 78 percent said they are considering relocating their business to Texas. Why Texas? Texas offers several advantages including a lower cost of living, favorable tax rates, and fewer regulations. Ranking high on the list of Texas cities decision makers are considering for relocation include: Dallas / Ft. Worth, Austin, and San Antonio, in that order. Decision makers also are considering a host of more rural Texas markets including El Paso, Arlington, Corpus Christi, Plano, Lubbock, Irving, Laredo, Frisco, Garland, Brownsville, Amarillo, McKinney, and others.

Yet businesses will need faster, more robust connectivity in order to execute their business strategies.

Executives surveyed said that they are planning, primarily, for Hybrid and Cloud infrastructure models. Their biggest priorities for connectivity upgrades include 1) Speed / Low Latency, 2) Security, and Diverse Connections.

Executives also said that they are prioritizing the following local infrastructure needs:

Data center access (29% of respondents): What today’s data center requires

The new data center requires an infrastructure that can provide rapid, secure data transmission through reliable, scalable, high-capacity bandwidth that meets the processing demands of next-generation technologies like blockchain systems. Many blockchain data centers are cropping up in rural areas of Texas; however, sourcing reliable connectivity to the internet can be challenging.

Public sector (22% of respondents): A broadband for all advocate for rural America

Public sector teams are critically important to finding solutions that deliver next-generation technology to underserved rural areas. By raising awareness of the need for broadband for all, connecting communities to funds and resources, and establishing partnerships, public sector teams can help municipalities, schools, and businesses access the networks that will help them to grow and scale into the future.

Cloud migration (20% of respondents): Key factors to consider

For enterprises choosing to migrate operations and workloads to the cloud, robust and secure fiber connectivity within a mission-critical colocation facility is a must. Choosing the right data center with the best connection to the cloud is half the battle. Organizations must also ensure there is fiber network infrastructure that’s scalable and reliable providing interconnectivity between their locations and their chosen data centers.

Dedicated internet access (15% of respondents): The path to increased uptime, speed, and reliability

Enterprises of all sizes can benefit from choosing Dedicated Internet Access (DIA)––a private or fully dedicated connection between the internet and the customer. Enterprises, data centers, government institutions, and many more businesses today require a fully dedicated connection allowing large amounts of data to be transferred at faster speeds in order to keep pace with their business needs.

Dark fiber (12% of respondents): A cost effective network strategy to future-proof businesses

Dark fiber holds a lot of potential to rejuvenate the capabilities of businesses across many key vertical industries, including healthcare, finance, education, and beyond. This network strategy effectively future-proofs businesses, empowering them with the ability to cost effectively meet the growing needs of their end-users with bolstered bandwidth, reduced latency, and more.

Post-pandemic relocations are igniting digital transformation and highlighting the core infrastructure requirements to support business expansion. It will be exciting to see how rural areas around our country will begin to flourish as a result.

Jay Anderson is chief technology officer of FiberLight, a fiber infrastructure provider with more than 20 years of experience building and operating mission-critical, high-bandwidth networks. As CTO, he is responsible for evolving FiberLight’s infrastructure and technical capabilities to ensure the company can respond quickly to the changing digital ecosystem needs of its customers. This piece is exclusive to Broadband Breakfast.

Broadband Breakfast accepts commentary from informed observers of the broadband scene. Please send pieces to commentary@breakfast.media. The views reflected in Expert Opinion pieces do not necessarily reflect the views of Broadband Breakfast and Breakfast Media LLC.

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