Telemedicine Today: More Than Sending X-rays - Community Broadband Bits Podcast 352

This week, we have another interview that Christopher recorded while he was at the 2019 Broadband Communities Summit in Austin, Texas. Dr. Robert Wack from Westminster, Maryland, where the town is partnering with Ting Internet, sat down for a conversation on telemedicine.

As the United States’ healthcare system continues to degrade, hospitals, doctors, and other caregivers are looking for new and efficient ways to provide better care for their patients. Broadband is a tool that healthcare professionals are already using for preventative care, consultation, and treatment from a distance. Dr. Wack and Christopher discuss some of the innovations within the healthcare industry that use connectivity, data, and human engagement. These approaches reduce costs and help patients by reducing the stress that accompanies unnecessary trips to the emergency room or can identify when a patient requires medical intervention from the security of their home.

Christopher and Dr. Wack also discuss some of the new challenges that accompany these innovations and strategies for bringing these programs to large groups of people, rather than focusing on small populations.

Dr. Wack updates us on the progress of the network deployment in Westminster and discusses the community’s Mid-Atlantic Gigabit Innovation Collaboratory (MAGIC), the nonprofit established to optimize use of the fiber network they began developing in 2014.

Read more of our coverage about Westminster and their public-private partnership with Ting.

This show is 36 minutes long and can be played on this page or via Apple Podcasts or the tool of your choice using this feed

Transcript below. 

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Thanks to Arne Huseby for the music. The song is Warm Duck Shuffle and is licensed under a Creative Commons Attribution (3.0) license.


Robert Wack: And so, what we'd like to do is that same process that's occurring in intensive care units — move that out into the home, so that your home now becomes basically a nurse that's watching you, keeping an eye on your health, and hopefully anticipating problems long before they become a serious thing.

Lisa Gonzalez: Welcome to episode 352 of the Community Broadband Bits podcast from the Institute for Local Self-Reliance. I'm Lisa Gonzalez. While Chris was at the 2019 Broadband Communities Summit in Austin, Texas, he met up with Dr. Robert Wack from Westminster, Maryland. As a healthcare professional. Dr. Wack has a special interest in how a broadband network can help deliver better care, and in this interview he and Christopher discuss some of the interesting programs he's been working on. From broadband for home monitoring to assisting in triage to reducing costs, it's obvious that connectivity is a tool that we can't afford not to develop in the battle for better healthcare. Now here's Dr. Robert Wack and Christopher talking about healthcare and broadband.

Christopher Mitchell: Welcome to another episode of the Community Broadband Bits podcast. I'm Chris Mitchell with the Institute for Local Self-Reliance and I'm in Austin, Texas, for the Broadband Communities Summit, which is an event that I do interviews at every year. Actually, I think three years now, maybe this is the fourth, I've done an interview with Robert Wack, City Council president of Westminster, Maryland. Welcome back.

Robert Wack: Thanks Chris.

Christopher Mitchell: So you're a very entertaining person to have on for a variety of reasons, just a very eclectic thinker and whatnot. Yesterday, you gave a really interesting presentation about healthcare and telemedicine, and so we're going to focus on that. But first of all, let me just ask you, how are things going with your network, the public-private partnership with Ting?

Robert Wack: It's going extremely well. We are pretty much on schedule, under budget, and preparing to wrap up the main construction of the backbone and signing up customers. From a financial performance perspective, we're right on track. We're hitting our customer acquisition goals on schedule — actually ahead of schedule. Our target was 20 percent within a year of lighting up each phase, and we, meaning mostly Ting, are beating that goal. Well, they have beat it for every phase that we've lit. The next step is, internally for Westminster, our goal is 40 percent at five years, Ting's goal is 50 percent at five years, and we're on track. So it's still a long way to go, ramping up subscriber acquisition, but the way we put the project together, the way we modeled it was all, you know, for very long term, slow ramp up and we're doing that.

Christopher Mitchell: Aside from being the city council president who I think had the vision for this and was a driving force for it, you're an author, which I always like to bring up and you always giggle about, but you're also a doctor. And so you have some hands on experience and you're paying close attention to this, and Maryland is a really fascinating state for a variety of reasons. Then we have the Affordable Care Act, which is Obamacare, which has changed some incentives for hospitals. So give me a sense of maybe setting a broad stage, just like you did yesterday on the session we didn't record. What's the stage for broadband in healthcare right now?

Robert Wack: Well, let's just start like yesterday with a very broad picture of healthcare. And you know, this is a very oversimplified generalization and it's somewhat pessimistic and I'm sure people might take issue with one piece of it or another, but the general —

Christopher Mitchell: No, if there's one thing Americans can agree on it's healthcare. I'm pretty sure about that.

Robert Wack: So our healthcare system is broken and is failing, unfortunately, even despite recent progress with, for example, the Affordable Care Act. The Affordable Care Act was a great step in the right direction, but it was not sufficient to fix the many problems that our healthcare system has. And those basically boil down to three main areas: One, we spend way too much on healthcare. Two, we do not get the same results from our healthcare system that other countries do, so we deliver healthcare very inefficiently. And three, there are still massive, terrible inequities in our healthcare system. There are parts of the country that don't have access to the same levels of healthcare that other parts of our country have, and there are certainly major socioeconomic discrepancies between the quality of healthcare — and you know, racial discrepancies as well, so there's huge problems. So that's the big picture, is our healthcare system struggling and not heading in the right direction. There are pockets of hope and things that seem to be going well, but there are many, many more changes that need to happen. So in that context, in the state of Maryland, we have participated for many years as part of a pilot project from CMS, the Center of Medicaid and Medicare services, that places authority for setting rates for healthcare reimbursement at the state level. So unlike many other states, the state of Maryland says what reimbursement rates are going to be for a hospital, and that effectively controls how much a hospital can make in a given year. And what that does is they've created the mechanism for capping hospital expenditures in any given year, and then that in turn flips the incentives for how hospitals deliver care. So instead of in the past, or what most of the rest of the country has, where there's this incentive to drive volume — more surgeries, fill the beds, build a bigger hospital — it's the exact opposite. Now it's keep people healthy, do fewer surgeries, keep people out of the hospital.

Christopher Mitchell: So hospitals actually in this situation, they have a real incentive to spend on things that other hospitals don't have an incentive to spend on.

Robert Wack: Correct. Absolutely. So now there's much bigger focus on community health, preventative health, wellness programs, many new things — things that we've always talked about, but there just weren't the financial incentives there, so that's a big, big change. So in that context now, programs that look at, for example, using technology to provide preventative healthcare or chronic disease management in the home as opposed to in the hospital now become much, much more interesting, and so that's the area where I've started to really do some interesting things.

Christopher Mitchell: My rudimentary understanding of healthcare was sort of really broadened, I think, when I understood that there are a very few number of diseases that massively drive the costs of healthcare up. I mean, diabetes and dementia, like sort of . . . schizophrenia. And so, getting a sense of how dealing with a few chronic diseases, if you can get those managed, you can dramatically change healthcare expenditures. So tell me a little bit about how that may play into what you're talking about here in broadband.

Robert Wack: So, I took a full time job recently with a home care agency. I'm over the medical director for a home care agency, and they have a fascinating pilot program that they're calling the chronic care management program, that's generating some really impressive results in terms of keeping costs down and keeping people out of the hospital. They just completed an analysis of a two year pilot program. There've been about 200 patients came through the program, but there were 120 that were part of the analysis. And they did a preintervention assessment of healthcare utilization, emergency room visits and readmissions, and then they were enrolled in the program, and then they looked at the following 12 months and again looked at readmissions and emergency room visits. And what with the intervention of using this remote patient monitoring technology, which I'll explain a little bit more detail, they were able to reduce emergency room visits by over 50 percent and hospital readmissions by over 80 percent, which resulted in $2.1 million in avoided costs from hospital utilization.

Christopher Mitchell: Over . . . ? Now remind me of the timescale. Over one year, over two years?

Robert Wack: Well, the one year of the intervention. So they tracked the data over two years before and after, and so during that 12 months, $2.1 million of savings.

Christopher Mitchell: And this just in the community of Westminster?

Robert Wack: No, no, actually this is in Frederick, Maryland.

Christopher Mitchell: Oh, Frederick. Ok.

Robert Wack: But it was just those 120 patients. Those 120 patients accounted for $2.1 million worth of healthcare savings, so imagine the impact it could have if it was used more broadly. So we're looking at aggressively expanding that program. But the key thing there is the technology is actually pretty simple, and the technology is not what generates the savings. What generates the savings is the higher level of patient interaction and communication that the technology enables, which is usually the case with technology. The technology is not necessarily the solution; the technology is an enabler of a better solution. Christopher]: Right. It's how we use it, right?

Robert Wack: Correct. Yeah. So what this is, is these are basically like an iPad, a tablet, that's armored, so if they drop it or you know, whatever, leave it out, it's not going to fail. And it has a little SIM card in it that's connected to a cellular plan to transmit the data. The patients are taught how to use a Bluetooth enabled blood pressure cuff, a Bluetooth enabled scale, and a Bluetooth enabled pulse oximeter, which checks pulse rate and oxygen level. And those three things for certain kinds of patients, for example, patients with congestive heart failure or patients with chronic obstructive pulmonary disease, are enough to get a general sense of how a patient is doing in the home. But the key is daily check ins with a nurse who they have a relationship with, and then the ability for that nurse to sort of intervene very, very early if they start seeing any changes that either they see in the vital signs that they are remotely monitoring or in what the patient reports through their check ins. That's what's making the difference, is that they can talk patients through minor changes in their lifestyle or their medications before they even think about going to the emergency room, and that's having this major impact in their hospital utilization. So it's a huge step forward with actually a fairly minor technological fix.

Christopher Mitchell: These daily check ins, are they video check ins or . . . ?

Robert Wack: Sometimes it's a phone call, sometimes it's a video check in, and so the tablet has the capability of doing a simple, you know, Skype-like video chat, but it's mostly just, again, for that personal touch. The quality of the video is not so great that they're doing any sort of assessment because of the video. That's a whole other thing which we can talk about in the other project we're working on.

Christopher Mitchell: Right. Well, we'll get to that in a second. I think, you know, one of the things that I might hear from someone who is skeptical of the need for better fiber networks throughout the nation would be, "Aha, the 4G networks are great, and you know, problem solved."

Robert Wack: Yeah. So, no. Problem not solved. So for example, cellular networks become congested, cellular networks occasionally go down. So yes, they're good, and yes, in this case it works. But if you're talking about scaling, well, let's just look at the expense. So for this particular service, that cellular connection is 56 bucks a month and —

Christopher Mitchell: Oh, ok. Yeah, that's a lot.

Robert Wack: That's a real lot, and it really impairs the scalability of the program in terms of the financials of it because there's a significant labor cost, as you can imagine, with the nursing service. But that's where the value is. This particular service, although effective and certainly demonstrating some results, is going to be tough to scale because of that communications expense.

Christopher Mitchell: I mean, just back of the envelope, I'm thinking that's, you know, the monthly communication costs just for the subscription of the 4G is probably on the order of $70,000 to $90,000 for a year across 120 patients.

Robert Wack: Yeah, right. That's quick math.

Christopher Mitchell: Well, I was doing it for a while you were talking. And someone might write in to say, "No, you're off by an order of magnitude," which happens to me sometimes.

Robert Wack: Yeah, no. So yeah, it's a nontrivial expense, and so that's where, boom, right off the top, if you had cheap, ubiquitous broadband, then that part of it goes away and the solution becomes more scalable.

Christopher Mitchell: And in a place like Maryland, given the incentives, it wouldn't be unreasonable for a hospital to say, okay, you have a home connection. Maybe we can give you a coupon or we can do something in which the hospital would pay some portion of the cost of that home connection to drive the cost down.

Robert Wack: Well, there's also a copay. So there are Medicare codes now to bill for this sort of thing, which also improves the economics of it, but those codes require a copay and some of our patients can't even afford the copay. So we have to figure that out. We've got to figure out how to manage the economics of this. Clearly, the intervention works. Clearly, that higher level of daily communication and monitoring of that data has a major impact on healthcare utilization. Now, how do we make it scale? How do we manage the economics of that in a way that makes it so that we can use it more broadly?

Christopher Mitchell: One of the things you mentioned yesterday is that — I mean we were talking about this Maryland specific thing, but this is relevant for hospitals all across the nation because the Affordable Care Act has very high penalties for hospitals that are readmitting people for the same problem over a period of a certain — I think it's within a month or something.

Robert Wack: Right, and in future iterations of healthcare reform, it's going to happen. It has to happen. As I said in the beginning, our system is failing. And at some point the political tides will shift, and we will have major healthcare reform. It might be after there's some series of catastrophes, you know, but either way it's gonna happen. And that's one of the things that will need to happen, is what's going on in Maryland, where you flip the incentives and make it so that people are focusing more on preventative care, wellness, and community-based healthcare, not hospital-based healthcare.

Christopher Mitchell: Tell us about — a perfect case in the example, you had a specific person who had a challenge of anxiety.

Robert Wack: She had anxiety and some heart problems that were real, legitimate heart problems. But she also had anxiety, and one of the things that we discovered is that she was afraid of the dark. And at sunset or shortly after sunset, her anxiety would mount, she would start feeling her heart beating rapidly, and she would start thinking she was having an exacerbation of her underlying heart issue. So in the past, she would call 911 and then the EMS folks would get there. They'd check her heart rate and sure enough it was elevated and put her in the ambulance and bring her to the ER. And she'd get a big workup, and it turns out it really wasn't her heart, it was just . . . And so with this remote patient monitoring now, she now has a way to — the nurses will see her heart rate going up. They may call her first before she can call them, and then they have a conversation and they kind of do that initial assessment that would happen at the emergency room and avoid the 911 call, avoid the unnecessary ER visit, and keep her happy and keep her in her home. And it's a perfect anecdote about how this higher level of communication really makes an impact on keeping people happier and in their home.

Christopher Mitchell: If you didn't have those tools, it would be harder to have that personal relationship because it is the personal relationship that matters, but the nurse has to have access to some of the diagnostics —

Robert Wack: Data.

Christopher Mitchell: — on the body. Right.

Robert Wack: Exactly. Data she can trust. So let's say they didn't have the remote patient monitoring, but they did have the communication. The patient calls or they have a conversation, and she said, "Well, what's your heart rate?" Well, you don't know that the patient really knows how to check their own heart rate, but she's got objective data that says her heart rate's, you know, 120 and that's a real piece of information. So yes, it's the combination of the data and the communication and the relationship that that makes the difference.

Christopher Mitchell: So what's the other program that you alluded to?

Robert Wack: Yes, I think we talked about MAGIC before, didn't we?

Christopher Mitchell: Yes. The Mid-Atlantic . . .

Robert Wack: Come on.

Christopher Mitchell: Oh no, I'm just stuck on the "g" — Gigabit.

Robert Wack: Gigabit.

Christopher Mitchell: Gigabit . . .

Robert Wack: Innovation . . .

Christopher Mitchell: Innovation . . .

Robert Wack: Collaboratory.

Christopher Mitchell: Yeah, I was going to say center, but that's the wrong word.

Robert Wack: Yeah, collaboratory's a cool made up word that I picked up from a conference one time. They were research scientists talking about their collaboratory, and I was like, ooh, I like that.

Christopher Mitchell: Yeah.

Robert Wack: So, yes.

Christopher Mitchell: If Shakespeare got to make up words, you can too.

Robert Wack: Exactly. So magic is a nonprofit in Westminster whose mission is to realize the economic development potential of our fiber network, and we have a number of programs and projects to do that. A lot of it's around workforce development, working with students, developing tech skills, but another one is our healthy smart home project. And in that we are using sensor technology and data collection to improve healthcare outcomes for the six residents in those two homes who are clients of another nonprofit that delivers residential services to adults with intellectual disabilities. These folks also have lots of medical problems and also go to the ER a lot.

Christopher Mitchell: Right. I dated a woman who provided care at one of those facilities and just one of the challenges is having people overnight, I mean, frankly, because it's hard for — these businesses usually don't have thick margins —

Robert Wack: Nope.

Christopher Mitchell: — and trying to figure out how to have that all night coverage is challenging.

Robert Wack: Yes, and it's very labor intensive as you can imagine. And so, any little deviation from the routine has a major impact on their staffing and their expenses, so if a client has to go to the emergency room or has to stay in the hospital overnight, it really blows up their staffing.

Christopher Mitchell: Right.

Robert Wack: So these folks are frequent utilizers of emergency room visits and are often admitted to the hospital, and the nonprofit that we're working with has kind of tasked us to find a way to decrease that from happening. So we started putting in technology similar to what what's being used in this other program, but now we have to figure out a way to not only generate the data but also create remote viewing capabilities that allow a much more detailed assessment and triage to happen in the home. And that's going to end up being high resolution video to allow the same sort of thing that's happening in the other program but at a much higher level of fidelity and scope. So let me lay out a scenario for you: The way the current healthcare services are provided for the clients is if something happens with a client — they fall and hurt themselves or they develop a fever or cough — the staff calls a triage service that's contracted, and these people are remote, but it's just a phone call and they have a conversation about it. And unfortunately, because of the lack of information and the lack of transparency into the situation, the result of that conversation is more often than not the advice to go to the emergency room, which really doesn't help anybody because then once they're in the emergency room, somebody can actually lay eyes on them and say, "Oh, this isn't a big deal," and now they've spent four, six, eight hours in the emergency room really basically for nothing. So what we're going to do is in addition to collecting the data, we're going to put in a 4K cameras and then have that connected to the emergency room and give that view into the house so that those sorts of assessments can be done by a healthcare provider. It might not be a physician; it might be a PA or a nurse practitioner. But to give a much higher level of comfort for making a decision not to escalate the care because that's what you need. You need that level of trust. You need that level of quantity and quality of data, to include visual data, about what's really going on in the home so that a healthcare provider can say with confidence, "This is okay. You don't need to come to the emergency room. This will keep until tomorrow or this doesn't really need anything. Everybody can relax." You can't do that over the phone or it's hard to do over the phone absent a longstanding relationship, and the reality is staff turn over. You know, so the nonprofit, their staff turns over, and at the nursing agency that's doing the triage, they have staff turnover. So it's more likely than not that the people on either side of the conversation don't know each other and may not know the client very well. And so in that vacuum, that information vacuum, it's impossible to have any kind of trust about really how reliable is the information I'm getting, and I'm not going to take a chance on making the wrong decision because I don't trust the information. So how do you change that? You build that trust, you give a better view into the house, and that's going to be through video and correlating that with data — vital signs data and other data that we're collecting, for example, about diet and about daily activities and behavior patterns. We are accumulating a substantial database of past behaviors that the staff log in through a software platform that now a clinician, they can say, "Oh, they threw a tantrum and hurt themselves, but this is their usual thing." Well how does the clinician know that? Well now we can show them. Look, here's the pattern of behaviors over the last two years, and yes, after a holiday, behaviors deteriorate, or after a big meal of candy or whatever, behaviors deteriorate, you know? So, it just generally gives more information and a better view into the situation so that people can make better decisions.

Christopher Mitchell: Is there a liability angle to this in terms of preserving the video? I mean, because liability is a major issue around health.

Robert Wack: Absolutely. And not as much on the clinician side, like in the context of an emergency room visit, but that's certainly a piece of it.

Christopher Mitchell: Right, because actually, I mean, it just seems [unintelligible]. As I was thinking about this, if they were in your office, it feels like it would be an affront to privacy to record that, but the nature of a video chat is that it is recorded anyway. And so, one could preserve it so that if there were a question later — did the clinician make the right call? — one would be able to evaluate it and say this is evidence I was presented with and, you know, a competent person in my position would have made that decision.

Robert Wack: That's exactly right. That's a really, really good point that this will be a challenge for implementing this kind of technology across the whole healthcare system because everybody's going to have to get used to this new thing that now there are other ways to document the interaction that occurred. And that's the future, but, you know, the doctors are going to have to get used to it, the family is going to have to get used to it, the lawyers will have to get used to it. It will probably eliminate some spurious sort of lawsuits about stuff, but when it does happen, there will be that evidence and, you know —

Christopher Mitchell: Right.

Robert Wack: But the goal is everybody gets good care and everybody does the right thing, so that's not necessarily a bad thing.

Christopher Mitchell: Right.

Robert Wack: It's why we keep a medical record, is to document the care that was given, so this is just an extension of that.

Christopher Mitchell: So you told a story about Johnny yesterday that I enjoyed about the 2:00 AM phone call.

Robert Wack: Sure.

Christopher Mitchell: Which my wife and I had to make an emergency room [call] on 104 fever — I think if we had talked to you then, you would have said you got to come in.

Robert Wack: If only you had called me, Chris, maybe we could have avoided that visit. No, so you know, as a pediatrician, sometimes parents become worried about situations that may or may not warrant that much anxiety. And when that phone call happens, and it's usually in the middle of the night to the on call doctor or the on call nursing service, same problem — they can't see your child. They only hear the anxiety in your voice and then the scant details of, you know, what you're relating: fever of 104, you know, etc. So usually, the answer to that is go to the emergency room, even though most times that's probably not necessary. And so a high resolution video that's, you know, reliable and secure and always there if you need it would help give that reassurance that even with 104 fever, Johnny's okay because you can see him running around in the background going, "I want a juice box, I want a juice box." Sometimes people sort of fixate on one piece of data, but there are many other pieces of data that really paint a different picture. And an experienced clinician could see that, yes, Johnny has 104 fever, but he's doing okay.

Christopher Mitchell: Right.

Robert Wack: And so, dose of Motrin and everybody go back to bed. So yeah, I think it's more broadly applicable, but again, people are going to have to get used to the presence of some kind of camera technology in their home and that occasional intrusion into their privacy, but we could really solve a lot of problems

Christopher Mitchell: Are there high speed broadband applications that aren't video? I mean, so much of this is about video that allows you to use the judgment that you've spent decades honing, but are there other things in terms of sensors that just would require, you know, high capacity?

Robert Wack: Somebody yesterday asked me after the talk about thermal imaging, you know, and I thought, well, I've never thought of that. Or what did he call it? Something else . . .

Christopher Mitchell: Hyper spectrum?

Robert Wack: Yeah, yeah. Hyperspectral imaging or something. Yeah, and I thought —

Christopher Mitchell: He was a guest last week.

Robert Wack: Yeah. That's a really great question because what it does is it opens the door to other sensory modalities that could be used diagnostically. I think the reality today is that if you thermally imaged somebody with a fever, the clinician wouldn't know what to do with that information because it's not part of our standard data set, you know. We know what temperatures mean, we know what heart rates mean, we know what, you know, respiratory rates mean, and we know what they mean in the context of different disease problems, so we know how to act on that information. We wouldn't know how to act on thermal imaging for example. But, I think your point, your larger point, is absolutely spot on, is that having that high capacity data connection and the ability to share that information does open the door to potentially new data channels that would beneficially impact that therapeutic decision making.

Christopher Mitchell: A few weeks back, I did an interview with David Weinberger and we talked about machine learning a bit, and it'll be fascinating as you're creating these data sets with this information that you would only have among people who are hospitalized and being able to get like that data —

Robert Wack: That's exactly right.

Christopher Mitchell: As you create these data sets of people in their homes, you know, machines may see patterns that we would not, that would predict certain, you know, negative health outcomes.

Robert Wack: That's absolutely right, and that's actually one of the broader strategic goals of the healthy smart home project, is that sort of machine learning is happening right now inside hospitals, particularly inside intensive care units. So there are algorithms now that are being applied to the data that's generated from a patient that's in an intensive care unit that are being used to assess the probabilities of deterioration over the next 6, 12, 24 hours and looking at every bit of data that's generated — heart rate, respiration rate, changes in those things, temperature, laboratory values, white blood count, urine output, oxygen levels — the whole thing, and then also nursing assessments as well, which turns out is one of the most valuable pieces of information. It's still the humans involved where the machines depend on the humans for that critical data input, but using that critical data input, they can look at the data in ways that humans can't and then make some predictions. And so, what we'd like to do is that same process that's occurring in intensive care units — move that out into the home so that your home now becomes basically a nurse that's watching you, keeping an eye on your health, and hopefully anticipating problems long before they become a serious thing.

Christopher Mitchell: Sure. As long as we don't have Nurse Ratched, we'll be set.

Robert Wack: That's exactly right. So, of course it raises all sorts of privacy issues. It raises all sorts of security issues, data integrity issues, all of which — and costs, you know, so we're trying to do the healthy smart home project in as cheap a way as possible. How do we pack as much capability into the home at the lowest possible price and still achieve those goals of security, reliability, stability, privacy?

Christopher Mitchell: And so one of the things to come back to the beginning about, I think, is that if you do extrapolate across the United States, you could build, like, broadband to a lot of places that don't have it with the avoided cost of hospitals. I mean, with just a fraction of it.

Robert Wack: Oh yeah.

Christopher Mitchell: Beause I mean, we're looking at hundreds of billions of dollars in avoided cost potentially.

Robert Wack: Absolutely. Yeah. So these are — I think you used a word the other day about —

Christopher Mitchell: Diggity? [laughs] Spillovers?

Robert Wack: Spillovers, yeah, maybe.

Christopher Mitchell: Right.

Robert Wack: So this is absolutely a spillover. You know, so with better broadband, you start having these ancillary impacts on education, healthcare, etc., which are hard to quantify, but in this instance, not terribly hard to quantify. In Maryland, we know in this instance $2.1 million over 12 months. That can build you some fiber. Now, unfortunately, the hospitals desperately need that cost savings, so they're probably not going to plow that into fiber, but the point still stands.

Christopher Mitchell: So this is just totally — people who are just in broadband could probably sign off right now because the last question I wanted to ask you — I was just going to end the interview, but there is an interesting point, I think, that I worry about very low probability, high impact events, and as we have hospitals that are focused on reducing bed counts, are we putting ourselves in danger in the event of a horrible catastrophe?

Robert Wack: We already are there.

Christopher Mitchell: We are there. Okay.

Robert Wack: Absolutely.

Christopher Mitchell: We're worried about the margin there. I'm really just [unintelligible].

Robert Wack: So, back when H1N1 flu was out and about, there were heightened concerns about a legit influenza pandemic like 1918 where Spanish flu killed millions of people. And so, there were some in Maryland, but I think, I'm pretty sure this happened nationwide as well, there were efforts to, you know, assess the system, see how the system would handle something if this H1N1 really took off and became a serious pandemic, where mortality was significant. What they found was, with multiple tabletop exercises, is that because we have squeezed all of the surge capacity out of the system in the pursuit of efficiencies and reducing costs, that the system will fail. It will absolutely fail because we don't have enough ventilators, we don't have enough isolation rooms, we don't have enough capacity in the morgues to handle the people who die, you know. And then when you start factoring in people missing work, the whole system breaks down pretty quickly.

Christopher Mitchell: Sure. For people who want a picture of that, Stephen King's uncut version of The Stand, I think, paints a very clear picture of it.

Robert Wack: Or, there was a movie that came out with Matt Damon and it had like a one word name, like Pandemic or something and —

Christopher Mitchell: Yeah, it wasn't outbreak, but it was something similar to that.

Robert Wack: Yeah. And it was actually a very — Gwyneth Paltrow was the index case. She caught some virus in China when she was having an affair with somebody and brought it home.

Christopher Mitchell: More likely goop would cause it.

Robert Wack: But it was actually — you know, there were some embellishments for Hollywood effect, but in terms of how it rolled out and the impacts it had, it was actually not far from the truth. It's going to happen. Maybe that's the crisis that gets us over the hump for trying to really reform our healthcare system.

Christopher Mitchell: Well, I mean, the good news is, is that as we quantify this stuff, we can make better arguments for the ancillary benefits of broadband and why we need public investment in it and we need to do it intelligently.

Robert Wack: Sure, sure. And get your flu shot.

Christopher Mitchell: Absolutely, yes. Thank you so much, Robert.

Robert Wack: Alright, thank you, Chris. 

Lisa Gonzalez: That was Christopher talking with Dr. Robert Wack about how broadband is assisting healthcare professionals to improve care at home and in the clinical setting. We have transcripts for this and other podcasts available at Email us at with your ideas for the show. Follow Chris on Twitter. His handle is @communitynets. Follow stories on Twitter. The handle is @muninetworks. Subscribe to this podcast and the other podcasts from ILSR, Building Local Power and the Local Energy Rules podcast. You can access them wherever you get your podcasts. You can catch the latest important research from all of our initiatives if you subscribe to our monthly newsletter at While you're there, please take a moment to donate. Your support in any amount helps keep us going. Thank you to Arne Huseby for the song Warm Duck Shuffle, licensed through Creative Commons, and thank you for listening to episode 352 of the Community Broadband Bits podcast.