Internet Connection Study
Prepared for:
Northeastern Health Services, Inc.
Prepared by Joe Smith, Health Care Technology ConsultantAnnotated Bibliography:

Haggard, J. (2014). America’s Embrace of the Mobile Internet : Analyses and Issues. New York: Nova Science Publishers, Inc.

In this collection of articles, the editor brings together papers covering three different topics - adoption of mobile internet and how it differs between demographic groups; how culture is able to impact design and usage of mobile devices; and how text and multimedia messaging present new challenges for policymakers. With regard to this proposal, the first article discusses how mobile internet usage in rural areas has lagged behind the rest of the population. The article also points out that while there have been improvements in coverage, the build-out of mobile networks has typically been less extensive than in urban areas.

Solution: Mobile/Wireless Internet

Its Use: Mobile Internet service could potentially be used in conjunction with site-to-site VPN connections, in order to establish connectivity from the remote locations to the hospital.

Application: Mobile Internet hotspot devices could be used to get Internet access in Northeastern Health Services’ remote offices. In conjuction with these hotspots, firewall appliances can be used to establish a site-to-site VPN connection from each of the offices to the hospital’s radiology department. However, because of the lower levels of network build-out in rural areas, there is an increased likelihood of poor network coverage in some or all of these rural locations.

DeBeer, M., & Williams, J. D. (2004). Unwiring With Wi-Fi and Cellular Technologies. Behavioral Health Management, 24(1), 18-22.

The authors of this article explain the differences between wi-fi and cellular Internet access, and they also discuss the security of each of them. Additionally, there is a case study describing the experiences of Childrens Hospital Los Angeles, and the challenges they encountered with cellular internet at remote clinics, and there is also a discussion of how cellular internet can come into play with electronic medical records. While the article is several years old, the discussion of gaps in network coverage are still relevant today.

Solution: Mobile/Wireless Internet

Its Use: Mobile Internet service could potentially be used in conjunction with site-to-site VPN connections, in order to establish connectivity from the remote locations to the hospital.

Application: Mobile Internet hotspot devices could be used to get Internet access in Northeastern Health Services’ remote offices. In conjuction with these hotspots, firewall appliances can be used to establish a site-to-site VPN connection from each of the offices to the hospital’s radiology department. However, as the article points out, coverage of mobile Internet is spotty and not as reliable as other options. With this inherent unreliability, combined with the observed issues in the northern parts of the state that appear to be caused by solar flares, we have come to the conclusion that mobile Internet access is not a viable option for Northeastern Health Services.

DSL Sourcebook - 2nd Edition : Plain Answers on Digital Subscriber Line Opportunities. (n.d.). Retrieved from https://web.archive.org/web/19990422014835/http://www.alliancedatacom.com/paradyne-dsl-tutorial.htm

This publication was created by the Paradyne Corporation to provide a technical overview of digital subscriber line (DSL) technology. They cover topics such as the copper infrastructure needed to supply DSL service, the various equipment components involved in DSL, and how DSL compares to other services delivered over the Public Switched Telephone Network (PSTN). While the publication is several years old, and thus some of the speeds mentioned are outdated, the overall explanation of DSL technology is still valid and relevant.

Solution: Digital Subscriber Line (DSL)

Its Use: DSL service is able to provide high speed access to the Internet, and is typically offered at a reasonable price. This would need to be installed in conjunction with a VPN firewall, in order to supply connectivity to the hospital.

Application: By installing DSL service at each of the remote locations, in conjunction with a VPN firewall to connect to the hospital’s radiology department, we could have a potentially viable solution for Northeastern Health Services. However, because DSL service is typically installed with a lower upload speed than download speed, we do not feel this would be the best alternative solution for Northeastern Health Services, is this could lead to an unacceptably long time required to transmit images to the hospital.

Franklin, C. (2004). How DSL Works. How Stuff Works, http://computer.howstuffworks.com/dsl. htm/printable, printed Nov, 16. Retrieved from https://s3-ap-southeast-1.amazonaws.com/erbuc/files/5717_13c42b94-8e03-4bb6-b1bd-665d35539e1e.pdf

In this article, the author breaks down the various components of a typical DSL connection. He also lists various limiting factors on DSL, and explains why the voice signal is able to be carried much farther than a DSL signal. In particular, as it relates to this proposal, the author mentions the limitation of 18,000 wire feet from the central office to the customer, which would likely be difficult or impossible for many of the rural locations of Northeastern Health Services.

Solution: Digital Subscriber Line (DSL)

Its Use: DSL service is able to provide high speed access to the Internet, and is typically offered at a reasonable price. This would need to be installed in conjunction with a VPN firewall, in order to supply connectivity to the hospital.

Application: By installing DSL service at each of the remote locations, in conjunction with a VPN firewall to connect to the hospital’s radiology department, we could have a potentially viable solution for Northeastern Health Services. However, as the author has pointed out in this article, DSL service is distance–sensitive, which means that unless each clinic is close to the central office of their local telephone company, they could suffer from unacceptable degradations in speed, or they may have difficulty connecting at all. For this reason, as well as the asynchronous speed differences mentioned earlier, we are not recommending DSL service as a connectivity solution for Northeastern Health Services.

Arora, V., Suphasindhu, N., Baras, J. S., & Dillon, D. (1996). Asymmetric Internet Access over Satellite-Terrestrial Networks.

While this article is several years old, the overall explanation of satellite-based Internet access is still valid. The authors provide a detailed explanation of the communication mechanisms involved connecting to the Internet via satellite. They also discuss some of the challenges in satellite-based Internet access, such as high latency, as well as the possibility of needing an asymmetric connection - in other words, a connection to send, and a connection to receive. While the last part isn’t necessarily as common with modern satellite technology, the rest of their explanation, including the parts about the high latency involved in this type of connection, are still valid today.

Solution: Satellite-based Internet access

Its Use: This would allow the clinics to access the Internet via a satellite connection, using a satellite dish installed on the roof of the clinic. In addition, by installing a VPN firewall at the location, connectivity could be established to the hospital.

Application: While this type of connection, in conjunction with a VPN firewall, could potentially provide connectivity from the clinics to the hospital, we feel that with the overall slow speed and high latency involved in this type of connection, as well as the susceptibility to weather-related outages, this would not be an acceptable solution for Northeastern health services.

Zhang, Y., DeLucia, D., Ryu, B., & Dao, S. (1997, June). Satellite communications in the global Internet: Issues, pitfalls, and potential. In Proc. INET (Vol. 97, p. I997).

The authors of this article present an examination of some of the pros and cons of using satellite-based Internet access. In the article, they have provided a listing of a number of various web-based applications, such as email, web browsing, and videoconferencing, and the feasibility of using a satellite-based connection for each of them. They have also included an explanation of the differences between geosynchronous earth orbit, medium earth orbit, and low earth orbit satellites. While medium and low earth orbit satellites do not have the same issues with the latency as does a geosynchronous earth orbit satellite, they are not able to remain in a fixed position above the earth, and thus a network of satellites is required in order to provide consistent coverage.

Solution: Satellite-based Internet access

Its Use: This would allow the clinics to access the Internet via a satellite connection, using a satellite dish installed on the roof of the clinic. In addition, by installing a VPN firewall at the location, connectivity could be established to the hospital.

Application: While this type of connection, in conjunction with a VPN firewall, could potentially provide connectivity from the clinics to the hospital, we feel that with the overall slow speed and high latency involved in this type of connection, as well as the susceptibility to weather-related outages, this would not be an acceptable solution for Northeastern health services.

Esbin, B. (1999). Internet over Cable: Defining the Future in Terms of the Past. CommLaw Conspectus: Journal of Communications Law and Technology Policy, 7(1), 37-118.

In this article, the author provides a thorough analysis of the issues surrounding the regulatory challenges surrounding cable internet service, especially when regulations previously intended to cover other telecommunications services are applied. In the course of developing this analysis, the author provides the reader with a background explanation of a number of different Internet technologies. While the focus of the article is intended to point out the need for the FCC to update the current regulations to cover newer technologies, the author also provides a detailed description of the architecture and delivery of Internet service over cable.

Solution: Cable Internet access

Its Use: By connecting to the Internet over the cable television network infrastructure, in conjunction with a VPN firewall, we could provide connectivity to the hospital from each of the clinics.

Application: By installing cable Internet access at each of Northeastern Health Services’ clinics, in conjunction with a VPN firewall, we would be able to establish connectivity to the hospital, as well as provide a stable, fast Internet connection. However, because of the asynchronous speeds offered with cable Internet access, where the upload speed is typically significantly slower than the download speed, we do not feel that this would be the best possible solution for Northeastern Health Services,

Genin, D., & Splett, J. (2013). Where in the Internet is congestion?. arXiv preprint arXiv:1307.3696.

The authors of this article seek to provide an explanation of the distribution of traffic congestion on the Internet. In 2010, the FCC contracted with the private company SamKnows to perform a large scale measurement study of America’s broadband access networks. Using data from this study, the authors point out that more than 20% of the time, cable internet subscribers received less than 80% of their assigned speed tier. Furthermore, they found that the distribution of congestion in cable networks predominantly tends to happen in the “middle mile”, indicating a more systemic type of congestion, as opposed to congestion occurring on the initial segment, or “last mile”. As it relates to this proposal, the prevalence of congestion in cable networks poses a potential issue for Northeastern Health Services, because of the high bandwidth requirements associated with the rapid transmission of large radiologic images.

Solution: Cable Internet access

Its Use: By connecting to the Internet over the cable television network infrastructure, in conjunction with a VPN firewall, we could provide connectivity to the hospital from each of the clinics.

Application: By installing cable Internet access at each of Northeastern Health Services’ clinics, in conjunction with a VPN firewall, we would be able to establish connectivity to the hospital, as well as provide a stable, fast Internet connection. However, there is a statistically higher amount of congestion on cable networks, which would potentially delay the transmission of radiologic images to the hospital. When this factor is combined with the asynchronous speeds offered with cable Internet access mentioned earlier, we do not feel that this would be the best possible solution for Northeastern Health Services,

Kittredge, F. (2013). Maine’s Three Ring Binder. Maine Policy Review, 30-40.

Because of the rural nature of the state of Maine, there are many areas in the state where it has been difficult, or even impossible, to get fast and reliable Internet access. Because of this, the state of Maine, with funding from both the federal government and private investors, has installed a fiber optic network known as the Three Ring Binder. The Three Ring Binder is a network of 1100 miles of dark fiber running through rural Maine, and is so named because of the three rings formed by the fiber runs. As the CEO of Great Works Internet (GWI), the company which applied for and won the federal grant to fund much of the Three Ring Binder, the author is well-versed in the history of the project, as well as the conditions that existed prior to the project. The author provides a thorough account of the history of the project, and also gives us the current status and future economic and policymaking opportunities associated with the project.

Solution: Fiber optic Internet access

Its Use: By connecting to the Three Ring Binder fiber optic network, there is the opportunity to get very high speed, highly reliable Internet access at each of the clinics.

Application: With a fiber optic Internet connection, Northeastern Health Services would be able to get a fast, highly reliable means for transmitting radiologic images to the hospital. Prior to the installation of the Three Ring Binder, the distances involved between the rural clinics and the major metropolitan areas of Maine would have made such a connection cost-prohibitive.

Herold, B. (2014). Districts Get Creative to Speed Up Internet. (Cover story). Education Week, 33(17), 1-13.

While the article is focused on school districts, it describes situations that are somewhat parallel to that of Northeastern Health Services. Similar to NHS, these districts have encountered difficulty with obtaining a reliable, high-speed connection to the Internet that was able to meet their needs. The author goes on to explain how there is a growing trend with these kinds of school districts to install fiber optic connections to the Internet, and how fiber is generally considered to be the fastest and most reliable means of connecting to the Internet.

Solution: Fiber optic Internet access

Its Use: By connecting over fiber optic lines (via the Three Ring Binder mentioned in the previous article), Northeastern Health Services would be utilizing what is generally considered to be the fastest and most reliable means of connecting to the Internet.

Application: With a fiber optic Internet connection, Northeastern Health Services would be able to get a fast, highly reliable means for transmitting radiologic images to the hospital. With a fiber optic connection, this connection can be handled either via VPN, through a VPN firewall at each location, or it can be established at the carrier level. While there is additional communications overhead associated with a VPN connection, we feel that is the best solution for ensuring the confidentiality of any patient data transmitted over this connection.

Recommendations

Based on Northeastern Health Services’ goal of providing state of the art health services, as well as due to the need for rapid transmission of extremely large files, it is our recommendation that Northeastern Health Services move forward with the process of installing fiber optic Internet connections at each of their remote clinics. Typically, this would be a cost prohibitive venture for most organizations, especially where rural locations are concerned, but the Three Ring Binder was created in Maine for precisely that reason - to be able to bring cutting edge Internet access technology to remote parts of Maine, where it would otherwise not be possible to get such a connection.

With the fiber optic connection at each of the locations, connectivity will need to be established to the hospital in New York. This can be accomplished in one of two ways-the connection can either be established by the carrier, or the connection can be established via VPN. In many cases, our recommendation would be to have the carrier establish the connection, as there is additional processing overhead with maintaining a VPN connection, which essentially reduces the available bandwidth by several percent or more. However, because of the need to securely encrypt the data in order to maintain the confidentiality of patient information, it is our recommendation to use a VPN firewall at each location, which would have the responsibility of establishing a secure tunnel to the hospital’s radiology department. Fortunately, the impact of overhead is much smaller on larger files, so this reduction in throughput should be negligible.

It is our belief that this approach will not only serve the immediate needs of Northeastern Health Services and their clinics, but it will serve them for quite some time into their future as their needs might expand. For example, since their goal is to provide state of the art health services, there might come a point in time where they want to add in a telemedicine component, so that the patient and the doctor at the clinic can videoconference with a specialist at the hospital. By installing a fiber Internet connection now, Northeastern Health Services would have the flexibility and available bandwidth to add that kind of functionality at some point in the future.
Analysis of Organization

Based on our understanding of Northeastern Health Services, we would identify them as Innovators, when evaluating them within the Diffusion of innovations framework that was developed by Everett Rodgers (Diffusion of innovations, n.d.). According to Rodgers, an Innovator is defined as follows: “Innovators are willing to take risks, have the highest social status, have financial liquidity, are social and have closest contact to scientific sources and interaction with other innovators. Their risk tolerance allows them to adopt technologies that may ultimately fail. Financial resources help absorb these failures.” Based on this definition, we feel that this matches up closely with Northeastern Health Services.

If we break this down into pieces, we can see that virtually all of the various components of the definition are in close alignment with the Northeastern Health Services organization.
Willing to take risks: The very process of creating a new method of health care delivery is a risky proposition. They may have trouble with establishing a high enough patient load in order to be profitable (or to at least cover their costs).
Have the highest social status: The medical profession is held in high regard in this country, and doctors are typically very prominent members of society.
Have financial liquidity: We can’t speak to the degree of financial liquidity, but there would have to be a good deal of liquidity before undertaking a venture such as Northeastern Health Services has undertaken. The imaging equipment alone that must be purchased for each clinic location is extraordinarily expensive, in addition to all the other costs associated with opening a medical facility.
Have closest contact to scientific sources and other innovators. The very nature of the medical field requires that one maintain contact with scientific sources and other innovators, in order to know when new advances are made in the medical field, or to know whenever new treatments or procedures are discovered.
Their risk tolerance allows them to adopt technologies that may ultimately fail: Most doctors that start up their own practice are entrepreneurs. Part of being an entrepreneur is the willingness to take risks, in the hopes of eventually reaping financial rewards.

With regard to this recommendation, we believe that this would also fall into the “Innovator” category. According to data from the Organisation for Economic Co-operation and Development, the current US penetration for fiber as a percentage of overall broadband connections stands at 8.9% (Percentage of fibre connections in total broadband subscriptions, Dec 2014). According to the curve developed by Rodgers, an Innovator would fall between the first 2.5% and the first 13.5% to adopt a new technology. With the current penetration at 8.9%, that would fall very near to the middle of the range given by Rodgers.

Finally, we believe that the stated goal of Northeastern Health Services to provide “state of the art” health services helps to solidify their classification as an Innovator. According to Dictionary.com, the definition of “state of the art” is follows: “the latest and most sophisticated or advanced stage of a technology, art, or science” (state-of-the-art, n.d.) By definition, their goal would be to use the latest and most sophisticated treatments and medical equipment that are available, and that would seem to place them firmly in the category of Innovator.

Summary
Based on the requirements of Northeastern Health Services, we believe that the recommendation to deploy fiber optic Internet connections at each of the remote clinics makes good business sense. There will certainly be some build-out cost associated with the deployment of fiber optic at these locations, although that should be mitigated substantially by connecting to the existing infrastructure created by the Three Ring Binder.

Once installed, this connection will enable them to rapidly transmit the large radiologic files from the clinic to the hospital, allowing them to be able to deliver the best possible patient care. The high data capacity of the fiber connection also provides them with room for expansion in the future, should they decide to add additional services, such as telemedicine/videoconferencing.

Finally, for the communities that are farther away from the Three Ring Binder, there is an opportunity for Northeastern Health Services to be able to partner with the local community. By doing so, they may be able to lower their own costs, as well as assisting the respective local communities get connected to the Three Ring Binder, and in turn be able to off better Internet access to their residents. References

Arora, V., Suphasindhu, N., Baras, J. S., & Dillon, D. (1996). Asymmetric Internet Access over Satellite-Terrestrial Networks.

DeBeer, M., & Williams, J. D. (2004). Unwiring With Wi-Fi and Cellular Technologies. Behavioral Health Management, 24(1), 18-22.

Diffusion of innovations. (n.d.). Retrieved August 24, 2015, from https://en.wikipedia.org/wiki/Diffusion_of_innovations

DSL Sourcebook - 2nd Edition : Plain Answers on Digital Subscriber Line Opportunities. (n.d.). Retrieved from https://web.archive.org/web/19990422014835/http://www.alliancedatacom.com/paradyne-dsl-tutorial.htm

Esbin, B. (1999). Internet over Cable: Defining the Future in Terms of the Past. CommLaw Conspectus: Journal of Communications Law and Technology Policy, 7(1), 37-118.

Franklin, C. (2004). How DSL Works. How Stuff Works, http://computer.howstuffworks.com/dsl. htm/printable, printed Nov, 16. Retrieved from https://s3-ap-southeast-1.amazonaws.com/erbuc/files/5717_13c42b94-8e03-4bb6-b1bd-665d35539e1e.pdf

Genin, D., & Splett, J. (2013). Where in the Internet is congestion?. arXiv preprint arXiv:1307.3696.

Haggard, J. (2014). America’s Embrace of the Mobile Internet : Analyses and Issues. New York: Nova Science Publishers, Inc.

Herold, B. (2014). Districts Get Creative to Speed Up Internet. (Cover story). Education Week, 33(17), 1-13.

Kittredge, F. (2013). Maine’s Three Ring Binder. Maine Policy Review, 30-40.

Percentage of fibre connections in total broadband subscriptions, Dec 2014. Retrieved August 24, 2015, from http://www.oecd.org/sti/broadband/1.10-PctFibreToTotalBroadband-2014-12.xls

state-of-the-art. (n.d.). Dictionary.com (http://Dictionary.com) Unabridged. Retrieved August 24, 2015, from Dictionary.com (http://Dictionary.com) website: http://dictionary.reference.com/browse/state-of-the-art

Zhang, Y., DeLucia, D., Ryu, B., & Dao, S. (1997, June). Satellite communications in the global Internet: Issues, pitfalls, and potential. In Proc. INET (Vol. 97, p. I997).