Written by Mike Finley
651-644-4540
mfinley@mfinley.com
Let’s hear it for this beautiful morning in Willmar, Minnesota. [put hands together for applause] Good morning to you all and thank you for inviting me to kick off this conference on telecommunications and rural healthcare. It’s an honor to be here with you all.
My name is Janice Aune, and I make my living as CEO and chair at Onvoy, a Twin Cities broadband company. You might say that we create and maintain the roadbed for the information superhighway. And that is our business.
But we made up our minds some time ago that we wanted to be about more than just roadwork. After a lot of mission-and-vision thinking, we decided that we needed a special cause to affiliate with, something bigger than bits and bytes. In the end we chose improving our healthcare network as our company’s special cause. So this is a special morning for me, and for all the people at Onvoy.
I also want to tell you that, whether I’m on the road visiting Willmar or Worthington or Winona, that I never feel that far from home. The reason is that I’m an outstate girl myself, having grown up in Crane Lake, north of the Iron Range, right up on the Canadian border. I’ll bet some of you dropped a fishing line there in your time. I still have family there, and I visit as often as I can.
The big news in Crane Lake these days is that this year we finally got broadband. So when I visit and tell people what I do for a living, now they know what I’m talking about. Before, when I talked about T1 lines and fiber-optic networks, they just frowned and nodded, as if I had lost my mind. I could tell they were praying for me.
Now, Crane Lake and Willmar are in different parts of the state, but they face similar problems. For years, they connected to the rest of the world primarily through our system of blue highways. One look at a highway map tells you where all the power is. The blue highways crisscross our state, creating a system of hubs and spokes. Crane Lake, being an empty circle on the map, very small and remote, is a spoke to the little yellow dab that is Virginia, 60 miles away. Willmar is likewise a yellow hub for its immediate region, but a spoke to the Twin Cities, that swarming yellow blotch on the right side of the state, 150 miles east on Highway 55.
What I am here to tell you today is that these very highways that connect us to one another play a giant role in determining our progress and prosperity. Through much of the past century, Willmar prospered because it was an essential hub for a fantastically prosperous system of small-town spokes. Agriculture in our state directly employed tens of thousands, fueled the national economy, and fed the entire world. Along the way it also supported a vigorous service sector, including healthcare. When we speak of the “good old days,” this postwar period is probably the one we mean. The system really worked, and cities like Willmar were the Atlases that held it all together.
But we know what happened, and it happened to Willmar just like it happened to Crane Lake. The highway leading to the Twin Cities increasingly became one-way. Much of our wealth left the area. Fewer new people, new businesses, new graduates, ventured out to where we were. Worse still, more and more young people – like me, leaving Crane Lake as a teenager – are lured down that blue highway to all the opportunities that technology makes available in the city.
I don’t need to tell you what a negative trend this is. In the space of a single generation a bustling community becomes a community bleeding its talent away, and unable to attract fresh blood. Locally-owned businesses are replaced by chains headquartered somewhere else. The sense of being in charge of one’s own fate takes a major hit. Help-wanted ads placed in metropolitan papers fail to attract qualified candidates. No one wants to go out there – they’re on the slippery slope. There’s nothing to do out there. I’d be so isolated. Everybody’s getting so old.
And the paradox of this decline is that the culprit is good old American progress. Our entire culture is driven by technology, mobility and choice. And those blue highways work great, but usually one-way only – headed out of town.
That’s the bad news, and it’s nothing you haven’t heard before. The good news is that the highway heading out of town can be made two-way again. In fact, it doesn’t connect Willmar to Minneapolis, but to the entire world. It blows up the whole notion of hubs and spokes. It has the potential to restore choice and power to even the remotest locales.
You know that broadband networks rely not on old-fashioned copper wiring, but on long looping rivers of fiberglass cable. This is nothing new. We’ve had fiber-optic cable in service for over 25 years. But only in the past few years has this technology begun to mature into a seamless network for high-speed digital communications.
In the past, telephony made do with copper wire. It was wonderfully suitable for the simple tasks we applied it to. It was even easy to repair – you just spliced it, and it was ready to go.
Fiber-optic is different. To understand how it works, imagine a really long drinking straw, one that’s several miles long. Now imagine that the inside surface of the pipe has been coated with a perfect mirror, and you are looking into one end of the pipe. Several miles away at the other end, a friend turns on a flashlight and shines it into the pipe. Because the interior of the pipe is a perfect mirror, the flashlight's light reflects off the sides of the pipe (no matter how much the pipe curves and twists) and as a result you see the light at the other end.
If your friend flicks the flashlight on and off in
Morse-code fashion, your friend can communicate with you through the pipe. A
universal code exists that turns analog signals, like voices or images or data
into 1s and 0s – this code is called digitization. Modern fiber systems with a
single laser can transmit billions of bits per second -- the laser can turn on
and off billions of times per second. As a result, a fiber the thickness of a
strand of hair can be a conduit for thousands of messages simultaneously.
It all sounds a little crazy, but it is here today and it is robust. The only disadvantage fiber has over copper wire is that it doesn’t splice easily. When a trunk line breaks, it can take days to repair.
Now, here’s the part of the story you will like. Did you know that the principle of fiber optics was discovered not by someone like me, in the telecommunications industry, but by medical doctors?
I love this story!
Going all the way back to the cave era, doctors have wanted to be able to see what’s going on inside the body, without having to cut it open or turn it inside out. In the early 1900s, to get a peek at what’s going on inside a patient, doctors used to insert stiff, straight telescopes with little lanterns on them down a person’s esophagus, or up the other end. The procedure was every bit as painful as it sounds, and I have no idea how they handled the gag reflex. The idea was right on – but technology had yet to provide a proper light source, or a proper flexible material. Clearly, a breakthrough was called for.
The breakthrough actually had already begun. Thirty years earlier, physicist John Tyndall made a remarkable demonstration to a group of scientists. He took a constant stream of water, sort of like a teapot endlessly pouring into a cup, and shined ordinary sunlight through the stream of pouring water. His audience in the amphitheatre saw something very weird. The light followed a strict zigzag path inside the curved path of the water. The light did not leave the stream. Instead, it just kept bouncing around inside it, in geometrically predictable caroms, like an infinite game of Pong.
Tyndall had shown that light could be ordered into a pattern. Indeed, that it practically wanted to be ordered into a pattern. This was a property of optics that no one had ever guessed at.
Now fast-forward seventy years. It’s 1957, and you’re at the University of Michigan campus in Ann Arbor. A researcher from South Africa named Basil Hirschowitz has achieved a breakthrough. He has created the first fiber-optic device – it is a rope of flexible fiberglass. Lighted at one end, it holds its light and translates the images from one end to a receiver at the other. It’s really a kind of television camera that allows doctors to see what is going on deep inside a patient’s body.
This was the modern endoscope, which has revolutionized diagnostic procedures for a host of medical problems, from injured joints to esophageal, stomach and colon cancers. Thanks to fiber optics, doctors are no longer groping in the dark.
Hirschowitz’ model wasn’t the be-all/end-all, of course. Other inventions and advances had to come along to push the idea along. An outer layer of harder glass had to be developed to house the inner strands, so that the light trapped in the glass did not escape from it. Lasers allowed the light to be used in a far more focused fashion necessary for digital transmission – beamed, not sprayed.
And then there’s a little thing called the Internet. Did you know that the technology underlying the Internet came into being as a way to communicate in the wake of an atomic bomb detonation? True story. The ARPAnet arose partly out of research conducted at the RAND Corporation in the early 1960s so that, if a missile took out the city of Denver, military commanders stationed in Chicago could still communicate with their counterparts over in San Francisco.
The RAND Corporation study believed that a separate, secure system needed to be created that was not as easily knocked out, as our public telephone system at that time was. It led to the invention of packet switching, which is the root idea to the Internet.
First, it holds that information is most easily distributed in digital, not analog form. (Digital meaning: it’s made of bits, endless translatable combinations of 0’s and 1’s. Analog meaning: not digital, like vinyl LPs, or regular phone calls, or a book you hold in your hand.) In the 1960s, hardly anything was digital. But computer scientists knew that much military and scientific information could easily become digital. It could be broken down into little 8-bit packages of 0’s and 1’s –a given package is never more than a single short word or syllable. Then, when you send that message from one point to another, the system breaks your message into thousands of little bits, and sends them out willy-nilly. The bits split up and go in different directions. It is not possible to intercept them en route, they are truly unreadable until they arrive at the named designation, and reassemble in exactly the order they were transmitted in.
It’s an amazing process of encryption, chaotic transmission, and miraculous rearrangement on the other end. The next time you send an email around the world and wonder why it takes ten minutes to arrive, realize what that message had to do – disintegrate, fan out, and regroup to be of use – with a very high degree of reliability, and zero chance of being hijacked.
And all this is governed by the ordering principle of IP addresses, which give every 8-bit packet of information a rightful name and a place to be. The Internet confers order on what would otherwise be the biggest traffic jam in the universe.
It’s been a while since I lived in Crane Lake, and I’ve made my career in building up this remarkable superhighway that was first paved by those scientists in the 1960s. But it still is amazing even to me. We are really only in the ninth year of the Internet as we know it, since the people who created the look-and-feel of the World Wide Web opened the net up to the world.
Only nine years, and look what we’ve done with it. The great promise of telemedicine has been to connect teaching hospitals with community providers. We’re doing it, right now, today. And I’m here to tell you, we’ve only scratched the surface of the surface of the surface of the surface of what this capability can do for us. I heard someone say that telemedicine today is roughly where the Internet was 20 years ago, when Al Gore first invented it.
Now, I know this is all very appalling to some of you. The idea of an information superhighway unfurling at your feet can be threatening. It suggests that there will be winners and losers, that the “new adapters” – the people who are good at trying out new things (you know the type – when they push buttons good things happen, and when you do, smoke just billows out) that they will triumph and the rest of you will lag behind, feeling like you’re practicing medicine way back in the buggy-whip days of the 20th century.
But consider the advances.
Telecardiology has around for a long time. You could consider stethoscopes a fledgling form of telemedicine – it was originally developed because doctors felt embarrassed putting their ears against young women’s chests. With the Internet has come the capability of transmitting echocardiograms -- the gold standard test for heart diagnosis -- over a distance.
Teleradiology is a natural adaptation of broadband technology. We know a radiologist up in Bemidji. For years he was doing his job the traditional way, picking up orders by telephone, and driving them around himself, often driving 200 miles a day – a terrific waste of his time and talents. Now, using the Internet as a base, he functions as a hub himself for local providers. Transportation occurs entirely online.
Telepathology is an ideal adaptation of telemedicine because results lend themselves to digitization. No local labs can afford to have all the equipment to run every test for every ailment. Biopsies must still be locally prepared for microscope slides. But this microscope features an electronic camera feature, which can be sent on, along with necessary comments, to one or more net-based pathologists, located anywhere in the world.
Telepsychiatry is changing the way mental health services are delivered. Small towns are hard put to provide a wide choice of therapists. Patients who may live far from a professional office, or for whom travel is too stressful, are able to see their doctors via teleconferencing. Many mental health professionals use email to facilitate communication.
Home health is a major center for telemedicine development. It’s hard for chronically sick people to get frequent access to medical care. We’re all so busy, and schedules are so full. But think of your health centers as hubs for Internet-based patient health education and health maintenance.
Imagine heart monitors connected to home PCs so people can track their own heart rates and other vital information at home and then transmit it to their providers. They can log in every day, and enter info themselves. Or they can supply data passively on a 24/7 basis, transmitting information directly via radio signals – in essence, a continuing phone call from their bodies to their doctors. We all can name patients who will brighten at that prospect.
Here’s an item already in development: a toothbrush with a biosensing chip that checks your blood sugar and bacteria levels while you're brushing your teeth. The brush comes with a holder that transmits information to a database containing the person's medical file.
Or skin surface mapping, an imaging technology that collects images of the skin surface over time and allows people predisposed to melanoma to detect malignant moles as soon as they develop.
Or "smart" bandages made of fiber that can detect bacteria or virus in a wound, and tell the wearer whether treatment with antibiotics is warranted, and which one to apply.
This is “gee whiz stuff,” and it knocks even me out. But here’s something that already has happened that I think shakes the very foundations of medicine. File this under the term telesurgery.
Picture this. The patient is prepped for surgery. The anesthesiologist asks him to count backward from 10. Everyone is on hand in the operating room except one -- the surgeon.
Not only is the surgeon absent from the operating theater, in the town of North Bay, Ontario; he is 250 miles away, in the city of Hamilton, performing remote laparoscopy in a special room with dimmed lights, multiple television monitors, a surgical console, and a computer that connects him via a high-speed fiber-optic link to robotic arms in the operating room.
Telesurgery probably isn’t something you want to welcome with open arms, especially the surgeons among you. But for very remote locations, and very special circumstances, it may sometimes be more economically feasible to operate using broadband linkups and robotics – like, if only one surgeon can do the procedure, and is in great demand.
More modestly, it illustrates how easily surgeons in Willmar might have access to skilled specialists in real time, in the operating room, providing consults on the fly. This is a benefit not just to patients but to doctors themselves – call it CME on the fly.
Here’s a quote from the surgeon who conducted this procedure, Dr. Mehran Anvari, director of the Centre for Minimal Access Surgery, in Hamilton: Ontario:
"What we have done is to show that surgery is possible at long distances -- it could be hundreds of kilometers, it could be thousands of kilometers. It's very much like the Internet was a couple of decades ago. It really is a network for medical and surgical care."
Well, I’m here to tell you that telemedicine, the capability to provide advanced medical care using resources from afar, utilizing broadband fiber-optic transmission and an Internet-based information structure, will affect your practice in a positive way whether you actively participate in it or not.
Are there dangers from this technology? Is there a downside? Are there mistakes waiting to be made?
Yes, there are, and they are the same dangers you faced when personal computers came out 20 years ago. Some people asked, “Why would a single human being need a whole computer?” And now we look around, and everything around us is driven or measured or transmitted via this technology. And the people who said “This is never going to catch on” were the big losers then.
Another danger is going too far, and letting the technology take charge. Patient surveys show that the crying need is for providers to know their patients better. “Robotic” is the last thing most patients sign up for. So the challenge of technology is to free us up to be more human with our patient populations, not less. They, like we, will need more hand-holding, not less, in the hypercompetitive, cost-driven realm healthcare is evolving into.
Technology inevitably revolutionizes. One of today’s paradoxes is that the underdeveloped world is primed for the greatest growth. Bangladesh, one of the world’s poorest countries, is networked for fiber-optic because cable was providentially laid alongside the country’s railbed in the 1970s. So if you want high-speed transmission, Bangladesh is one of the best places to be.
And this will be an enormous boon to the country as it reaches out to improve healthcare for its people. Voluntary medical organizations no longer need to parachute physically into a country to make a valuable difference. The Internet can put their expertise to use without them leaving their homes.
But revolutions can be painful. True technophobes will find the new era to be tough sledding, because it is in their nature to hate this. The great danger is that the rate of change will push people of good will into the technophobe category. The need for leadership, to ease us through these difficult changes, could not be greater. And that means our leaders have to become more techno-smart.
Put it this way. If telemedicine catches on in a big way, providers who held back will be at a big disadvantage. It is like coming late to a dance – all the partners will be taken. That will reflect on a locale’s ability to attract new business, and on provider organizations’ ability to keep pace with the latest developments. Technology is a little like what you tell patients in rehab: use it or lose it.
Today rural America is in the awkward position of having been the root cause of our greatness as a society, yet we run the very real risk of depopulation and decay. And once we start down that slippery slope, it’s really bad news, whether you’re in Willmar or Crane Lake. Why would a talented young medical school graduate relocate from a city to a town? How do you recruit good people? How do you keep the people who stayed here alive and well?
These are questions of survival and identity. Technology can be a paradigm-busting part of the solution to this dilemma. If we do this right, the old hub-and-spoke system will disappear. In its place will be a new healthcare system, in which cities like Willmar are world citizens, and the highways out of town fan out in a thousand directions.
I know it’s scary. But it’s also exciting. In any event, it’s inevitable! So I hope you will join me in learning all you can today, from our other great speakers, about what this new world will be like, and what it will mean for our patients and communities.