Is the CTIA highjacking mHealth just to appeal for capacity increases?

The problem about spectrum is we’re talking about extremely intensive applications, bandwidth intensive applications, that require a lot of data. Spectrum is a finite resource we only have so much of it we can’t provision more of it and spectrum is available we think there is some really good opportunities to expand what is available to the carriers. But we have to have spectrum we have to have the air. You can look at it like highway think of it in those terms. we have highways in this country and it has a number of lanes and that will handle a certain amount of traffic. With spectrum that is our model those are our lanes and we know we have a lot more traffic coming than we currently have

John Walls, CTIA Vice President of Public Affairs, explaining to policymakers how “mHealth solutions are often bandwidth-intensive applications that need more spectrum” and how “the rapidly dwindling supply of spectrum threatens to hinder or even prevent access to medical care communication” at the “Mobile Health: Innovations in Care & the Spectrum Challenge” that took place this week in Washington DC.

I think this is a wildly inaccurate representation of the facts and highlights a naive approach to understanding the real needs:

1) “we’re talking about extremely intensive applications, bandwidth intensive applications, that require a lot of data

I’m not convinced that this is what mHealth represents and I think it could be counterproductive for the mHealth industry to be suggesting this. I think through design that incorporates foresight it can be an opportunity to manage network demand increase the variety of user profiles that will help telcos manage data volumes.

Of course there are plenty of technologists who evangelise dreamily about mHealth devices that can continuously upload vast quantities of bio data but the reality is very different. I think the step change is going to become more obvious in the very near future when we all wake up and realise patients already have smartphones and with that reliable computational processing and data storage power in their pockets.

2) “Spectrum is a finite resource we only have so much of it

This is untrue and I’m surprised that the CTIA is propelling this myth. Refarming of 2G for 3G has shown us that 3 into 1 does go. Likewise the cell tower caching tech that is being rolled out across the UK by IBM is clearly showing that networks can be much better optimised.

3) “we think there is some really good opportunities to expand what is available to the carriers

I agree completely with this and welcome it thoroughly but let’s me straight about why the industry needs spectrum – we don’t need to be pulling the wool over peoples eyes or confusing others by trying to make up a story that there is some mHealth bottle neck that’s going to jeopardise the health of patients.

4) “You can look at it like highway think of it in those terms. We have highways in this country and it has a number of lanes and that will handle a certain amount of traffic. With spectrum that is our model those are our lanes and we know we have a lot more traffic coming than we currently have

I think this straw man highlights the quality of the case being put forward by the CTIA here. We all know there are a range of ways of getting from A to B and the same goes for connecting devices. One look at the download stats for the UK and it’s obvious that the majority of backhaul to mobile cell towers is needless eg. IBM engineers are reporting massive end user network speed improvements and 70% less backhaul to cell towers that they have updated with local storage capacity.

Opportunity:

I’m surprised that the CTIA isn’t being a bit smarter and playing to their technological strengths. Long criticised for attempts to segregate access and threaten the principles of net neutrality I’m surprised their members aren’t jumping at the chance to leverage mHealth to differentiate their data pipes. With healthcare uses they have this opportunity because it’s one of the very few areas that the public wouldn’t want to demand net neutrality (would anyone really argue that they have some protected right to share a Blueray movie via BitTorrent while an emergency ambulance struggles to stay connected?)

What could the CTIA do to help mHealth adoption and improve the interests of their members?

I think this should start with educating their member organisations on the opportunities for the mobile industry to differentiate itself:

Increasing adoption of mobile and mobile data services amongst seniors. Compared with other developed countries US seniors have some of the lowest mobile adoption levels in the world.

Offering ABC (Always Best Connected) priority connection options could kick start a lot of network innovations. I’m at a loss as to why this golden opportunity is being ignored by carriers but if I was with a US network I’d start by making this available to emergency personnel. Even in modern cities here in Europe we’ve got ambulance and police services misled into thinking they need to have their own expensive networks and we’ve heard of such poor decisions being made across the USA too.

mHealth provides an enormous opportunity to fix the problems with US network capacity. With mHealth comes a need for reliable mobile connectivity options and there are countless ways that mHealth could be used eg. to drive more distributed demand on networks (night time data uploads etc) or as a trojan horse to drive wider consumer appetite for femtocells. Not only would femtocells in the homes of patients effectively add lanes to the highways that John Walls refers to but they’d also help take data off the wireless infrastructure – with the added benefit of avoiding the CTIA member organisations having to spend on the normal planning, site rental etc costs that normally accompany the deployment of more cell towers.

UPDATE: 1 AUGUST 2011

Great to see that the CTIA are sharing John’s talk on YouTube:

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13 Responses to Is the CTIA highjacking mHealth just to appeal for capacity increases?

  1. NETWORK RELIABILITY is a far bigger issue. Calls that are dropped or don’t connect can be life threatening if the call includes a medical sensor alert. The remote monitoring service, physician, or family caretaker may never be notified that vital signs just varied from norms or that a fall or other incident occurred.

    NETWORK CAPACITY directly affects few mHealth apps, such as a teleconference with patient and doc, but capacity constraints can affect other apps without giving certain packets higher priority. The medical alert, for example, is potentially lifesaving but may only need to send 100 characters. Someone’s streaming video may be worth only $2 but can consume gigabytes. The priorities seem out of whack.

    As low-value apps consume more bandwidth and leave less for higher-value apps, network capacity does become an issue, but it’s NOT because mHealth is the culprit. It’s the victim.

    Because I have an Apple iPhone, I use AT&T. Verizon signals don’t reach my neighborhood. I also use AT&T uVerse at home for Internet & TV. Verizon does not offer its FiOS fiber-to-the-home service in my town, because they’ve agreed not to directly compete against AT&T (an antitrust issue).

    I’ve complained to AT&T about spotty cellular service that would drift from 5-bars to 1- or 0-bars and drop calls, so much so that they gave me a Microcell device that connects to my Internet connection and acts as an in-home cell tower. Now I get more bars, but I still drop calls because of problems deeper in the network.

    Until those Network Reliability problems are addressed, mHealth will deliver catch-as-catch-can benefits at best and give false security that threatens lives at worst.

  2. Hi Wayne,

    Thanks for your thoughtful comments.

    NETWORK RELIABILITY is a far bigger issue. Calls that are dropped or don’t connect can be life threatening if the call includes a medical sensor alert. The remote monitoring service, physician, or family caretaker may never be notified that vital signs just varied from norms or that a fall or other incident occurred

    What’s the alternative? Are you aware that there are ways to design services so that they can monitor for network failure?

    When properly designed remote monitoring services can eliminate the need for a notification to be sent. A good example of this can be found with the SeNCit device. The key thing I think more people need to recognise is that the devices may be dumb but the services that leverage them can be as intelligent as you want them to be.

    In our use of the SeNCit device for example we have it set to signalling status notificiations at set times so that the service provider is always aware that the home has power, is warm, the owner is active. In the event of network failure we have notifications and other ways to automatically check on patient health status eg. SMS, calls to the patient/carers.

    “NETWORK CAPACITY directly affects few mHealth apps, such as a teleconference with patient and doc, but capacity constraints can affect other apps without giving certain packets higher priority”

    As the founder of a company that connects patients via mobile video calls with remote Doctors I think it’s worth me clarifying that this is a common red herring. Capacity constraints have never affected our use of video calling and even if they did we always have the fail-safe of using a voice call for the consultation.

    “Until those Network Reliability problems are addressed, mHealth will deliver catch-as-catch-can benefits at best and give false security that threatens lives at worst”

    Not sure about your particular network experiences but the idea of “false security that threatens lives at worst” is more often than not a myth. Whats the alternative? Does it threaten lives to offer 911 services?

    Well I suppose it does if there’s no one there to answer the calls or the training and emergency response teams are so ineffective that patients would be better off driving themselves to the hospital.

    But there is a massively neglected mHealth opportunity in the millions of emergency service operator calls today that don’t require any more network reliability than we already have. I mention some of these in this post where I also point out it’s just inertia that’s preventing this move.

    It’s not a fear of there being “false security” that prevents the move to informed calls (ie where the operator can securely access your medical data using caller ID profiles etc) but it’s a fear of innovation amongst providers who wrongly think that it will adversely affect their liability because once they have this information they may become responsible for using it properly.

    If that was the case they might as well cut all risks and just not bother answering any calls!

  3. David,

    Thanks for your quick response. Often short online exchanges don’t allow for the same understanding as phone, video or in-person meetings, and I didn’t completely express myself in the space used.

    RELIABILITY – Yes, I’m aware of design methods to circumvent the problem, but they’re not often used. Home security is an example: burglars can simply cut the home’s phone cord before breaking in to prevent alerts from going out. Yes, designers can design in cellular backups or use polling schemes like you described, but they cost more and are rarely used.

    REGULATION – I think the medical alert reliability issue needs to be part of FDA & FCC discussions of how to regulate mobile/consumer medical devices, noting that the FDA is seeking public comment on its proposed approach. While I generally don’t like regulation, especially if it stifles or slows innovation, if device manufacturers and service providers don’t include the sort of safeguards you described on their own, then regulation may be required.

    CAPACITY – This is a complicated issue that includes the Net Neutrality debate. My AT&T uVerse system with in-home microcell “should” be make for rock-solid phone calls, but even on voice calls, I’m told that my voice drops out for 10-30 seconds or more several times during a call – an issue that I’m about to escalate with AT&T. uVerse was designed to simultaneously stream and record 4 HDTV programs while also providing Internet and phone access, but my problems occur when only streaming one show or none at all, so the capacity issue is somehow embedded deeper in the network.

    FALSE SECURITY – This too may eventually get back to a regulatory issue, much like e-911 calling did with VoIP services. The issue then was that people’s expectations didn’t match what was delivered by services that couldn’t report the calling location. I like how 3G Doctor carefully positions itself as NOT replacing primary care. It’s kind of like a hierarchy of benefits and cost where simple door and window locks provide basic home security, but security systems, remote monitoring, and surveillance improve security at additional cost.

    PUBLIC EDUCATION – I enjoyed reading through some of your blog entries and especially liked the thinking behind products featured in your BIO video which stressed (1) simplicity, (2) authentication, and (3) education. At some point, I may ask permission to republish an article or two, with full attribution and link-back, of course.

    MODERN HEALTH TALK – I’ll be adding mHealthInsight.com to my Links list and encourage you to check out mHealthTalk.com. It’s a new online community with a similar objective but different primary audience: baby boomers sandwiched between caring for their adult children and elderly parents while worrying about their own health.

  4. Hi Wayne,

    I think you’ve misinterpreted what’s happening here.

    “Each of these health-related applications generally depends upon the timely exchange of information and could be jeopardized by wireless data gridlock, a critical problem that can only be solved by providing additional spectrum for broadband”

    Once you accept that it is almost inevitable that networks will be congested (once you make more capacity invariably there will be customers wanting to use it to up/download more high definition movies etc) it becomes obvious that the objective for carriers should be directed towards being smarter.

    There are smarter cell networks that are already deployed today that avoid the issues you point to eg. by caching locally they reduce celltower backhaul requirements by as much as 80%, throttling certain users (widely seen when it reduces the QOS of VOIP services etc), etc, etc

    I also think you’ve misunderstood the capacity needs of mHealth:

    Are you aware that a smartphone connected medical device does not need to always connect to work eg. data can be processed on the mobile device?

    Are you aware that a low power bluetooth glucose meter or spirometer uses less network capacity than a single SMS?

  5. I don’t think I misrepresented anything. I just reported on my own real-world experience with AT&T, using some of their latest microcell technology. Even though I live in a suburban environment where one would expect better service, I had an even worse experience with Sprint. I can’t speak personally about Verizon or others that “avoid the issues I point to”, as you put it.

    While serving as a volunteer member of the FCC Consumer Advisory Committee and flying to Washington several times a year on my own dime, I repeatedly called for rule changes to hold network operators to promised service level agreements. I argued that that consumers should be able to cancel service with no penalty if QOS degrades due to operator choices such as adjusting cell antennas to direct more energy to new and more profitable customers at the expense existing and less profitable ones. BTW, I served on three working groups: Advanced Technology, National Security, and Rural & Underserved Communities. So I take offense to your claim that I’ve “misunderstood the capacity needs of mHealth.”

    I do know it’s possible to design systems to circumvent the reliability issues that I raised, but doing so adds costs and makes me worry about setting proper public expectations and whether regulatory oversight is needed.

    Apparently, this blog response/reply format is not the best way to effectively communicate, since my thoughts don’t seem to be coming across as intended and are being misread. I suggest continuing by phone if you’re interested. Otherwise I’ll just drop it here with this rebuttal.

  6. Pingback: High Fiber and the Future of the Internet (and mHealth) | Modern Health Talk

  7. Hi Wayne,

    “Apparently, this blog response/reply format is not the best way to effectively communicate, since my thoughts don’t seem to be coming across as intended and are being misread. I suggest continuing by phone if you’re interested. Otherwise I’ll just drop it here with this rebuttal”

    Whilst a 1-2-1 might be a little easier for us I’d encourage you to openly share your opinions where you can and I thank you for adding to the debate.

    All too often the work of regulators goes without challenge because those who are informed have vested business interests and can’t/don’t want to rock the boat.

    I value your opinions, the opportunity they offer to help me reassess my own views and I trust that readers will form and add their own opinions where we’re not in complete agreement. Right now there are no right or wrong answer but let’s hope that we encourage decisions to be made that are in the best interests of patients ok?

    “I don’t think I misrepresented anything. I just reported on my own real-world experience with AT&T, using some of their latest microcell technology. Even though I live in a suburban environment where one would expect better service, I had an even worse experience with Sprint. I can’t speak personally about Verizon or others”

    To be more specific the mHealth use case example you led your post with (medical workers can now utilize a high-magnification microscope attachment (the “CellScope”) for cell phones to take images for analysis. This device takes pictures at up to 50x magnification, enough to see red blood cells and the parasite that causes malaria). Maybe I lack your confidence in the future role of microscopy but what’s the chance of a healthcare worker in a suburban environment like yours finding this to be the best use of resources?

    A better example might be healthcare worker resources (eg. mobile medical libraries such as Dr Companion) or educational/training videos. The advantage here is that these applications can be used in areas where there is no cell coverage. Yet it’s interesting to point out that the driver for this design feature hasn’t been regulation but customer user experience (eg. Healthcare workers using these tools want to be able to use them everywhere with no latency, healthcare providers want this video content to be loaded onto patients mobiles before they leave the clinic).

    “While serving as a volunteer member of the FCC Consumer Advisory Committee… …I repeatedly called for rule changes to hold network operators to promised service level agreements. I argued that that consumers should be able to cancel service with no penalty if QOS degrades due to operator choices…”

    I think you’ve given here an excellent example of how the absence of regulatory red tape can drive mHealth forward much more effectively than adding more. I think that you’d have found in your own experience with AT&T that there would be much more focus on maintaining you as a customer had you the ability to cancel and choose another provider.

    “I do know it’s possible to design systems to circumvent the reliability issues that I raised, but doing so adds costs and makes me worry about setting proper public expectations and whether regulatory oversight is needed”

    Let’s consider your experience with AT&T here:

    Would it have cost more for the provider to provide you with the advertised service: yes

    Is it fair that you’re lumped with a service that doesn’t meet with your expectations: no

    Would regulatory oversight help address your problem: probably not because the telcos are working together with the regulators and turkeys don’t vote for Christmas.

    Would a 30 day lemon law that allowed you to cancel a service with no penalty help: you bet – providers would feel the financial impact of churn and be forced to do something about it.

    To thrive does mHealth need regulation or good ole consumer rights: I’m with patients and providers on this one 😉

  8. ???“CellScope”??? Where did this come from?

    I started out by saying NETWORK RELIABILITY is a bigger issue than CAPACITY, and I described using a “MICROCELL,” not a “CellScope,” which you described as a high-magnification microscope attachment for cell phones that can take pictures at up to 50x magnification, enough to see red blood cells. I’ve never even heard of a CellScope, so apparently one of us was talking about Oranges while the other was thinking Lemons. Maybe that’s why you proceeded to disagree with almost most everything I said and implied that I didn’t know what I was talking about. It may also be because we come from different industry perspectives using different terminology.

    BTW, a microcell, at least in the context I described it, is a low power cellular phone base station (tower), covering a limited area such as a mall, a hotel, a metal factory building, or (in my case) a home. It was supposed to solve the problem I was having with low signal strength from existing cell towers, which caused me to drop calls. AT&T describes the device as a “microcell”, but the industry calls it a “picocell” since it covers a much smaller area.

  9. Hi Wayne (mHealthTalk.com),

    You referred to “cellscope” in the article titled “Need More Wireless Spectrum for Telehealth Innovation” in your blog so I presume you’ve either forgotten writing it, someone else has written it or you cut and pasted it from somewhere without reading it through.

    I’m not sure but here’s the link to your article:

    http://www.mhealthtalk.com/2011/06/promoting-more-wireless-spectrum-for-innovation-in-telehealth/

    And here’s a cut and paste of the full text of the article (I’ve made bold the bit referring to the cellscope):

    Need More Wireless Spectrum for Telehealth Innovation
    06/20/2011

    The lack of good cellular connections threatens the future of mobile healthcare solutions. I once got 5 bars on a regular basis, but the wireless signal in my neighborhood has diminished to the point that I’m lucky to get one bar or any connection at all. I took my problem to the AT&T store and showed them a picture of me outside, outside in my PJs standing under an umbrella in the rain to get enough signal to make a call. The headphones I wore prevented my head from blocking the signals, and the phone itself was dangling from a tree branch so my hands weren’t touching the phone. AT&T finally relented and gave me a micro-cell device to connect to my broadband connection and act like a mini cell tower for my home. Now I get 5 bars again. Do you still get 5 bars? Consistently?

    Rising demand for wireless broadband Internet access has created a spectrum crisis that jeopardizes economic productivity, job growth, innovation, and societal gains. Cellular networks once dedicated to voice calls are now used for streaming music, downloading apps, and sharing photos and videos. Mobile data access is consuming much more bandwidth than voice calls and taxing network capacity. We need a national imperative to allocate additional spectrum for wireless broadband, because it will produce numerous economic and societal benefits. Failure to do that could result in wireless data gridlock.

    This was the message in Broadband Spectrum: The Engine for Innovation, Job Growth, and Advancement of Social Priorities, a policy paper by the Telecommunications Industry Association TIA. As a broadband and wireless evangelist myself, I highly endorse the paper’s recommendations and include the healthcare portion below.

    MOBILE HEALTHCARE

    Wireless technology has improved healthcare management in the United States.

    First, wireless devices have expanded the availability of medical services into previously unserved areas. Physicians can utilize mobile tablets to access patient data wirelessly, in real-time from a portable medical chart. Similarly, medical workers can now utilize a high-magnification microscope attachment (the “CellScope”) for cell phones to take images for analysis. This device takes pictures at up to 50x magnification, enough to see red blood cells and the parasite that causes malaria. Newer versions of the scope will diagnose tuberculosis, skin conditions, dangerous insect bites and abnormal mole growth.

    Second, wireless technology has empowered patients to monitor their health. Examples of such healthcare improvements include:

    Glucose Meters: These meters transmit daily glucose readings to a patient’s caregiver and relays daily coaching to the patient.
    Monitoring Asthma: A wireless peak flow meter for asthma combines monitoring technology with wireless communications. Physicians can be alerted when a patient falls below respiratory flow safe levels or when a patient stops testing.
    Medicine Compliance: Programs can remind patients by email or text to take medicines and conduct remote monitoring. Voice-interactive systems can also ask questions key to treatment and deliver the answers to a care provider.
    Third, wireless technologies can be used to protect the public from epidemics and to monitor for chemical and biological agents. The Center for Disease Control is using emerging mobile technologies to increase the dissemination and potential impact of CDC’s information and tailoring specific health messages to meet unique challenges, such as the response to H1N1 and natural disasters such as hurricanes. New technology also will permit wireless devices to “sniff” for chemical or biological agents in the air and alert homeland security and medical officials before patients become symptomatic from exposure. Each of these health-related applications generally depends upon the timely exchange of information and could be jeopardized by wireless data gridlock, a critical problem that can only be solved by providing additional spectrum for broadband

  10. PS I’m familiar with microcells and their use (they’re quite widespread here in Ireland eg. Vodafone Sure Signal).

    Again there seems to be some crossed wires though because in the article you have commented on I have referred to them as Femtocells and refer to the opportunity they provide to fix the problems with US network capacity (which is of course closely related to reliability).

  11. I’m wasting my time here. Brick Wall.

  12. Pingback: UK’s first 4G network asks “what mHealth services would 4G enable that are not practical now?” « mHealth Insight: the blog of 3G Doctor

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