SANDY AND DAVE'S REPORT ON THE BROADBAND HOME (tm)
Provided by: System Dynamics Inc.
The December 13, 2009 Issue:
Sandy Teger and Dave Waks publish this free newsletter as our
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In this issue:
- Heard on the Net: People, Companies and Trends in the BBH industry
- Briefly Noted: Updates, Observations and Trends
- TelcoTV 2009 -- The Changing Face of TV
- Deja Vu All Over Again
- Partners' Connected Health Symposium 2009 -- Moving To the Mainstream
- Upcoming Conferences
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Heard on the Net
----------------
News about People and Companies Influencing The Broadband Home
People News
-----------
Steve Craddock has become EVP and CTO at PCT International. Craddock was
previously in the Office of the CTO for Comcast Corporation. (
http://www.pctinternational.com )
Andreas (Andy) Melder has joined Gigle Networks as VP Business
Development, concurrent with the company changing its name from Gigle
Semiconductor. Andy has extensive experience in home networking, having
previously been with Intellon and Staccato.(
http://www.giglenetworks.com )
Company News
------------
Investments
Arteris has raised the first tranche of a strategic investment round
totaling $9.7 million from a group of investors led by Qualcomm
Incorporated and including ARM. ( http://www.arteris.com )
Clearwire Corporation is raising more than $1.5 billion in new
investment capital in exchange for newly issued shares priced at $7.33
per share. The sources of new financing and their approximate
contributions include: Sprint Nextel with $1.176 billion; Comcast with
$196 million; Time Warner Cable $103 million; Intel $50 million; Eagle
River $20 million; and Bright House Networks $19 million. (
http://www.clearwire.com )
WiMAX provider DigitalBridge has raised undisclosed financing from new
and existing investors. ( http://www.digitalbridge.com )
IPWireless Inc., a ten-year-old mobile broadband technology company, has
raised a $15.5 million Series A round. It has gone through previous
funding and acquisition but is now being run by some of the original
founders. ( http://www.ipwireless.com )
picoChip has completed a $20 million funding round. (
http://www.picochip.com )
Sezmi has announced $25 million in additional financing. (
http://www.sezmi.com )
Verizon Wireless is leading a new effort called the 4G Venture Forum
(http://www.lte.vzw.com/4GVentureForum/tabid/6217/Default.aspx) in which
venture capital firms will invest as much as $1.3 billion to identify
and commercialize next-generation 4G-related technologies (Long Term
Evolution, or LTE). ( http://www.verizonwireless.com )
Xirrus which makes Wi-Fi systems for use inside buildings, said it is
finished with fund-raising after bringing in an additional $20 million
from inside investors. ( http://xirrus.com )
Acquisitions
Comcast and GE are forming a content joint venture initially owned 51%
by Comcast and 49% by GE. GE is contributing its interest in NBC
Universal to the new JV and Comcast will contribute its cable channels,
regional sports networks and two Internet assets. Comcast will pay GE
approximately $6.5 billion. ( http://www.comcast.com ) (
http://www.ge.com ) ( http://www.nbcuni.com )
Google is buying mobile advertising network specialist AdMob in an
all-stock deal valued at $750 million. ( http://www.google.com ) (
http://www.admob.com )
Kudelski Group said it has completed a tender offer to acquire 60
percent of OpenTV. Added to its current ownings, Kudelski will have 91
percent of the voting rights in OpenTV. ( http://www.kudelski.com ) (
http://www.opentv.com )
Liberty Global is acquiring Unitymedia GmbH, Germany’s second-largest
cable operator for an equity purchase price of €2.0 billion ($3.0
billion). ( http://www.lgi.com ) ( http://www.unitymedia.de )
Motorola has signed a definitive agreement to acquire BitBand, a
provider of content management and delivery systems for IPTV video on
demand. ( http://www.motorola.com ) ( http://www.bitband.com )
NetStreams has been acquired by ClearOne for an undisclosed amount. (
http://www.netstreams.com ) ( http://www.clearone.com )
Other News
----------
Broadcom announced a new set-top box system-on-a-chip solution enabling
interactive HDTV, connectivity, whole-home media distribution and
advanced 3D user interfaces. ( http://www.broadcom.com )
A new initiative called One Voice, formed by 12 mobile operators, has
agreed to use a profile based on IMS (IP Multimedia Subsystem) for
offering SMS (Short Message Service) and voice services over
next-generation mobile network technology LTE.
TiVo and Virgin Media have entered into a mutually exclusive agreement
under which TiVo will develop a converged TV and broadband interactive
interface to power Virgin Media's next-generation HD set tops. Virgin
Media will be the exclusive distributor of TiVo services and technology
in the UK. ( http://www.tivo.com ) ( http://www.virginmedia.com )
Standards and Organizations
---------------------------
The 1394 Trade Association is formally assuming the assets of the High
Definition Audio-Video Network Alliance (HANA) effective immediately. (
http://www.1394ta.org )
The 3D@Home Consortium released two documents, ST4-01 3D Glossary and
ST4-02 3D Technology Family Tree Poster, aimed at defining and
documenting emerging technologies that enable 3D to the home. (
http://www.3dathome.org )
HomeGrid Forum announced that the ITU-T G.hn workgroup completed its
definition of a "low complexity" profile targeted at Smart Grid
applications. ( http://www.homegridforum.org ) (
http://www.itu.int/ITU-T/index.html )
Countries
---------
U.S.
The US Federal Communications Commission (FCC) initiated a Notice of
Proposed Rulemaking regarding so-called "net neutrality," aimed at
prohibiting discrimination against certain Internet traffic. Comments
are due January 14, 2010 and reply comments are due March 5, 2010. (
http://www.fcc.gov )
Under newly-developed California smart grid legislation
(http://info.sen.ca.gov/pub/09-10/bill/sen/sb_0001-0050/sb_17_bill_20091011_chaptered.html)
(Senate Bill 17) the California Public Utilities Commission (CPUC) is
required to outline a specific smart grid deployment plan by July 2010.
Additionally, all electric utilities with over 100,000 customers must
submit a smart grid strategy plan by July 1, 2011.
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Briefly Noted: Updates, Observations and Trends
-----------------------------------------------
Briefly Noted
--------------------
Each month, we collect miscellaneous happenings, studies, trends or
observations you might have missed. This month's briefs focus on market
forecasts, interactive TV in the UK, 4G patent holders and more.
Fixed and Mobile Subscribers Market Forecast
Infonetics Research released the highlights from its new Fixed and
Mobile Subscribers market forecast report, showing that:
- There were nearly 4 times more mobile subscribers than access line
subscribers worldwide in 2008 (3.9 billion vs. 1 billion)
- The number of mobile subscribers grew 17.4% in 2008 over 2007, while
access line subscribers declined 5.5%. Access lines are disappearing
fastest in North America and China.
- The number of worldwide mobile subscribers will reach 5.9 billion by
2013
- The number of PON FTTH subscribers worldwide is expected to increase
at a compound annual growth rate of 32% from 2008 to 2013.
( http://www.infonetics.com )
Interactive TV in the UK
We've always thought of the UK as the home of "red button" interactive
services, so the results of a recent survey were quite a surprise.
According to a survey by Opinium Research for Moneysupermarket.com
(http://www.moneysupermarket.com/newsandcommunity/press-releases/red-button-world-passes-by-20-million-brits_0007336%20.aspx)
, 45% of UK adults (20m) have never used interactive TV, of which 19%
(9m) cited a fear of costs as their reason. 13% of UK viewers claimed to
have no idea of what the Red button Service offers. On the flip side, of
those currently using the service, 28 percent claimed it was one of the
best TV innovations ever.
GSA Statistics
The Global Mobile Suppliers Association reports that LTE (mobile 4G)
network commitments are growing rapidly. The report
(http://www.gsacom.com/downloads/pdf/lte_3gpp.php4) indicates that there
are 51 LTE network commitments in 24 countries, up to 19 LTE networks
will be in service by yearend 2010, and up to 36 LTE networks should be
in service by yearend 2012. ( http://www.gsacom.com )
U.S. Broadband Status
The FCC requested two independent studies as part of their development
of the National Broadband Plan. Drafts of the Berkman
(http://www.fcc.gov/stage/pdf/Berkman_Center_Broadband_Study_13Oct09.pdf)
and CITI (http://www.broadband.gov/docs/Broadband_in_America.pdf)
studies have been released and placed on Public Notice.
4G Patent Holders
ABI Research's analysis of 4G patent holders concluded that Qualcomm
appears to be the current leading patent holder in 4G wireless
communications. Other notable players include Interdigital, Huawei, LG,
Nokia and Samsung. ( http://www.abiresearch.com ) (
http://www.qualcomm.com )
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TelcoTV 2009 -- The Changing Face of TV
---------------------------------------
In November we took time out from our vacation in southwest Florida to
attend the TelcoTV Conference
(http://www.lightreading.com/live/event_information.asp?event_id=29081)
in Orlando. TelcoTV is a good place to get a feel for the evolution of
IPTV and the evolving aspirations of telcos large and small.
This year, we came away with a better understanding of their aspirations
to "lock in" the customer to their full range of triple- and
quadruple-play services. We also learned about the rapid evolution of 3D
TV, the expanding role of the Broadband Forum, and one approach to
providing an easy-to-navigate guide to the rapidly expanding content on
the TV set.
Owning the Customer
-------------------
The TelcoTV Conference is a fascinating mix of giant players like AT&T
and little guys like Nsight. Close your eyes during their talks and
you'd expect to tell which one is speaking.
We'll paraphrase a vision from one of them: "We'll be offering both TV
services and 3G. .... We want to provide a femtocell in the home, so
when you come home from work it recognizes your presence. Your phone
interface changes to your in-home view and the movie you selected to
download to your phone loads over your home Wi-Fi."
We were startled that this vision came from Rob Riordan, EVP and
Director of Corporate Development of Nsight, rather than a company like
AT&T. Riordan made clear that he is a fan of providing complete
solutions to customers--he said the goal was to "make it very simple and
impossible to leave." Holding up his iPhone, he said admiringly "They
own me." He was frank in aspiring to have Nsight do the same.
By contrast, the message from Jeff Weber, VP Video Services, AT&T, was
TV-centric. He emphasized that "Everything starts with TV" and "You have
to be great in TV". Weber talked about U-verse's capability to record 4
streams of video and provide total home DVR. He also mentioned being
able to schedule your DVR from your phone or PC and that DVR is included
without extra charge in most packages.
The "Any" Theme
Weber also had a "futures" story about "U-verse Everywhere"--AT&T
customers will be able to consume and control content on any screen and
see related content on any device. Weber believes U-verse is a powerful
platform for integrated IP services--75% of U-verse subscribers already
have a triple-or quad-play package.
The "any" theme was repeated in several talks and portrayed in many
booths.
Brook Longdon, Head of Global Home Entertainment of Nokia Siemens
Networks spoke in terms of an expanded user experience anytime,
anywhere, on any device. He distinguished between:
- Service Convergence: Same services from different sources on
different devices (any content, any device)
- Service Portability: Same services on multiple devices within home
network, and
Service Mobility: Same services on multiple devices outside home network
(any device, anywhere).
- Session Continuity: You can watch a movie in your house on the TV via
IPTV and pick up where you left off on your mobile phone as you leave
the house. This implies a common subscription in the set-top box and
mobile phone worlds.
All of the above seems premised on the assumption that you have one
service provider for your mobile, TV, phone and Internet services.
TV Everywhere -- The Entitlement Enablers
"TV Everywhere" is all about keeping the value in valuable content.
Today, video subscribers pay for content, but can consume it only on
their TVs in their homes (unless they have a Slingbox type device). With
TV Everywhere, video subscribers would be able to access their content
not only on the TV in their home, but also over the Internet and via
their mobile phones. Underlying the ability to get protected content to
authorized users are a wide variety of "entitlement enablers".
Jim Brandt, Director TV/Video at Synacor and Chris Drake, Senior
Director of Business Development, thePlatform, spoke about the mechanics
of entitlement. Several steps are involved, including securely
identifying a user (authentication), mapping the user to what they have
access to (authorization), and applying existing policies to these new
access rights (entitlement). Ideally this will involve a common and
consistent user experience across devices.
Myriad issues arise when attempting to implement TV Everywhere. These
include working out licensing deals between service providers, content
owners and other rights holders; increased IP video traffic on broadband
service providers' networks; and the implications of potential FCC net
neutrality rules on the types of deals that video service providers can
make with content providers.
Other questions include whether DVR functionality is feasible on any
device; whether content is streamed, downloaded, or both; what user
intervention is required for authentication and authorization. Content
presentation and audio quality need to be adapted to match the
capabilities of the end devices and preserve the best end-user
experience.
Last, but far from least, is the issue of audience measurement. That
metric drives ratings and therefore advertising revenue. If viewing
shifts from on-air to online without audience measurement metrics, there
will be very negative effects on ad revenue.
Service providers are starting to roll out beta versions of "everywhere"
offerings. A few weeks ago Rogers Communications announced the beta
release of Rogers On Demand Online. Any customer with a Rogers account
can visit rogersondemand.com and register to experience Rogers On Demand
Online content free from any streaming Internet connection within
Canada.
MSOs are vocal about their support for TV Everywhere, so we hope they
have solutions to the many issues the service raises.
3D TV
-----
TelcoTV included a session and several exhibits on 3D TV. The upcoming
release of James Cameron's Avatar will be a big deal in focusing
attention on this emerging content form.
News releases about 3D come with increasing frequency--for example:
- Up to 25 of the 2010 FIFA World Cup matches in South Africa will be
produced in 3D.
- Reliance Mediaworks has partnered with In-Three Inc. to set up the
world’s largest 2D to 3D conversion facility in India. The project
will start in February 2010.
- LG Display has begun mass production on their Full HD 3D LCD monitor,
a 23-inch display with 1080p resolution, with an initial focus on
video games.
- Sony will add 3D capability to its PS3 gaming console via a future
firmware update
- BSkyB has promised to launch a channel devoted to 3D content next
year
- HDlogix had the first public demonstration of their real-time
conversion of 2D HD video into 3D this weekend; it will be on view at
CES.
Judging from some sessions at Telco TV, lots of issues remain to be
resolved. Standards are a key piece of this:
- Will the glasses ("eyewear") be "passive polarized" or "active
shutter"?
- Is the transmission format one that combines the left and right eye
images side by side in a single interlaced frame, or a sequential
display of a full frame image for each eye?
- What format makes the most sense for distribution over existing cable
and IPTV infrastructure? Does it take a lot more bandwidth than
today's HD? Can it be supported by today's set tops?
- Which organization will define the standard(s)? Contenders include
CEA, SMPTE, DVB, CableLabs, Blu-ray Disc Association, 3D@Home
Consortium, etc.
There are also many issues beyond standards:
- What are the impacts of eye-strain and fatigue, as well as possible
unpleasant side effects like nausea?
- Will shows in 3D be interspersed with 2D commercials?
- What is the financial justification for the extra expense involved in
3D?
This year's CES promises to be a banner year for trumpeting 3D TV. There
will be an Experience 3D TechZone and lots more across the show floor,
so we'll watch as this area develops.
The Broadband Forum
-------------------
We met with Laurie Gonzalez, Marketing Director, The Broadband Forum at
Telco TV to learn more about the Forum's activities. The mission of the
Forum is to "develop multi-service broadband packet networking
specifications addressing interoperability, architecture and
management."
Our conversation with Laurie focused on their work to avoid duplication
of efforts. Laurie explained that the former name "DSL Forum" no longer
described their wide scope of activities. Current efforts include
liaison with the Home Gateway Initiative for collaboration on the
development of standards and specifications for broadband networks
worldwide; their working with the Home Grid Forum to develop a
certification program for G.Hn; and their union with the IP/MPLS Forum
to establish a central body for next generation packet network
specifications.
The organization has both technical and marketing initiatives. Laurie's
presence at Telco TV was on behalf of the Broadband Forum's Ambassador
Working Group, which promotes the Forum's objectives through speaking
engagements at industry events.
Orca Interactive: The Guide is King
-----------------------------------
Once upon a time, a printed weekly magazine called "TV Guide" was the
definitive source for information about what content was on what channel
at what time. It was summarized in a series of grids, divided by day,
time and channel. Most on-screen guides -- both simple scrolling guides
and interactive guides -- still follow the old grid model.
Piece by piece, technology has destroyed the underpinnings of that
notion of the guide as sufficient to explore the possibilities of what
you can view. The DVR and "start over" did away with the notion of a
program only being available at a given time. Slingbox undid the notion
of "place". VOD, the Internet and the home server did in the notion of
"channel".
With a plethora of content choices and no more bonds of time, place and
channel, providing a great guide is an area that is open for innovation.
During a visit at TelcoTV with Haggai Barel, CEO of Orca Interactive, we
saw one notion of content discovery that appealed to us. Orca's Compass
guide is designed from the start for converged services.
Haggai described Compass as "a content discovery recommendation
platform." In a world of so much choice and potential confusion, its
purpose is to help you discover what you want to watch. He said the
Compass model has a close affinity to that of Amazon, which remembers
what you have previously bought and looked at. Like Amazon, it allows
you to see other people's opinions and reviews and what people who have
bought a certain item have also purchased.
Haggai said that in most people's minds Orca is closely associated with
its middleware platform, but Compass can be used along with whatever
middleware a service provider is using. Compass is based on Web
technology, rather than being client intensive. Their SDK supports both
HTML and Flash. It is also operable on multiple set-tops and can be
accessed not only on TVs, but also with PCs and mobile phones.
To create its "blended recommendations," Compass assigns different
weights to several different recommendation engines, including: most
popular, what your friends like (social engine), related videos,
operator promotion, your previous viewing patterns and choices, and
extensive search functions. The service provider can set the weights to
create the blend of various engines. The operator is provided with
analytics to decide what the appropriate weights are for their
objectives.
Portions of Orca's technology are based on the work of the Israeli next
generation personalized video services consortium, called Negev. We
liked the intuitive and attractive user interface and the idea that you
could find something that truly appealed to YOU with only a few clicks.
(There may have been other innovative guides on display, but did not
come across them at this show.)
OTT -- Over the Top Video
-------------------------
Amino Communications new IPTV set-top boxes were one of the most
interesting items we saw at Telco TV regarding "over the top" (OTT)
video. These boxes, powered by Intel's Atom CE4100 media processor, will
make it simpler for providers to mix and match video from many sources
on the TV screen. Amino said the CE4100 "will enable IPTV STBs to
deliver a full open Internet experience." Amino's new box supports HD
video, home-theater-quality audio and advanced 3-D graphics.
The market for OTT video continues to attract more entrants. Boxee
recently announced a partnership with D-Link to make a settop for
browsing Internet videos on TVs. Others include Roku, which can stream
Netflix, Amazon and MLB video; game consoles like the Xbox 360 and Sony
PlayStation 3; and connected Blu-ray players which can receive Netflix
Instant streaming.
( http://www.att.com ) ( http://www.nsight.com ) (
http://www.nokiasiemensnetworks.com ) ( http://www.synacor.com ) (
http://www.theplatform.com ) ( http://www.rogers.com ) (
http://www.adlabsfilms.com ) ( http://www.in-three.com ) (
http://www.lgphilips-lcd.com ) ( http://www.sony.com ) (
http://www.sky.com ) ( http://www.hdlogix.com ) (
http://www.broadband-forum.org ) ( http://www.homegatewayinitiative.org
) ( http://www.homegridforum.org ) ( http://www.orcainteractive.com ) (
http://www.negev-initiative.org ) ( http://www.aminocom.com ) (
http://www.intel.com ) ( http://www.boxee.tv ) ( http://www.d-link.com )
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Deja Vu All Over Again
----------------------
History keeps trying to teach us lessons, but sometimes we are slow to
grasp them. Speaking at the UBS Annual Conference last week, Ralph de la
Vega, President and CEO, AT&T Mobility and Consumer Markets, said that
"a small number of heavy users are hampering network performance" for
the rest of its customers. ... About 3 percent of [AT&T's] smart phone
customers are driving about 40 percent of the [wireless data] traffic."
He wants to convince those heavy users to reduce their usage
"voluntarily" or he will start charging them more: "Longer term, there's
got to be some sort of pricing scheme that addresses usage"
Where have we heard this before? In 1991, early online services company
Prodigy reportedly discovered that "20 percent of the users were sending
90 percent of the email messages, costing the company millions of
dollars with a mail flow growing 20 percent a month." Prodigy
characterized these heavy users as "abusers" and revised its formerly
unlimited flat-rate pricing: for the $12.95 monthly fee, each household
now got 30 emails per month and was charged 25 cents for each additional
message. The result was probably the first nationwide protest organized
largely online. (Prodigy later abandoned flat-rate pricing in favor of
three options, ranging from $7.95 to $19.95, combining monthly fees and
hourly usage charges.)
Mindful of that lesson, we (Sandy & Dave) spoke about the coming
opportunities for high-speed data services at several conferences in
1996. We pointed to Prodigy's experience and suggested that while
customers prefer flat-rate pricing, a single flat-rate plan would
inevitably lead to "run away" applications with a few users consuming
most of the resources. We suggested tiered pricing alternatives to
accommodate the needs of both light and heavy users.
But marketeers love the simplicity of flat-rate pricing. Our message
went unheeded, and flat-rate pricing became the norm for consumer data
services. Over the years, we have followed the attempts of broadband
service providers--both cable and telco--to recoup the costs for usage
that they view as well beyond the norm. For example, in April, 2009,
Time Warner Cable announced tests of "Consumption Based Billing" in
several markets. This resulted in an uproar that drew the attention of
Congress. Subsequently CEO Glenn Britt put the trials on hold, saying
"we will not proceed with implementation of additional tests until
further consultation with our customers and other interested parties".
The company said it was postponing tiered pricing until it could better
educate customers on the new fee structure.
So here we are once again, this time with AT&T and iPhone flat rates. De
la Vega told his audience that AT&T will address their problems by first
making customers aware of how much wireless data they're consuming and
then charging heavy users more if they don't cut back their usage. It
sounds a lots like what Time Warner decided--first educate users on how
much they are using and then charge the very heavy users if they don't
cut back. It will be interesting to see how customers who were sold
iPhones under the premise of unlimited data usage react to this revised
offer.
So what have we learned from this?
- Customers love flat rates, and flat-rate services are easy to sell.
- If you tell people they can use as much as they want of something, it
is not "abuse" if they take advantage of what you have offered.
- Once you have made an offer to customers and they have accepted it,
don't be surprised if they're outraged when you try to change it to
something less generous.
Why don't we ever learn?
The situation with the cable operators was not so surprising. In their
world, it didn't matter if one person or a million were watching a TV
program. They didn't think in terms of Erlangs -- indeed, most of them
had never heard the word.
But AT&T is steeped in traffic engineering. It's hard to understand how
they fell into this trap. They're likely to find that it's hard to get
out of it.
( http://www.att.com ) ( http://www.timewarnercable.com )
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Partners' Connected Health Symposium 2009 -- Moving To the Mainstream
---------------------------------------------------------------------
We're very glad we got to the Partners' Connected Health Symposium in
late October. Although we've covered connected health since 2003, the
last conference we attended was Healthcare Unbound in July 2007. At that
time, we were disappointed in the lack of progress on significant
implementations. In the two and a half years since, there has been
noticeable progress, including within the U.S. healthcare reform agenda.
Past conferences have focused more heavily on some of the changes that
must happen to the system in order to improve quality while controlling
costs. One example is the need to change the traditional "fee for
service" model into value-based payments. Although suppositions about
necessary changes were part of this year's agenda, we came away feeling
that we are closer to reaching the tipping point in which people will
come to take connected health for granted in the same way that email and
blogs have become part of our social fabric.
Broadband connectivity is pervasive. Most consumers own mobile devices.
Connected health device standards are being set. Certified devices and
services are starting to reach the market, with many more coming. Many
types of health data platforms are available to healthcare practitioners
and consumers.
With the national focus on improving the cost-effectiveness of
healthcare, it's clear that connected health will play a major role.
Some Take-Away "Nuggets"
------------------------
At any conference, there are some quotes that you take away with you.
Before we delve into some areas that deserve more focus, here is a brief
summary of some of these nuggets.
- "Most every powerful constituent group favors health reform, but if
it is not their plan, they prefer the status quo." Stuart Altman,
Professor of National Health Policy, Brandeis University
- "One of a physician's best tools is not a black bag, but a
Blackberry." Congressman Ed Markey
- "Follow the dollar. The debate has never been about healthcare, but
about who pays." James Mongan, CEO Partners HealthCare
- "What is missing is infrastructure to scale these programs." David
Ahern, Clinical Research Psychologist, Brigham & Women's Hospital
(speaking about today's telehealth programs)
- "You'll know when this market has made it when the (connected health)
products are in Best Buy." Laurie Orlov, Founder,
AginginPlaceTech.com
Enabling Everyone to Participate
--------------------------------
Connected Health enables people to become active participants in their
health care. It's important for people recovering from a serious
illness, suffering from a chronic disease, or just interested in
improving wellness. Connected health provides the key tools for both the
patient and healthcare practitioners.
These tools start with simple mechanisms such as email exchanges between
patients and their doctors, and online access to health records and test
results. They progress through home monitoring systems which measure
blood pressure, pulse rate, weight and other vital signs, and upload
them to a system where health professionals can view them. Ultimately
the patient and the professionals become collaborators.
Dr. Joseph Kvedar, Director of the Center for Connected Health at
Partners Healthcare, expressed this progression in his keynote
presentation at the conference. His opening slide titled "Where We’ve
Been And Where We’re Going…" shows four stages. We're currently at
"Clinician and Patient Collaborate and Share Info" and heading towards
"Patient Self-Mgmt...Clinician as Coach...Employer as Enabler".
Tools exist today to enable clinician/patient collaboration. Several
companies offer email systems specifically for doctors, and medical
practices are signing up for these services. As an example, RelayHealth
provides a comprehensive system for medical practices, including email
communications and email-based "Web visits", prescription renewal, lab
results, online personal health records, and more. (Our primary care
physician recently signed up with RelayHealth, and we're now using it
ourselves.) Other companies offer similar systems for group practices
and hospitals.
Standards and Devices
---------------------
The most important change in the past three years has been in
establishing standards for connected medical devices intended for
personal use in the home. When we first started attending these
conferences, every device had a proprietary interface, with the entire
end-to-end system provided by a single company. Many of these products
had price tags of $1000 or more.
Today there are IEEE standards for device communications. Many companies
are developing products to meet the standards. Certification mechanisms
are in place, and the first certified devices are now on the market.
Prices are falling.
Continua Health Alliance and IEEE 11073
The Continua Health Alliance is playing a leading role in driving the
standards. Formed in mid-2006, Continua is an open industry group
comprised of more than 200 companies involved with connected personal
health and fitness products and services. In addition to providing
products and services to healthcare providers and consumers, some
Continua member companies are actively using them with their own
employees.
Continua efforts are focused on three "use cases": Disease Management,
Aging Independently, and Health & Wellness. For each, it envisions
devices in the home communicating with an "Application Hosting Device"
such as a mobile phone or a PC, which can in turn communicate over the
Internet to care givers, healthcare professionals, and services.
Communication standards are required for all these use cases. An IEEE
group P1073 has been working on protocols for interoperable medical
devices for more than 20 years. Its efforts moved into high gear with
the formation of the ISO/IEEE 11073 Personal Health Devices Work Group
in July of 2006 with active participation from Continua members. The
first set of new 11073 standards was published in October 2008, with 24
more under way. These cover many kinds of devices, including
thermometers, scales, pulse oximeters, cardiovascular fitness and
activity monitors, and an "Independent Living Activity Hub."
The 11073 standards form the core of Continua's "Version One Device
Connectivity Standards". The device standards are transport independent;
in Version One, they can communicate with the "Application Hosting
Device" over USB or Bluetooth.
Continua has established a formal certification process. The first
certified device was a Nonin pulse oximeter. Continua has announced five
more certified devices, including a blood pressure monitor, scale, and
blood glucose meter.
Every major medical device maker is a Promoter Member of Continua. All
of these companies prominently displayed the Continua logo in their
booths at the Partners conference. Although few of their devices have
been certified, it's reasonable to expect many more now that
certification is under way.
Connected Health Services
-------------------------
Several companies provide services which accept and store clinical data
from medical devices, and provide analysis and information for patients
and clinicians. The simplest services run on a PC in the home, with data
uploaded from the devices by USB or Bluetooth. An example of these is
the Omron Health Management Software
(http://omronhealthcare.com/product/detail.asp?p=1116&t=186&sf=1) which
works with Omron's USB-enabled HEM-790IT blood pressure monitor and
HJ-720ITC pedometer.
Partners SmartBeat
Partners' Center for Connected Health takes this a step further with its
SmartBeat program. SmartBeat couples remote blood pressure monitoring,
Internet-based feedback, and personalized coaching for hypertension
self-management. After trialing SmartBeat for six months with EMC
Corporation between 2007-2008, Partners launched SmartBeat for its own
employees in Spring 2009. It is now offering it to large employers in
New England.
Personal Health Data Platforms
In addition to platforms like RelayHealth for healthcare providers, and
those such as SmartBeat for employers, several personal health data
platforms are offered directly to consumers. The leaders of three of
these platforms -- WebMD, Microsoft's HealthVault and Google Health --
participated in a panel at the Partners conference. While WebMD is
primarily focused on providing health-related information to patients,
HealthVault and Google Health are focused on collecting and storing
patient data, making it available--with the patient's permission--to
caregivers and healthcare professionals.
HealthVault and Google Health both include tools to maintain an online
personal health record showing conditions, family history,
prescriptions, and the ability to share those with providers.
HealthVault includes logging measurements of blood pressure, weight,
etc. The measurements can be entered manually through a Web interface.
Even better, HealthVault includes the capability to upload measurements
directly from a connected device by installing a PC program called
HealthVault Connection Center. Many connected medical devices are
already supported by HealthVault; some are also Continua certified.
Success Models
A session on behavioral health provided the opportunity to hear about a
success story in using telehealth for mental health in areas such as
post traumatic stress and depression treatment. Dr. Linda Godleski who
is the lead for Telemental Health at the Veteran's Administration spoke
about how they have an extensive program in place for mental health
issues of veterans. Their focus is remote access into the clients'
residence.
One of the key values of the program is privacy--no one except the
client needs to be aware of their use of mental health support. Patients
with certain diagnoses such as schizophrenia seem to prefer to be remote
from the therapist.
The VA has studies that document that this program really works. The
same quality measures are used for teletherapy as for face-to-face. The
VA is now looking at effectiveness measures compared with more
traditional modes of therapy.
Is Disruption Necessary?
In a keynote speech, Dr. Jason Hwang of Innosight Institute summarized
his recent book, The Innovator’s Prescription: A Disruptive Solution for
Health Care, co-authored with Clayton Christensen of Harvard Business
School. The book applies Christensen's well-known "disruptive
technology" model to the healthcare system.
"Disruption is facilitated when historically valuable and expensive
expertise becomes commoditized." In the move to "connected health" new
technologies like expert databases and videoconferencing are a lever
toward that commoditization. The problem is that cramming new
technologies into an old business model is futile.
Huang observed that although most service businesses are decentralized,
the healthcare delivery system is highly centralized around large
general hospitals. He said that the traditional general hospital is not
a viable business model and that decentralizing the system would open
the way for investment in new business propositions.
We saw some signs of this disruption at the conference. Although
Partners Healthcare is the parent of Massachusetts General Hospital and
Brigham and Women's Hospital in Boston, its "connected health"
initiative is encouraging a movement toward a more decentralized
approach, with patients, employees and data platforms all playing a
role.
Another sign of disruption was the introduction of a new medical
publication, the Journal of Participatory Medicine (JoPM). A free online
journal, JoPM says its mission "is to transform the culture of medicine
to be more participatory". Its advisory board includes IT visionaries
such as Esther Dyson, Kevin Kelly of Wired Magazine, and Howard
Rheingold, and its editorial board includes many doctors and healthcare
administrators.
The founders or JoPM believe passionately in patient participation, and
aim to provide the evidence to demonstrate its value to all parties.
They view themselves as disruptors of the traditional "doctor knows
best" approach to medicine.
What About Broadband?
What role does residential broadband play in connected health? In
principle, data can be moved between the home and healthcare platforms
over any type of transport. When we first started attending these
conferences, most medical devices communicated over dial-up modems. Now
high-speed connectivity is taken for granted as one of the key enabling
technologies.
As healthcare delivery systems embrace connected health as a key element
in improving healthcare while managing costs, it will be a major
opportunity for wireless and wireline service providers.
Led by Qualcomm, the wireless industry has long promoted the use of the
cellphone as the primary tool for connecting medical devices to
healthcare platforms. Since many medical devices connect with Bluetooth,
and most patients have cellphones, wireless carriers and their vendors
view it as natural to carry data through the cellphone to the healthcare
platform -- without using PCs and fixed-line broadband links. Wireless
carriers and vendors were very visible at the conference, promoting
their views.
Wireline carriers have started to see the opportunity. Cox
Communications -- the third-largest cable television company in the US
-- recently said that it would be focusing on healthcare opportunities.
Speaking at a recent conference in New York City, Cox Business vice
president Phil Meeks said that Cox already generates nearly $1 billion
selling its services to commercial customers, and expects that to double
within six years. Meeks said Cox sees the healthcare vertical as the
largest component of its future commercial services revenue. He said Cox
would provide services to hospitals, doctor's offices and consumer
homes: “We're creating this ecosystem where we're tying together the
hospital, tying it to the doctor’s office, and tying it to the home."
Influencing Consumer Behavior
One of the most fascinating elements of the Connected Health Conference
was influences on consumer behavior and its relationship to health.
Nicholas Christakis, Professor of Medical Sociology at Harvard Medical
School, gave a talk on "The Spread of Health Phenomena in Social
Networks". Christakis is the co-author (along with James Fowler) of
"Connected: The Surprising Power of our Social Networks and How They
Shape Our Lives."
Based on a variety of scientifically conducted tests and mathematical
analyses of data regarding social connections and other characteristics,
the authors concluded that a key factor in determining our health is the
health and behaviors of not only our partners and friends but also the
health and behavior of people in our extended social network. This theme
was echoed by Dr. Mark Carroll, Director Telehealth Program U.S. Indian
Health Service. He said "The social determinants of health are more
important than your cholesterol level." If you don't believe this, we
suggest you read "Connected".
Two other books that were discussed at the conference bear mentioning
here. The first is "Nudge: Improving Decisions About Health, Wealth, and
Happiness" by Thaler and Sunstein and "Free Market Madness: Why Human
Nature is at Odds with Economics--and Why it Matters" by Peter Ubel.
Although these books are not directly about health care, both bear on
how personal decisions about health care can be influenced toward
harmful or beneficial outcomes. The ideas in "Nudge" are particularly
useful for corporations which are trying to reduce their healthcare
costs by improving the health of their employees.
We give the sponsors and speakers in this symposium an "A" for depth of
content and intellectual stimulation!
For More Information
--------------------
We have been covering connected health for more than six years. We have
visited with companies and attended many conferences (and spoken at a
few). Our Topical Index: Connected Health
(http://www.broadbandhomecentral.com/guide_apps_telesocial.html)
provides access to our articles on connected health standards, devices
and platforms.
- Eric Dishman of Intel was the first to suggest that we pay attention
to connected health. Eric is passionate about the subject, and we
invited him to write a guest article Repurposing Broadband: Home
Health Technologies for the Worldwide Age Wave
(http://www.broadbandhomecentral.com/report/backissues/Report0307_3.html)
(BBHR 7/15/2003).
- In Transforming Disease Care Into Health Care: Can Broadband Help?
(http://www.broadbandhomecentral.com/report/backissues/Report0408_5.html),
we wrote about the Healthcare Unbound conference, where we also
participated in a workshop.
- We first attended the Partners Symposium in October 2005, one month
after Hurricane Katrina devastated New Orleans, and wrote about it in
Hurricanes and Healthcare
(http://www.broadbandhomecentral.com/report/backissues/Report0507_5.html).
- In Healthcare Unbound: A Progress Report
(http://www.broadbandhomecentral.com/report/backissues/Report0705_4.html)
we wrote about the 2007 Healthcare Unbound conference, which included
an introduction to Continua's work on device standards.
( http://www.connected-health.org ) ( http://www.partners.org ) (
http://www.relayhealth.com ) ( http://www.continuaalliance.org ) (
http://www.nonin.com ) ( http://omronhealthcare.com ) (
http://www.va.gov ) ( http://www.innosightinstitute.org ) (
http://www.hbs.edu ) ( http://www.jopm.org ) (
http://www.coxbusiness.com ) ( http://hms.harvard.edu ) (
http://www.intel.com )
---------------------------------------------------------------------------
Upcoming Conferences
--------------------
2010 Consumer Electronics Show
Its almost time to start a new year and that means that the Consumer
Electronics Show (CES), 2010 version, is right around the corner. It
will be held in Las Vegas, NV from January 7-10, 2010. This year 950
technology companies from outside the United States will be among the
more than 2,500 exhibitors. We'll be there, looking at what's noteworthy
and seeing what is in store for the future in areas ranging from 3D TV
to set-top boxes to connected health, smart grid and a host of other
topics we have been following. Please say "Hi!" if you see us there. (
http://www.cesweb.org )
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Sandy Teger and Dave Waks (editor@bb-home.com)
Sandy and Dave's Report on The Broadband Home
(http://BroadbandHomeCentral.com/report)
December 13, 2009
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