 telecom exchange CEO roundtables both for our guests here at telecom exchange NYC and for our viewers who are joining us from RCR TV and JSA TV thank you our third panel today is on the hot topic of telemedicine it's the telemedicine revolution big data IoT and 5G leading the way we are very honored to have Larry Walsh the CEO of the 2112 group a seasoned journalist analyst author an industry commentator Larry is also the founder of Channel Nomics which is a leading provider of IT channel news and analysis a specialist in the development and execution of channel programs disruptive sales models and growth strategies for companies of all sizes from startups to Fortune 500 Larry's worked with a roster of diverse technology players including ingram micro Intel security SAP and Verizon right here on our panel so go ahead and welcome Larry Walsh Larry afternoon everyone I just want to start by talking about why we're having this conversation today and I tend to as Jamie says you know when what my company and I do is strategy we look at the world around us and we try to imagine how to make it different and then try to bring routes to market to it or apply routes to market to it and lately the questions that we've been getting have been around you know how's the world gonna look in the future well it's it's not really a silly question we're already living in it we were just having at the panelists and I were just having a conversation about video phones that were introduced in the 60s that you know didn't really work but now we have them for free when we start talking about telemedicine the conversation gets vastly different and it's not because of the technology it's about demographics so by 2045 we will have worldwide 441 cities with more than a million people in population you know imagine that because it's truly the globe is urbanizing and it's urbanizing rapidly and many of the cities that we're talking about are our urban centers that we've never heard of combine that with what is happening in terms of life expectancy so currently the average life expectancy is 71 years globally if you're lucky enough to live in a more developed country like we are the life expectancy is about 85 now fortunately for women this is a little bit higher you know so you get a little bit of peace from us but it does start to exasperate the health care industry in a health care capacity because with that life expectancy and what's happening simultaneously even though you see these this urbanization this migration towards urban centers we're also seeing a decline in birth rate so most of the western most of the western and developed countries are actually a negative population growth you know the United States you know just for instance the United States is on the cusp of going into a negative population growth other countries Japan Germany Italy are all in decline in terms of population the Japanese are investing investing heavily in robotics not for the not for the industrial manufacturing capacity but to care for their elderly so when we start talking about things like telemedicine and automation and health care it's not necessarily about applying technology because we can it's because we're doing it out of necessity we simply do not have the manpower to care for for the people particularly if you think about it we spend today six point five trillion dollars globally on health care and most of that spend is on the last two years of life so when you we start looking at the demographic trends and we start looking at the cost and we start looking at the decline in talent you know if you look at if you just look across North America and Europe we're importing health care providers because we simply cannot grow enough grow enough fast enough domestically so telemedicine is really about applying our resources in such a way that we can gain the economies of scale and provide a quality of life for the population and to augment the limited resources that we have a lot of this is as Jamie said you know is coming about because we are in a position to where technology is caught up with our imagination and if you hear me talk about you know in other in other venues you'll hear me talk about that our imagination is actually outpacing our ability to deliver but we are actually at the intersection of where these these mega trends and technology of big data and high-speed ubiquitous networks are converging to allow us to give us the capacity and the ability to deliver technology in ways that we thought weren't weren't possible before so that's what we're going to talk about today we're going to talk about the evolution of the telecom infrastructure the ability to pass data across wide areas around the world and to be able to apply technologies from mobile devices cloud computing big data in automation to improve quality of life and to deliver health care in places where they can't be where it hasn't been available before so we have a great panel here and I want to start with Brian profit of Attel Brian why don't you tell us just a little bit about yourself and also why don't you tell us about you know if you have a telemedicine or remote healthy experience sure so again Brian profit from Attel I've spent 18 years in the industry primarily in a role working for carriers but in an advocacy role working with internet to national lambda rail NIH NASA Noah working through being able to be the advocate to the carriers to be able to partner on these advanced research networks for health care for education for research personally I ditched the Fitbit about a year ago from that standpoint I found it was very few places that I was not carrying my phone so I thought letting a nap do that was a was a little easier from actually wearing it one more device very good next to the panel Philippe Alvarez the CEO of axion fiber networks Philippe hi Philippe Alvarez CEO of axion fiber networks we're a provider of data comms telecoms sorry high capacity infrastructure services in New York my experience in health care is really tied to being that fiber provider that connects sites primarily data centers you know high end very high end things so my interest in this panel is really I mean what's happening with the evolution of the taking broadband essentially to the rest you know in many cases I mean on how that impacts delivery of services basically so it moves to what I read about which is in sort of the IOT is the IOP which is the internet of patients right I'm gonna steal that one all right next cliff Kane the co-CEO of clearing on fiber networks cliff yeah hi cliff Kane co-CEO of clearing on fiber networks we are New York area telecommunication services provider primarily focused on the wholesale community we sell to carriers but we are extending that into the enterprise space I have no I've been thinking about it I don't have a any device that is I don't use Fitbit or anything like that to carry a phone with no apps that that monitor my health I guess I feel I'm healthy enough but you know our you know our interest here is because we are having a strong proponents of what's happening on the edge especially in light of 5G and IOT coming on board and what is the infrastructure going to have to look like to support that and telemedicine you know this is a lot of different applications within telemedicine but if you look at holistically it's a lot of that's gonna all happen on the edge and it's gonna be about how you transport that data back and forth to to storage to the different positions to get diagnosis and like so the edges you know critical importance to us and and I think that supports the whole telemedicine infrastructure okay next Drew Mullen the senior vice president of business development strategy at light tower fiber networks Drew yeah I do not have a Fitbit either so I think that we're gonna take down the average age on this panel there my name is Drew Mullen I'm SVP of business development strategy for light tower fiber networks so we build an operate fiber networks across the east coast and we've got about 33 route miles 33,000 route miles of network that we offer up you know this morning someone talked about trying to predict how much bandwidth you know is is going to be coming from internet of things or telemedicine I'm a fiber guy so I don't care what the thing that we can just throw more fiber at it and that's the answer for a fiber guy always you know telemedicine here I'm excited about this because I think telemedicine is very personal personal for everybody in this room just a quick little thing about me my wife is a pediatrician and my father in law is an orthopedic surgeon so in preparation for this my wife doesn't know anything about fiber but she actually gave me some things about how she does what she does and how the telecommunications in the fiber world are solving those problems so this this past weekend I was I was at a softball tournament with my 17 year old daughter and she's a catcher which if you've got kids never happen to be a catcher but so my my daughter was catching in a girl came up to play she was really large she had a really long swing and she wound up catching my daughter on her hand as she was doing that so meanwhile we immediately go to the emergency room or whatever she gets her hand scanned you know we're there for about eight hours and finally they came back and they said you know okay you're good to go and we said what took so long for this and they said well the person that needed to read the scan wasn't here they were actually on break and then they got you know involved with other stuff and I said really they said yeah this should probably should have taken an hour for you to get in and out of here I said just because that one person wasn't there and I thought here's a really practical way and that sort of affected me and I'm sure everyone here has kids or parents or something else that telemedicine is going to affect you so you know that's that's sort of my personal most recent story so I'm looking forward to the discussion good and last but not least of course Nancy Green the global healthcare business development strategy executive leader from Verizon hi so I come at this from a completely different ones than all this I live telemedicine and work within telemedicine probably for the last 15 years I've been in healthcare for 25 years around the technology not a clinician so but so in the role that I have with if you think about Verizon most people go what in the world that you're doing in the healthcare space so I kind of set the stage I'm one of five vertical leads so I lead healthcare there's no one for media entertainment insurance I take insurance now there's energy utilities things like that so they pulled from the industry to say how can we use all of the size and scope and scale that Verizon has to apply to a verticals business problem so telemedicine has been a health care business problem for a very long time and it's not a technology problem it is a workflow problem which you just identified and an interoperability problem period and as you as we go further I can talk more about that but I really it's not about the technology there is an age thing with physicians who want to use it and who doesn't but I would probably ask how many of you have ever done a virtual visit a video call with their with your physician three and four it's it's every one of the insurance carriers offers this as a service to keep you out of the emergency rooms and no one uses it so it is there it has to do with how the business problem is looked at by the industry if I'm a payer or a provider world it's vastly different and who's paying for it so it's not it's just now in the last couple years gotten to be reimbursed so this hotel you know telemedicine covers a huge area lots of different ways to operate it's not just it's not just video it is just the movement of of information back yeah right alright so as Jamie said this is a roundtable it's not a panel discussion so let's be a little nontraditional if you have a question you want to get involved in the conversation which I encourage you to do I have a bunch of questions here and I'm not afraid to use them but it would be far better if we all participated in this because it's going to touch all of us at some point or another but I want to come back to you and Nancy I was gonna start with you with a with one of the prepared questions but I think you just said something very interesting this isn't new we've been talking about telemedicine and remote health care delivery for the better part of a decade I remember you know I think it was 10 years ago Cisco showing off using their telepresence technology to do remote remote examinations and clinics so why isn't it why isn't it more prevalent probably two things the biggest has to do with reimbursement it wasn't reimbursed for a very long time certain states didn't reimburse you like Texas finally just passed I live in Dallas finally just passed that you didn't have to see a doctor first before you did a telemedicine visit so then the payers weren't paying for it or they would pay twenty five dollars where if you went to the doctor he'd get a hundred dollars so the doctor didn't particularly want to do it so the reimbursement is happening it's getting there it's not fixed but it's getting there and I think but I think if you look at it from the push of how the industry works if you look at the the four or five main areas in health care they're trying to increase the access to care while improving the quality of care so and I was used as a New York City because you probably don't know this within the New York City area the five boroughs there are six areas that are considered federally underserved by physicians it is not a rural problem so physicians go where they want to live not necessarily where the patients are we have you know cases of cities who pay for doctors to go to school and to just operate in that area so they're trying to lower cost increased access to care increased quality of care but now the entire focus is on patient experience and clinician experience and the clinician experience almost overrides a little bit of the patient experience so as the clinicians start to put it into their workflow it gets part of their business you got to understand if you ask your father-in-law he's done the same thing the same way since he went to med school and you introduce a telemedicine you have to introduce it into that workflow and they are probably what a hundred plus year old system of doing it the same way and so it's it's difficult and so when someone puts together a program to interconnect and have a virtual visit in your rounding we've had hospitals who have put together a room in a hospital because they round in a floor they put a room in there that's a video room so he goes and grabs the chart goes into you know just to get it part of the flow right so yeah other than that's always because from a telemedicine the tele component of a medicine telemedicine the not only technology advances but the penetration of readily available reliable broadband right has increased dramatically over the last I gotta say it goes up every year but certainly the last 10 years especially the wireless side you have gotten the advances that allow a lot of that information to happen with enough sufficient latency and clarity and so on and so forth that you can actually problem right because so it's not a delivery you need a fiber pair into the physician's office ideally yeah you would but you don't have to anymore so some of that drives adoption of better economics because think about the premiums I mean what happens when you start but a leveraging technology to do that remote diagnostics remote testing you know dishes and things like that the information from it is more important than the actual interception so if you're doing a video consultation the doctor can do a lot of what he's normally use here she's normally used to doing you're moving data from remote monitoring equipment anything that's in a hospital or at home that's just pieces of data that is overwhelming to the medical community they want to put in context so once it's put in context and the smarts are put around it it makes it usable data and actionable for them to make a better health decision for you otherwise it's just data so to answer your question it's been so long that it's just a lot of data which is how many people have stopped wearing the Fitbit most doctors don't care if you walk unless he's an orthopedic surgeon he cares when you put a brand new hip in you are you taking 10,000 steps a day but so it's it's that whole data just went okay here doctor here's all my stuff and he's like that's nice thanks so it was now it's starting to get like if I can get context around it I'm good I'm still trying to figure out who said 10,000 steps was the right level so I'm just gonna throw this out to the panel because before we get up to the application layer of all this because a lot of great magic can happen up there but and Phil you said is that we have the infrastructure for it is it the long-haul infrastructure that we have and is the is the last mile there or are we looking at that we have enough infrastructure to support a true saturation of the markets with you know they have ubiquitous use of telemedicine so I'll let everybody answer on this I'll take a shot that I think it's its location specific I you know you could be someplace where you know the doctors may have good infrastructure to support telemedicine and some high bandwidth applications but the patients that are music that those doctors are trying to diagnose maybe some places that aren't you know one potential remedy for that would be to create centers where the patients could you know basically come in and you could have the broadband connectivity and and telepresence that you need to to conduct a good diagnosis but I think it's the same story as broadband across the country it's really very location-specific you have thousands of buildings in New York City it don't even have fiber in them I mean that's commercial buildings so that as one perspective on that it's just I think it depends on where you are yeah and to add to that I mean from light hours perspective health care continues to grow I mean we've been in the space for 15 years now and every year we're amazed at how much more band with these hospitals are using and and finding ways to do it so whether they have dark fiber or gigi or a hundred gig they contain it's like closet space soon as you have it you know need a little bit more and and so you know about 10% of our revenues are healthcare related and continues to grow yeah and Brian please thank you and I think one of the things to keep in mind too you know the core backbone is not the issue you know the big shiny hospital buildings are not the ones that have problems getting the connectivity to them you know the business model works there to get fiber to them and if the carriers won't do it you know it's easy enough whether in a large city or the second third-tier markets for the carriers the hospitals to justify building out fiber rings themselves if they can't get it through wholesale available fiber I think what you have to start looking at is getting you know as we talked about getting closer to the edge you know when you go to that clinic for the emergency center and these emergency centers are popping up everywhere because pushing healthcare to the edge is the same as pushing data to the edge when you start looking at it from a standpoint of bringing these things to the edge being able to you know have an x-ray machine x-ray the hand at the you know the clinic near the baseball field if there's somebody in a data center type environment you know of radiologists that are able to read read that and provide real-time feedback this is how you start having remote care this is how you start bringing that to the edge and when you start looking at is it a last mile or a backbone issue I think you have to start looking at you know to justify that it's not just the backbone of the hospitals you have to start looking at the ecosystem of healthcare in the communities be to the doctor's offices to the labs you know and that creates opportunity to justify some of that metro expansion when you start looking at you know kind of the schools the hospitals the libraries again as an ecosystem in a neighborhood so that the tenant of that driver of increasing access to care means that they have to what he just said they have to push care as far out as they can which then gets into the problems of how do we get information there how do we communicate back and that's in a clinical environment to your point you know or whoever said it to go to a center to be able to do that the bigger driver is this whole consumerism model is that I don't want to go somewhere I should be able to do it off my phone I do everything else off my phone and that's driven them to change their business model and become up into a very competitive world so some of the very unique solutions that you have can have you compete in in a marketplace so an MSK or you know Sloan Kettering can complete with someone here in the local market that is doing the same thing but being able to offer some type of service that allows them to do something unique because they are now as a consumer think of yourself as a consumer you've done your research you're not really loyal to your brand right I'm trying to think of my New York hospital sorry you're not typically loyal to that just that brand you can go to whoever you want to so whoever is advertising the best whoever has the best ranking whatever that is you're going to go that way and so this whole piece of being able to offer services that are unique and they're in their specialties is something that's pushing them because of the consumer side of the business what's driving what's driving the adoption though is that is it the is it a capacity issue that's the the the clinicians the hospitals the the the physicians offices of practices are coming in saying that we need to scale more we need to connect to these resources is it a regulatory is a regulatory climate changing where the government is coming in saying that we have to we have to automate and we have to do more sharing what's the driver behind behind the trend I think it's money I mean I at the end of the day if you look at where most of our health care is at where the biggest expense is going to be in the next decade of Medicare and Medicaid you've got to look at how the you know the payers will look at telemedicine you know there's three categories that they look at you know and that you start looking at real-time you know interactive visits you start looking at you know store and process of data and then you start looking at remote monitoring those are the three reimbursable categories the problem has been really just as an adoption happens to Nancy's point for a very long time you know over the past decade or so as the technology stopped being the problem it really became a process of the only thing that was coverable was real-time interactive you had to be looking at the doctor and and working with them it couldn't be the step in between it couldn't be a remote call center full of radiologists reading x-rays and providing that feedback back that wasn't a reimbursable expense because that was in a radio the radiologist didn't walk in and go okay this looks great and the doctor didn't come in and look at the x-ray to look at the report that the radiologist gave them to say yep it's broken or no it's not yeah that's a monetary decision the only thing I'd add I'd agree with Brian that it is a monetary decision but I mean the quality of the care that you also get from that is a key benefit and I think you know in a health care environment you know doctors don't discount the fact that they're trying to give the best care you know to their patients always so you know certainly there's a the monetary aspect where it's more efficient but I think that it's also just better quality of care my wife does the newborn nursery so when she has to discharge a child she has her cell her smartphone there and she gets these you know Billy Rubin tests and she has literally a thing that comes up pops up on her phone that this test got back should I discharge this you know this baby or not and you know in the old times you know you wouldn't get that and you might be in the hospital for another five six hours before the doctor sees it now she hits the dope okay Billy Rubin's good off the baby goes you know so that family's happier with the with the care that they got to and you know it was probably more cost-efficient efficient too well and it's about that real-time information to Drew's point I mean it's you know pre-telecom the first ten years of my life I was in EMT and you know did that professionally and I think there's a lot of the time where it's that real-time information it's triage right if they if they say that my hands broken you know if they said your daughter's hand was broken it doesn't mean you're not going to follow up with a proper orthopedic surgeon for the proper level of care but being able to make a decision you know in 30 minutes we took the x-ray we had a picture we knew there's a fracture now I know what to do next you're cut eight hours of time and management in you know interaction from that experience of that care to the to the person to the consumer to the point this is really what it starts looking at from a consumerism of health care yeah I think if you talk about adoption and I'm thinking as we as people were talking it's really around in health care we call them service lines so ED is a service line dermatology service line that kind of stuff so cardiology service line so their use case driven and some have better adoption than others so the radiology example was happened ten years ago because it didn't get paid for it just was ease of use and now all your radiology went overseas they looked at it sent it back and you just didn't even know it right so as you start to see some of the use cases that are the subspecialties especially in behavioral health or some of the surgeon surgeons or some of the neurosurgeons they're they're such a subspecialty which means there's not very many of them that is that's where the adoption is super high and in some cases they need really high bandwidth because they're looking at a mate you know all kinds of things to help diagnose or or help another patient globally not a patient another physician so for many years it was physician to physician because it didn't matter right because they got paid for that that's a consultation they got paid for it so they used a lot of that and then as they started to get done okay I don't need all of that to be able to do it over the phone I don't have to go home to look at this because it really has to do with the use case and the center that you're part of and their view of it if you are part of the Cleveland Clinic you have a very different view because of the management of it than a smaller facility in South Carolina that might not quite be worried about that yet because they're just trying to take care of their community and to Nancy's point having worked with the you know the internet to in the research community you know the top research doctors you know those hospitals those facilities the University Medical Centers they have the connectivity that they need again it's getting that connectivity out to the doctor in that you know that remote South Carolina Hospital so that basically forces a network to be secure to protect that data so HIPAA is you've all signed it every time you go into a doctor right and it's really the sharing of your personal information wherever it should be so the HIPAA regulations are tippet are purposely void and everyone every lawyer in the world has said this is how you should look at it but it's really about the protected health information or PHI so if the data coming back and forth has no consideration of that that's Nancy Green's information it's not for it's not under the HIPAA regulations if you're just transmitting and you're not storing so a video virtual video is you don't have to go by HIPAA laws because you're not storing the video the minute as a service provider the minute you store something then now that data center has to be secure all of that kind of stuff the transport piece Verizon or any fiber there's a transport exception in the HIPAA laws because you're just transporting right but the minute you start to touch it look at it manipulate it then the HIPAA laws start to come through so data centers have to be HIPAA compliant the person that will get the fine will be the hospital system they are the covered entity and you buy business associate agreement will get pulled into that lawsuit but I don't think it stopped adoption because of that the security piece of it is everyone's super worried about that so the security and thinking about security I mean there's multiple levels but as you go to adopting wireless and this device and this device becomes more potent in terms of health care potential capabilities you're transmitting all the stuff wireless and when you think about a generation of people that grow up just like I'm old enough not to be digital I learned to be digital my kids are digital they were born with that essentially gene in their in them right so though they would expect this or some similar device to actually do a lot of the things so they don't have to the doctor I mean if I don't have to go to the doctor if I could do it through this I would do it later that's why it's important when you're when you're making those that nothing resides on the device and so we do a lot of that consultation is don't have anything reside on the device everything's in the cloud or remote so it is a use as transport piece but you know but once you go wireless it makes it all easier to wrap that data off the air I think that if you have a physical connectivity so it as a covered in essentially as a covered entity though trying to comply with him but one of the one of the pieces of due diligence would be to encrypt everything and encryption does come with a bandwidth tax so do we have the does the infrastructure have the capacity of handling totally encrypted traffic. Cliff? Well it can and does it depends on where and how but what I was thinking about while this conversation was going on was as you know Talon medicine expands and over the future I mean how are you gonna keep these how are you gonna keep this fluid and keep these records private and I think you know actually blockchain's gonna play a huge role coming into into that into focus in the next few years as it will with many other many other sectors but you know I think the the ability to keep it fluid is is key right so you wanted to have you know the the patient and and the doctor interacting you know on a real-time basis and how do you do that on a scale that's you know massive again I would say it goes back to the edge and and then I think one of the ways to keep all those records safe is by using blockchain as the storage and forward technology. Okay so every we have a question back here please. So so far a lot of the conversation has been figured around the patient provider experience. My question is more around how are hospitals kind of adapting to IoT, how are they using it and are they dealing how are they adapting to managing the large data sets that come from the empaths that affect the folks. That's a good question because you know the question just to repeat for those that in here is that what is the impact of the adoption rate of IoT within the clinical settings and what's the impact on the infrastructure. I would ask how you define IoT first. Smart devices that are pulling back data to some central point. So clinical smart devices or non-clinical. So does it makes a difference? Well look you know just look at it as health care devices whether clinical or non-clinical that you know there's going to be a number of non-clinical devices that are going to be feeding health care information into clinical devices or clinical systems that will get aggregated up into big data. So if you look at that as a derivative of the 20 to 50 billion IP enabled devices that are going to be online in the next five to seven years it's a huge amount these these IoT devices are huge just package generators. Yeah so I think first of the reason I asked is that when to clinical has to go through the FDA if it touches the patient right so they're very regulated. So you can't just add something to a clinical device you have to go back through everything so if you're going to add and I and we work with all the major manufacturers on devices every Phillips Respiron Respironics device for sleep apnea there's several million of them all have a little chip on them that sends information back to Phillips that says where it is did you use it what it is and they're sending that information to your physician. So it's use space so lots of clinical stuff is done. Non-clinical it's kind of I call it the Wild West you can do lots of stuff with it but it doesn't matter if the information doesn't make sense or give context to someone else. So the question in IoT and I was on the IoT panel earlier we talked about in health care it's a lot around asset tracking and what's called cold chain which is temperature so is the blood bank correct the pharmaceuticals being kept at a certain temperature in the pharma space itself it's globally tracking that the drug so that it's the right drug as it goes there's no counterfeit drugs things like that. And so that's their IoT world in that space is really looking at how do I take all of this information that hospital systems run on their electronic health records and the electronic health records don't have fields for a lot of this data. So physician that none of that data is in there and there's only trusted data in there and they don't trust anything else that they don't know a person touched. So it makes a difference in like your Fitbit if it goes directly and it goes so there's some heart monitors that you can actually adjust the numbers they don't trust that data so they don't need to look at it. So why is there no trust in the data? I'm sorry? Why is there no trust? They're a physician they can make a bad medical decision and be sued on data that they don't trust. So to elaborate on this Nancy was on a panel this morning she talked about how the health care industry has been somewhat slow in getting to the technology which I couldn't agree with more. I think it's part of this is generational I hope my father-in-law is not watching this ever but you know because we were dragging through the mud but but certainly there's a there's a certain number of physicians out there that just aren't comfortable with technology and they're going to be retiring and you have a whole nother generation who are more comfortable with that they're going to be using it. In addition to that these hospitals I think are realizing in order to be competitive to give the level of care that is required and it is competitive then they need to do the work with the Internet of Things and they need to work with technology and they're actually having positions you know where they have someone in their hospital and that's their job is to work with departments and there's a huge success factor when when hospitals do that versus just saying oh well let each department roll it out themselves that doesn't work as well so you need somebody to be the champion within your your hospital for all these types of things and it's going to be a process that we can continue to go forward. I think people in the room I've heard a lot of data center conversations most hospitals don't have their data centers don't have any of their patient information in it. What they're storing is nonclinical patient information because they don't trust it right they don't trust anybody coming out of it. The breaches that happen in health care are not into that system. There's someone's lost laptop or an insider doing damage so you know which as you look at the data centers that's why you're getting so much fiber into a building it's their own center your own stuff and what they offload is storage or nonclinical applications. Do we have another question in the back? Oh well I mean I was just a man I get that and now that you brought that up so what do they where do they store the clinical on-site data centers on-site they manage. Okay because I had I mean kind of along the lines of I broke my ankle and luckily my husband was able they told me I had that surgery that night. Luckily my husband was able to call a friend who was a radiologist somewhere else he tapped into it within five minutes and saw my x-ray and he was completely somewhere else. How was he able to do that? So a couple things he had rights to do that so so he couldn't have gotten into that hospital system without rights to get into the access it so he was already connected he already had rights so physicians have rights into their into different facilities most physicians have multiple facilities that they work out of and they have rights to do that and they have a login to get it that's very secure in how they do that the you know that's what the biggest complaint is because it times out after like 10 seconds and they have to re-log in again so that's probably one of their biggest issues. It just seems like you know having second opinions you know what after you do something major or whatever being able to access somebody remotely quickly would be and it's just where the road walks to all that. Yeah I think I always say this and if there was some money in it and I would do it you have to be your own advocate as a patient you just absolutely have to question just like it it's like why is it taking so long or what else can I do and if you run under the premise and understand that the healthcare industry well I should say health providers when you talk about health care there's also payers but the providers think they own your information which is why they don't let anybody look at it it's your information it's not theirs so there's always this kind of butt up against who owns the information and where it goes. So we have time for a couple more questions this is going down in front here. Yeah we started with a discussion talking about the supply crisis that we had across the planet a lot of what was discussed was around either better matching demand and supply in terms of locations or in terms of improving the patient journey or patient experience but this telemedicine actually able to increase the supply in any way and you elaborate on this because telemedicine is in a way slightly fewer experience in terms of delivery might be actually generated decreases in supply because the process will have to be done multiple times so for every number of telemedicine visits the patient will actually have to see that the doctor. There's already studies that approve it's actually more effective. I was going to say you know it how many times do you have something where you're sick you know the patient experience you know will increase the supply because you'll be more willing to interact with your healthcare provider. You know I had a surgery and I had to have you know something checked out and I could have waited a week to go to the doctor but I called him up and I knew he had an iPhone and I said look I know this is out of the practice but I'd rather not come to the ER on a Sunday night at nine o'clock just to check this incision site can you look at it right and then the education was well I can't do that because a HIPAA right I said no this is real time there's no records there's no storage there's no nothing. That advocacy that understanding of that patient experience will make you not reluctant to engage with your healthcare provider to not be part of the healthcare system it's something that you avoid like going to the dentist right I mean you know if I could have my tooth checked without having to get it drilled that'd be great but from a regular health involvement if the process if I knew it wasn't going to take eight hours to get you know somebody to look at this I don't think it's broken right EMT for eight you know 10 years I don't think this is broken but it's my daughter I'm going to have them check it out it's probably not but I know that's eight hours of my day gone if it's my hand I'm going to wait till tomorrow morning and make an appointment actually that will increase the demand for the service how will the installment be able to increase the supply so Larry started speaking about the supply being an issue so basically this installment is able to make physicians significantly more efficient I don't know about significantly more efficient so the supply of physicians is going down the same with nursing so they have to become more efficient and we're always advocating for them teaching in medical school how to be a technologist as well as a healthcare provider so that they learn that but the interaction between a patient and a physician you have to remember they cannot diagnose over telemedicine so you know they can do follow-ups they can see you initiative but they're never going to they're going to say hang up go to the ER right now because they can instantly tell what's going on so the challenge to your point I think we kind of touched on a little bit earlier the challenge is to help those physicians become unable to do more visits so if you think about you only get five or ten minutes and you waited four hours to see them or her that's because they're backed up because they're they're scheduling too much so their problem is always well I got to start my day an hour early so I can see two more patients so a video normally virtual video under telemedicine is very quick so they can actually see 10 or 12 patients in that same time that they probably only saw two or three patients so but some physicians won't do it and that's just that's just the way they are one more question so two questions where is the crux why I mean I can understand the liability aspect but that's based upon the sensor data essentially from remote diagnostics so it where's the crux within that in order to make a viable we can have remote diagnostics through telemedicine the second question is with I mean there's there's just a big movement for disaggregation away from hospitals and the clinics and that sort of stuff and some states have started to take policies around fines or insurance companies as well fines around situations where somebody goes to the ER for a non-emergency set those sorts of monetary funding kind of penalties going to drive more telemedicine the carrot in the stick works sometimes you know but that's that's the carrot in the stick to the patient not the clinician so the patient pays more when they go to the emergency room rather than going and waiting the next time we're using virtual visit that's a training issue on making sure that the payer communicates that to you I think your first question when you when you look at remote patient monitoring remote patient monitoring is monitoring biometrics so you know weight scale blood pressure pulse ox those kinds of things that's information that a physician can use to help make a diagnosis or help prevent something so your blood pressure went up in three days it shouldn't have been you're now read nurse calls you what happened what you do because you're a chf patient so it's more preventative than anything else and for a long time payers didn't pay for that because if you think about it how and I don't know what it is who have time you are your lifespan at a payer is short so your lifespan at your employer is longer traditionally than it is at your payer so think about it how many times have you changed payers in your jobs or whatever right so for them if the unfortunately I should tell anybody people that in the payer business in the room that your longevity isn't their biggest concern it should be yours and it you know your as your employer or whatever so so I've been at Verizon eight years we've had two big insurance company moves so when you when you think about that and your records don't come from the old insurance company by the way so it's it's about trying to understand how that remote patient monitoring really makes a monetary difference for reimbursement we are already over time believe it or not so I do want to close out on one question because you know and there's a lot of topics we didn't get to with the impact of SD-WAN and 5G networks we did touch on IOT but none of this happens without the underlying network being able to transport all this data around as the providers of those networks how is it that you are going to make sure make sure that they are not only reliable available but reliable because downtime is the enemy of service in this regard so to the panelists we'll use this as our as our walk-off I will not say a word I guess I'll start as a fiber provider you know quality network is really important for us so we make sure that we build it ourselves always so we know exactly what we built so we can maintain the quality of it and then you know we want to make sure that we're nimble enough for these hospitals so that when they say I want a route between here and here we're not going to build it the way we want it we're going to work with the hospital figure out okay maybe we build it a little longer for you because it's diverse from your other route that you have from somebody else so having that sort of entrepreneurial you know very custom made network is it's pretty important for our vertical there I would add that you know my conversation about the edge before I think is very important and as the edge intensifies because of 5G IoT you're going to want to try to keep as much transactional activity on the edge as possible so in terms of building resilient networks you're going to have pockets of data centers or exchanges or meeting rooms or combined where where wire line and wireless services can interconnect and you can you know buy some smart technologies like sdn maybe even ai nfc nfv you know you can push or keep a lot of the non you know non-core type traffic on the edge and I think that's that creates resiliency and of course these these pockets or these these gateways are then interconnected in a meshed apology which even more promotes resilience networks fail I mean any of us that manage networks know that there are elements that are you know that you cannot control cars are going to crash into poles things are going to go down what we've found so addtel runs the fibrous school and we've worked with a private carrier on deployment as they have grown their network and what they have found is that the critical components of project management and documentation on the back end when it comes time to repair you know proper training of the project managers proper documentation and closeout packages you know that are communicated through to the knock and the people at the knock being able to read that information results in a 30 percent reduction in mean time to repair those are hard to build last word well said yeah for sure we build the networks with inherent architectures that actually help you know elegant issues when they do happen but at the end of the day the two things at the end of the day I mean it comes into economics if someone doesn't want to pay for that redundancy there's no way that we're going to put that in unless we're compensated and that's a stark reality we're dealing with investors whether private equity or not don't want to see a return on their money so that's one aspect of it it's challenging you know if you're a smaller entity if you're a larger entity you get you pay for it because you understand the requirement right and the impact if it doesn't happen the second aspect is once you get to the the real edge which is at the consumer level it's a broadband connection that you have with this wireless or wire line into your home or your office essentially that is inherently not redundant at the end of the day right so you have to think about that impact when it comes down to that individual user wireless is probably better because you can that their networks tend to be a little more resilient than let's say your typical cable operator or someone similar to that that drives fiber or coaxing to a home but that that's a single point of failure that you cannot avoid unless you also have the wireless backup so it kind of works itself but I go back to as a service provider it comes down to economics we can provide the best service in the world but somebody has to pay for it we're not going to do it for free because we have investors well I want to thank everyone for attending today's roundtable I want to thank our panelists Nancy Green, Drew Mullen, Cliff Kane, Phil Alvarez and Brian Prophet great conversation and I I don't want to be today and wishing everybody good health