Telemedicine: Putting it in the right perspective

The enduring promise of telemedicine. 

I got tagged in a fascinating discussion on Twitter on Telemedicine. Several open-ended issues merit a closure via a long-form blog format (of course, Twitter has its own limitations).

The fibre to nowhere!
  1. Ensuring universal access and the issue of “dumb pipes”. Laying fibre is an expensive proposition. Long time back, I used to run a blog on Telecom, and the constant refrain from companies and end-users was the “last-mile access”. Ironically, it is cheaper to lay fibre from a city to another. Still, it gets incredibly expensive intra-city due to right of way and severe penal limitations of fixed infrastructure.

    These are broad contours and too difficult to generalise, but cities like Singapore and some German municipalities got around by having fixed duct systems, earlier on. In the UK, there was “unbundling” of the “local loop” which essentially piggybacked on the incumbent British Telecom by providing a modicum of competition and a bountiful of choice to the end-users. These solutions have primarily arisen from local access policies and have been fine-tuned according to the local requirements. Whether one model can be scaled to another is a matter of policy debate and beyond the mandate. But these are illustrative examples.

    Why Telecom companies are dumb pipes

    Why the dumb pipes? Companies have minimal incentive to provide the Internet without adding any layer of monetisation or “value-added services” (VAS). VAS was a significant money-spinner till the over the top (OTT) applications like WhatsApp and iMessage essentially killed the VAS monetisation stream. That is the reason why telecom companies are primarily partnering with the likes of Netflix or getting into content creation game themselves (as a new form of digital gold rush). However, there’s also intense lobbying to do away with the time-honoured principles of “net neutrality”.

    There might be a lot of handwringing about the access to “underprivileged” communities, customary noises by senators/lawmakers and companies themselves- but the reality is that companies are only managing vast swathes of dumb pipe. Of course, they want to change the status quo. That’s the sad reality, and the viral pandemic crisis won’t change it overnight.

  2. Device endpoints. That’s another crude realisation for most votaries of Telemedicine. Most devices are “old”, and end-users have little incentives to “upgrade”. The crucial point missing in the debate is- how much is the production cost and how much the companies sell the final product for. Here’s for example, the cost of an iPhone 6 (now phased out). This is just an illustrative example to highlight the actual cost to the company versus the retail price.
    The cost of iPhone (as an illustrative example) after it ships from the factory versus retail costs. 

    Well-built hardware should ideally last (with the right to repair). Yet, companies now have planned obsolescence in hardware and software support. One can always argue that there are “research and development costs, patenting, licensing fees etc. However, those are sunk costs, and each successive iteration only provides rolling profits. However, that line of argument is too nuanced and complex and again, out of mandate here. I am only using it to buttress my point- the global digital divide is accentuated by the high cost of digital devices. The policymakers have a considerable leeway to tax them as essential commodities or bring down their prices. I don’t see that happening though.

    Open Source is an essential component for providing equitable access to telemedicine and merits more consideration. 

    Is it technically feasible to have prolonged software support, at least? Yes. Open source provides an excellent insight in the software layer- you can always update the kernel with a rolling release while keeping the user interface intact. Ubuntu offers a “long term stable release” that lasts for five years without the continual hardware-software upgrades increasing the strain on the finances.

Google tried to become a utility through its Google-Fi project, but I have a nagging suspicion that it was just a showcase project. A lot of ink has flowed on “people-owned” networks with community management, but they remain on the fringes. Policy changes cannot be wrought overnight with critical infrastructure like telecommunications because of implications on national security as well. 5G is another genie in the bottle waiting to be uncorked, but that by itself is contentious- it brings on no real benefit.

Encryption is always evolving.

3. Last but not least is the encryption layer and mobile applications. Most modern-day applications require careful consideration of usability and privacy. How many readers are aware of software tokens for two-factor authentication or using Yubikeys (I use both for my email). Data security, privacy and encryption standards are evolving all the time. It requires a careful understanding of trade-offs related to user-generated content and providing a meaningful service on the ground. Data retention is also a sore sticking point.

Telemedicine can become an actual reality provided the operators see a use case scenario and are materially part of the decision making process. It would help by co-opting with the 800-pound gorilla that’s battered and bruised by not being able to “unlock” the “full potential of its investments” (pardon the cliche). We also need to factor the end-user requirements while making Telemedicine smarter and flexible