An Independent Investigation into the Deployment of the Federal Communications Commissions' Rural Health Care Pilot Program

Abstract

Objective: The goal of this study was to provide an independent and objective evaluation of the implementation of the Federal Communications Commission's Rural Health Care Pilot Program. Materials and Methods: Thirty-nine of the programs that were provided funding through this program were interviewed and asked about their project deployment, network planning, and the involvement of their state in implementation. Results: Results showed that programs recruited project team members from a variety of fields to fulfill different roles. Network partners were often chosen because they were stakeholders in the outcome of the project and because they had a past working relationship with the grant-receiving programs. In terms of deployment, many programs had made progress in filling out necessary paperwork and were tracking milestones, but had experienced changes since first receiving funding, such as losing participants. Additionally, many encountered challenges that inhibited deployment, such as coping with rule fluctuations. Many of the programs received support from their respective state governments in project development, often through matching funds, but few states were involved in the actual management of projects. Conclusions : As rural healthcare facilities often lack the information technology infrastructure compared with many urban facilities, it is important to understand the implementation process for programs such as the Rural Health Care Pilot Program and to examine what contributes to progress, stagnation, or disintegration. Although the programs reported some success, almost all had encountered challenges that inhibited implementation. A follow-up study is planned to further investigate deployment and determine the implications of Federal Communications Commission funding.

Introduction

In 2007, the Federal Communications Commission (FCC) initiated a nation-wide Rural Health Care Pilot Program (RHCPP) to be administered by the Universal Service Administrative Company (USAC). This broadband initiative has awarded over 545 million dollars to health organizations with a goal to “facilitate the creation of a nationwide broadband network dedicated to healthcare, connecting public and private nonprofit healthcare providers in rural and urban locations.” Originally, 69 organizations spanning 42 states and three U.S. territories were awarded grant money for projects,¹ and 16 more grantees were recently added.² Thus, to date, the FCC has provided funds for broadband distribution for rural healthcare in almost every state.

Rationale for the RHCPP

In their original award call, the FCC stated that the goals of the RHCPP were to support the construction of statewide or regional broadband networks and the telehealth services that could be provided through them. Additionally, although not required, they suggested integrating networks with Internet2, later adding National Lambda Rail, which are both nationwide broadband backbones. The project sought to connect disparate healthcare organizations in anticipation that providers could benefit from innovative applications in both continuing education and research. Another goal was to improve the healthcare community's capacity to provide a coordinated and fast response to large-scale crises. In addition, they wanted to facilitate widespread adoption of electronic health records, as called for by former President Bush and required by President Obama. Lastly, the FCC acknowledged the “extraordinary benefits” of broadband-based telehealth, specifically its ability to improve access to medical care for those in remote areas. If available, it could provide individuals with access to specialists, help doctors to monitor critically ill patients, shorten hospital stays, and decrease the number of follow-up tests and treatments.³

Research has demonstrated that the FCC's position on the benefits of telehealth is well justified, as telemedicine applications have been clinically successful in many health realms^4
–6 and have been shown to be equivalent to traditional care methods.^7,8 These benefits point to the potential of installing a broadband network that could bring telehealth to rural areas, which is why it is key to measure the progress of such initiatives to inform future projects.

Because the RHCPP is such a sizable undertaking with ambitious goals, it is governed by a set of requirements regarding the administration of the grants, the funding provided, and the projects' implementation, which will be discussed in the following section.

Structure and Requirements of the RHCPP

In terms of how the RHCPP is structured, the FCC initiated the pilot program after selecting the eligible participants. The USAC, an independent, nonprofit corporation created by the FCC, administered the program. Through the FCC RHCPP, the FCC will cover 85% of the costs for design, build-out, and operations of the broadband network. The networks are to connect urban centers primarily to rural sites and must be used strictly for healthcare purposes by nonprofit healthcare organizations. The participants were also required to pay 15% of those costs as a cash match. The FCC did not provide funds to the participants for administration and management of their project.

Participants and their affiliated healthcare organizations completed a variety of forms provided by USAC requesting support for allowable services through issuance of a request for proposals (RFPs) to telecommunication service providers and a competitive bidding process. In addition, the participants had to submit an acceptable sustainability plan, a requirement instituted after the initial awards were announced, to have final approval and receive a funding commitment letter (FCL) from the FCC through USAC. USAC then disbursed funds based on submission of invoices from the participants once they had received the FCL. The RHCPP was originally designed as a 3-year program allotting funds by June 2010 but has now been extended an additional year to end in June 2011. The participants then have up to 5 years to complete their projects and invoice against those allocated funds after their first FCL. Detailed quarterly progress reports are required even if an FCL has not been received or the project has not formally begun, and projects are also subject to on-site audits.

This article is the first part of a two-part study. The goal of this portion was to provide an independent and objective evaluation of the RHCPP implementation based on the views expressed by individuals from the grant-receiving programs. The second portion of the study, scheduled to begin in the winter of 2010, will examine how local levels of broadband deployments were assessed, the implications of this scale of funding, and overall perceptions of the projects. This research seeks to serve as a guide for policymakers developing these types of programs and organizations that have recently received this type of funding. Additionally, creation of future, similar projects may benefit from the inclusion within this article of some lessons learned. Thus, with these goals, the researchers conducted interviews with individuals from grant-receiving programs to examine their processes of grant deployment and developing their broadband architecture, as well as the involvement of their respective state governments with their projects.

Research Questions

To critically examine the implementation of the FCC's RHCPP, this research explored the following questions:

RQ1: How did selected programs initiate grant deployment?

RQ2: How did the grant deployment develop and change throughout the implementation process?

RQ3: What was the process of developing the broadband architecture?

RQ4: How did the RHCPP affect state involvement in widespread rural broadband development?

Materials and Methods

In the initial selection of participants in November 2007, the FCC chose 69 organizations to receive funding. After the announcement of the awards, some programs consolidated or dropped out, resulting in a total of 62 active programs at the time of data collection. Researchers, through the use of public records and attending a meeting of the American Telemedicine Association for the award recipients, contacted these organizations, and representatives from 39 of them agreed to participate in phone interviews (response rate: 63%) during January 2009 through June 2009. With permission from the respondents, the interviews were recorded and then transcribed. After data collection, two trained research assistants, who had previous coding experience and background knowledge concerning the research, analyzed the interview data. With a sample of the interviews (50%), a coding scheme was developed collaboratively using a grounded method for those interview questions that were relevant to this study.⁹ Once a scheme was established, the two coders coded half of the interviews to establish reliability. First, the coders established unitizing reliability for all variables (Cohen's Kappa [κ] ≥0.8), and then discussed those that were inconsistent until agreement was reached. Then, coding proceeded until reliability was reached for all variables (κ ≥ 0.8), with necessary refinements made to the coding scheme during the process. Once reliability was established, coders again came together to reconcile any disagreements. The remaining interviews were then divided between the two coders, completed, and analyzed using descriptive statistical techniques.

Results

The respondents were able to give more than one answer per question, because the categories were not mutually exclusive and one respondent could have multiple answers, thus allowing totals to be ≥100%.

RQ1: Initiation of Grant Deployment

This research question examined how projects initiated grant implementation and was addressed through several interview questions about the project team, or those main members who put together the initial proposal, their network partners, or those facilities that would be connected to their network, their start-up steps, and the paperwork they completed. See Table 1 for a complete listing of results.

Table 1.

Results for Research Question 1

Did you have a project team in place before you were selected as a participant?
Yes	64%
No	28%
Some team members were	8%
If yes, where were the team members from?
Hospital	39%
Collegiate department	36%
Consortium/system of health facilities	32%
Health department	25%
Existing telemedicine department	25%
Telecommunication organization/provider	14%
Consulting group	7%
Stakeholders	7%
Mental health organization	4%
Nonprofit health organization	4%
Primary care facility/clinic	4%
Health technology-related business	4%
Other	7%
If yes, why were team members chosen?
Had needed background knowledge/experience	39%
Were stakeholders/target people groups	36%
Had a pre-existing relationship	29%
Volunteered/had interest in project	14%
Found the original grant	11%
If yes, what were their roles?
Technical people	43%
Stakeholders/participants	36%
Assembled needed paperwork	36%
Overseers/administration	32%
Project coordinator/manager	21%
Healthcare provider	18%
Business/financial	18%
Advisor	11%
Contact people/outreach	11%
Identified participants	11%
Evaluation/monitor progress	7%
If no, when was the project team selected?
After notification	73%
Still hasn't been finalized	27%
Were your network partners identified before you were selected as a participant?
Yes	90%
No	5%
N/A	5%
Where were the network partners from?
The same as the project team	23%
Hospital	46%
Mental health organization	21%
Collegiate department	18%
Health department	18%
Primary care facility	18%
Consortium/health system	15%
Nonprofit health organization	15%
Existing telemedicine program	13%
Telecommunication organization/provider	13%
Health technology-related business	8%
Indian Health Service/tribal health center	5%
Health center	5%
Consulting group	5%
Stakeholders	3%
How were network partners identified?
Had a previous working relationship	38%
Geographic location/rural status	18%
Volunteered/showed interest	18%
Recommended by a third party	18%
Had relevant experience	15%
The only partners available	3%
Were network partners part of the original planning?
Yes	54%
No	13%
Some of them were	21%
N/A	12%
Have you submitted USAC form 465 and associated RFPs?
Yes	51%
No	49%
Did you request a direct funding via Form 466-A for the Network Design RFP?
Yes	10%
No	87%
N/A	3%
What were your initial start-up steps when you received notification that you were selected as a participant in the FCC Rural Health Care Pilot Program?
Worked on RFP/assembled needed materials	59%
Attended USAC training in Washington, DC	38%
Called a meeting	33%
Notified people involved	28%
Sought out needed funding	23%
Recruited/finalized list of participants and vendors	21%
Hired needed staff/organized staff structures	18%
Ran into trouble with USAC or FCC	15%
Submitted materials to FCC/USAC	13%
Assembled/designed network	13%
Got letters of agency	10%
Spoke with other programs receiving grants	5%
Other	3%

FCC, Federal Communications Commission; RFP, request for proposal; USAC, Universal Service Administrative Company; N/A, not answered.

Sixty-four percent of the organizations had a project team in place before they were selected as a participant. These organizations were asked where project team members came from, why they were chosen, and the team members' roles. Of the programs, 39% had project team members from hospitals, 36% from universities, 32% from consortiums or systems of health facilities, 25% from health departments, and 25% from existing telemedicine programs. Common reasons for choosing project team members included that they had the necessary experience (39%) and that they were stakeholders (36%). Team members' roles included technical people (43% of teams), participants or stakeholders (36%), administration/executives (32%), and staff that assembled paperwork (e.g., proposals) (36%). For those programs that did not have a team in place before being selected as a participant, 73% chose a team after they had been notified and 27% had not finalized project teams at the time of the interview.

As far as the selection of network partners, 90% of the programs had identified the partners before receiving award notification. While many stated the network partners were generally the same as the project team (23% of programs), others listed partners affiliated with hospitals (46%), mental health organizations (21%), health departments (18%), university departments/schools (e. g., school of medicine) (18%), and primary care clinics (18%). Over a third (38%) indicated that these partners were identified due to a previous working relationship. A majority of the programs (54%) included their network partners in the original planning of the broadband proposal.

Another part of this research question addressed what the start-up steps were for each award grantee. The most common step was notifying the project team and network partners and/or holding a meeting regarding the RHCPP (62% of programs). A majority (59%) of the respondents stated that they worked on an RFP or other necessary materials. Thirty-eight percent said that they attended the informational meeting/training session held by USAC in Washington, DC, and, upon hearing that some of the funding regulations had changed, 23% started seeking out other funding sources. Fifty-one percent of the respondents stated they submitted the USAC form 465 package and associated RFPs as the first required step in the USAC process, whereas 87% said that they had not requested direct funding via USAC Form 466-A (a form that defines the selected telecommunication service provider and the costs) for a Network Design RFP. Many participants had already determined their network design and thus were not requesting funds for that component of their project.

RQ2: Development and Changes During Implementation

This research question examined how projects developed and changed throughout the grant implementation process. It was explored through several interview questions, including those that addressed challenges encountered, tracking of progress, revisions to project aims, and retention/addition of network partners. See Table 2 for complete results.

Table 2.

Results for Research Question 2

Did unexpected issues/challenges emerge during the planning stage?
Yes	10%
No	87%
N/A	3%
What were the unexpected issues/challenges?
Rule changes/problems regarding funding	53%
Organizational issues	35%
Sustainability plan	24%
Educate FCC and USAC on healthcare	12%
Conflicting information	9%
Technology problems	6%
Other	9%
Are milestones being tracked?
Yes/plan to	87%
No	13%
Did you revise any of the specific aims of your project since being selected as a participant?
Yes	49%
No	49%
N/A	1%
If yes, how did you revise aims?
Expanded scope	21%
Changed technology setup	21%
Decreased number of participants	16%
Had to compensate for lack of funding	16%
Fine-tuned details	11%
Brought in more participants	11%
Changed/clarified goals of the program	11%
Narrowed scope	5%
Are all the initial partners/sites included in the proposal still active?
Yes	46%
No	54%
If no, why?
Joined another network/chose not to participate	52%
Were not approved/eligible	24%
Financial issues	19%
Did not need the bandwidth	19%
Timing issues	19%
If no, how has this affected the overall deployment?
Has not affected it	52%
Some effects	29%
Minor/insignificant effects	5%
N/A	14%
Were any partners/sites added since being designated?
Yes	54%
No	39%
N/A	7%
If yes, why were they added?
Participants became aware of grant/expressed interest	48%
Were not able to make proper decision during application process	24%
Other participants dropped out	19%
Organizational changes since initial application	10%
Budget reasons	5%
Network issues	5%

N/A, not answered.

Eighty-seven percent of the participants stated that they had encountered unexpected challenges, such as rule changes (53%), internal organizational issues (e.g., coordinating between organizations) (35%), and the requirement of a sustainability plan (24%). An overwhelming majority (87%) were either currently tracking or planned to track project milestones. Perhaps due to the aforementioned challenges and information revealed by the tracking of progress, 49% of recipients stated that they had or planned to revise their specific aims since they were selected as an RHCPP participant. These revisions included expanding the scope of their project (21%) or changing the technology design plan (21%).

Another key to understanding the organizational issues expressed may be that 54% reported that some network partners included in the initial proposal were no longer active, but 52% of these programs said that this had not affected the overall deployment. The most frequent cause (52%) for partners to drop out was because the site(s) either joined another network or simply chose not to move forward with the project. Additionally, more than half (54%) of the programs reported adding new partners since being accepted as a participant. When asked about reasons for adding sites, 48% stated that this was because the sites had become aware of the project and had expressed interest in joining it.

RQ3: Broadband Architecture and Network Design

The third research question aimed to address some of the broadband architecture and network design issues that emerged during this process. See Table 3 for the complete data set.

Table 3.

Results for Research Question 3

Has the network design evolved since the original plan during implementation?
Yes	41%
No	31%
Don't know	15%
N/A	13%
If yes, how many iterations of a design were there?
1–4	44%
15+	6%
N/A	50%
If yes, why did the network design change?
Changes in/needs of sites involved	50%
Technical requirements/changes	25%
FCC/USAC requirements	25%
Funding/cost reasons	6%
If yes, how has it affected the overall project?
No change	44%
Some change	25%
N/A	31%

N/A, not answered.

Forty-one percent of the respondents stated that their network design had evolved since the original plan. Of those, 44% stated that their plan had gone through one to four iterations. The main reason (50%) for these revisions stemmed from changes in or a better understanding of the needs of the sites involved. Forty-four percent of those whose network designs had changed reported that it had no impact on the overall project.

RQ4: State Involvement

The last research question sought to understand how grant-funded programs would affect state involvement in rural broadband development. See Table 4 for the complete data set.

Table 4.

Results for Research Question 4

How was your state involved in the development of this broadband initiative?
Involved/will be	44%
Not involved	33%
Funding	15%
Don't know	8%
How was your state involved in the management of this broadband initiative?
Not involved	56%
Involved	33%
Don't know	3%
N/A	8%
Do you deal with a specific individual or group from the state?
Yes	62%
No	23%
Don't know	3%
N/A	12%

N/A, not answered.

Fifty-nine percent of the respondents reported that their state was involved with the development of the project, sometimes by providing grant matching. However, regarding management of the project, 56% indicated that the state was not involved. Sixty-two percent of the respondents had a specific individual or group who they regularly contacted from the state regarding the RHCPP.

Discussion

There are many lessons that can be learned from this project for both participants and grant-awarding programs. This research examined grant implementation of the RHCPP and provided information about the process, including how each program initiated work on their projects. The selection of the team members involved recruiting individuals from a variety of fields that contributed to the project in different roles, for instance, acting as resources for technical issues. The differences in the types of individuals selected for the project teams reflect the array of possible methods of implementing the RHCPP, and could explain why some programs were more successful than others. Future research could examine the characteristics of the more successful programs, including the composition of their project teams, and compare them to others to determine if there are any variables that lead to more successful implementations.

In terms of selecting network partners, many of the organizations that were chosen were also stakeholders in the success of the implementation. This relationship could be important to program success, because partners who are stakeholders are likely to be invested in the outcomes. Many of the partners were chosen because they had past relationships with the grant-receiving programs, whereas other programs identified network partners through a third party or were approached by partners when they heard about the award funding. Thus, promoting these programs within the state could assist in further connecting facilities that would have otherwise not worked together. A serendipitous effect resulting from the project could be the strengthening of communication between these facilities, as they were required to provide information about each site as part of the process.

This research also examined the development and changes that took place during grant implementation and uncovered several areas that should be noted. At the time of the interviews, the majority of the programs had completed the Form 465 packets, which indicates the progress being made in the project regarding use and disbursement of the committed funds. Additionally, many of the programs had members attend the training sessions in Washington, DC. There, as a way of assisting the project coordinators through the grant process, the FCC and USAC provided training regarding the required process for obtaining the funds allocated for each project, as well as an introduction to the USAC coaches assigned to the projects. This is promising considering that the programs had to provide their own funds to attend the training, and shows a genuine effort to implement the projects successfully.

Most of the organizations had their projects change in some way since the grant funds were awarded, either by adding or losing participants. This was often because of the lapse in time before the project was started and management changes in the participants' organizations. There were some challenges encountered in deploying this grant, such as dealing with rule changes, creating an acceptable sustainability plan, and the ambiguity in the interpretation of the rules. A positive aspect of the program management uncovered by this research is that a high majority of the programs are tracking their milestones, which can lead to future evaluations and assessments of the program.

Many programs were supported by their respective state governments in project development and several also received match money. However, the states' involvement in the actual management of the projects was limited. One important issue to consider in this area is the integration of the RHCPP with the overall broadband plan for the state and a community. Such integration could be valuable, as there is a greater potential for an economy of scale and better price-point through aggregation of broadband services for several domains, such as education, government, and business. Grouping these together can lead to sustainability through sharing of costs and provision of more services as desired or needed. Also, telecommunication service providers are more apt to make investments if they can predict a return on investment or develop a plan to subsidize the broadband through deployment in larger markets. The second investigation of the RHCPP will seek to further explore these issues.

Conclusions

As the landscape of FCC-sponsored broadband continues to evolve, it is important to understand how these original funds impacted the development of these organizations and the process of deploying broadband. Rural healthcare facilities are often in need of more advanced information technology and there are many potential benefits to broadband access, making it valuable to examine the process of implementing grant-funded programs like the RHCPP to uncover factors that contribute to success. The second portion of this study will help us to further understand how local levels of broadband were assessed and the implications of the FCC as a funding body to healthcare organizations.

Footnotes

Acknowledgments

This research was made possible by grant number G22TH07758 from the Office for the Advancement of Telehealth, Health Resources and Services Administration, Department of Health and Human Services (DHHS).

Disclosure Statement

No competing financial interests exist.

References

Federal Communications Comission. Rural Health Care Pilot Program [Internet] Washington, DC: Federal Communications Commission, 2010 June 22, 2010. www.fcc.gov/cgb/rural/rhcp.html. 2010 April 22.

Federal Communications Commission. Rural telemedicine program funds 16 more broadband telehealth networks(FCC Publication No. 418-0500)Washington, DC: U.S. Government Printing Office, 2010.

Federal Communications Commission. FCC adopts pilot program under rural healthcare mechanism(FCC Publication No. 06-144)Washington, DC: U.S. Government Printing Office, 2006.

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