Family physicians and the nationwide communications service outage in Canada
On Friday, July 8th, 2022 at 4:30 a.m. EST, Rogers Communications experienced its second nationwide outage within two years. The sudden interruption caused an immediate coast-to-coast disturbance in internet and cellular service. Connection for its 11 million wireless subscribers, its affiliated and subsidiary services, and services associated with the company’s infrastructure were completely dropped and remained without full restoration of service for over 24 hours(1,2). During this period, healthcare was considerably impacted, particularly for family physicians trying to effectively communicate and care for their patients.
The network disruption had multifactorial impacts for family physicians who either directly or indirectly rely on Rogers infrastructure (Figure 1). With the COVID-19 pandemic prompting many appointments to be conducted virtually, this outage of both wireless and cable internet prevented some clinics from operating as usual. Basic key components of traditional family practice were hindered including providing virtual care for patients, communication with other healthcare providers, and sending or receiving fax documentation. Offices were similarly inhibited from notifying patients of appointment cancellations due to the disruption. Family physicians with other internet or cellular service providers may have still faced obstacles in connecting with patients who relied on Rogers infrastructure themselves. A lack of internet connection created barriers accessing online clinical resource tools, digital health records, and electronic medical records (EMRs) for investigation reports or documentation of previous healthcare encounters. Web-based dictation services may have been inaccessible, even if family physicians had other internet service providers.
Figure 1
Various aspects of family medicine practice that require network services. Family practice is diverse and can include, but is notrestricted to, outpatient care, remote care, remote and rural practice, and hospital medicine. Items in each subset may belong to more that one category and have been grouped for illustrative purposes.
The outage disproportionately impacted remote, rural, and lower-resourced areas without in-house specialists, limiting the ability to consult specialists at larger centres or to call emergency consultation and referral services (i.e., CritiCall in Ontario).(3) This may have delayed important clinical decision-making, such as receiving approval for urgent imaging or arranging air ambulance services. Hospitalists attempting to discharge patients faced a barrier when unable to contact crucial home or community supports.(4) There was a similar barrier in contacting patient transport companies and health system partners, including long-term care and retirement facilities. An inability to reach 911 emergency services created a dangerous scenario for patients presenting with red flag symptoms at inadequately equipped outpatient family medicine clinics, delaying ambulance services from arriving and transporting patients.(5)
With public transit services impacted by the outage, patients and family physicians alike had fewer options for travelling to appointments and healthcare sites.(6,7) A lack of phone or internet services limited access to alternatives including taxis, ride-hailing (i.e., Uber, Lyft), and rideshare options.(8,9) Family physicians on-call may have been unreachable. Those who were unable to work due to ailment may not have been able to notify healthcare sites as well as their replacements. Submission, reconciliation, and payment of medical billing claims were impacted while the lack of debit or Interac transactions hindered billing for uninsured services (i.e. non-resident visit fees, completion of licensing forms, TB Mantoux Testing for employment) and medications. A lack of faxing or wireless printing services may have impeded prescription pickups and refills at pharmacies.(10,11)
The internet, and other services like television and radio, are regulated in Canada by the Canadian Radio-television and Telecommunications Commission (CRTC). In 2016, the CRTC declared broadband internet a basic telecommunications service highlighting its importance in modern society within the healthcare, financial, and retail sectors amongst many others.(12) The current Canadian telecommunications market is an oligopoly, with large incumbent and cable service providers such as Bell, Rogers, and Telus accounting for over 91% of total revenue market share and capturing at least 85% of all Canadian internet subscribers.(13) Oligopoly market structures dominate market share facilitating higher consumer prices due to lack of competition; Canada ranks as having one of the highest telecommunications service prices among the G7 countries and Australia across mobile wireless, broadband internet, and mobile internet categories.(14) As such, a network outage of even one of these retailers can result in considerable impact to entire systems and infrastructure leading to the drastic consequences seen on Friday July 8th.
The CEO of Rogers explained the breach as a network system failure following a maintenance update done between late Thursday night and early Friday morning, stating when interviewed:
“These are typically, very routine updates in our core network. That update caused some of the routers in our system to malfunction and that malfunction caused traffic overload. And as a result of that, the whole system just shuts down and the network became inoperable to our customers.”(15)
The internet is comprised of interconnected networks which can communicate with each other through Border Gateway Protocol (BGP). BGP allows networks, such as the one run by Rogers, to ‘announce’ their location to other networks helping determine the best route to send internet traffic, similar to a GPS system. If there are any errors made by networks in the process of announcing their presence or location, internet traffic may be routed incorrectly. Network monitoring data showed a large number of BGP updates from Rogers shortly followed by a complete drop in Rogers internet traffic to 0, indicating the entire Rogers network was not communicating with the internet.(16,17) This timeframe suggests errors associated with BGP updating (Figure 2).
Figure 2
On Friday, July 8th, 2022 at 4:30 a.m. EST, Rogers Communications experienced its second nationwide outage within two years. The sudden interruption caused an immediate coast-to-coast disturbance in internet and cellular service. Connection for its 11 million wireless subscribers, its affiliated and subsidiary services, and services associated with the company’s infrastructure were completely dropped and remained without full restoration of service for over 24 hours(1,2). During this period, healthcare was considerably impacted, particularly for family physicians trying to effectively communicate and care for their patients.
The network disruption had multifactorial impacts for family physicians who either directly or indirectly rely on Rogers infrastructure (Figure 1). With the COVID-19 pandemic prompting many appointments to be conducted virtually, this outage of both wireless and cable internet prevented some clinics from operating as usual. Basic key components of traditional family practice were hindered including providing virtual care for patients, communication with other healthcare providers, and sending or receiving fax documentation. Offices were similarly inhibited from notifying patients of appointment cancellations due to the disruption. Family physicians with other internet or cellular service providers may have still faced obstacles in connecting with patients who relied on Rogers infrastructure themselves. A lack of internet connection created barriers accessing online clinical resource tools, digital health records, and electronic medical records (EMRs) for investigation reports or documentation of previous healthcare encounters. Web-based dictation services may have been inaccessible, even if family physicians had other internet service providers.
The outage disproportionately impacted remote, rural, and lower-resourced areas without in-house specialists, limiting the ability to consult specialists at larger centres or to call emergency consultation and referral services (i.e., CritiCall in Ontario).(3) This may have delayed important clinical decision-making, such as receiving approval for urgent imaging or arranging air ambulance services. Hospitalists attempting to discharge patients faced a barrier when unable to contact crucial home or community supports.(4) There was a similar barrier in contacting patient transport companies and health system partners, including long-term care and retirement facilities. An inability to reach 911 emergency services created a dangerous scenario for patients presenting with red flag symptoms at inadequately equipped outpatient family medicine clinics, delaying ambulance services from arriving and transporting patients.(5)
With public transit services impacted by the outage, patients and family physicians alike had fewer options for travelling to appointments and healthcare sites.(6,7) A lack of phone or internet services limited access to alternatives including taxis, ride-hailing (i.e., Uber, Lyft), and rideshare options.(8,9) Family physicians on-call may have been unreachable. Those who were unable to work due to ailment may not have been able to notify healthcare sites as well as their replacements. Submission, reconciliation, and payment of medical billing claims were impacted while the lack of debit or Interac transactions hindered billing for uninsured services (i.e. non-resident visit fees, completion of licensing forms, TB Mantoux Testing for employment) and medications. A lack of faxing or wireless printing services may have impeded prescription pickups and refills at pharmacies.(10,11)
The internet, and other services like television and radio, are regulated in Canada by the Canadian Radio-television and Telecommunications Commission (CRTC). In 2016, the CRTC declared broadband internet a basic telecommunications service highlighting its importance in modern society within the healthcare, financial, and retail sectors amongst many others.(12) The current Canadian telecommunications market is an oligopoly, with large incumbent and cable service providers such as Bell, Rogers, and Telus accounting for over 91% of total revenue market share and capturing at least 85% of all Canadian internet subscribers.(13) Oligopoly market structures dominate market share facilitating higher consumer prices due to lack of competition; Canada ranks as having one of the highest telecommunications service prices among the G7 countries and Australia across mobile wireless, broadband internet, and mobile internet categories.(14) As such, a network outage of even one of these retailers can result in considerable impact to entire systems and infrastructure leading to the drastic consequences seen on Friday July 8th.
The CEO of Rogers explained the breach as a network system failure following a maintenance update done between late Thursday night and early Friday morning, stating when interviewed:
“These are typically, very routine updates in our core network. That update caused some of the routers in our system to malfunction and that malfunction caused traffic overload. And as a result of that, the whole system just shuts down and the network became inoperable to our customers.”(15)
The internet is comprised of interconnected networks which can communicate with each other through Border Gateway Protocol (BGP). BGP allows networks, such as the one run by Rogers, to ‘announce’ their location to other networks helping determine the best route to send internet traffic, similar to a GPS system. If there are any errors made by networks in the process of announcing their presence or location, internet traffic may be routed incorrectly. Network monitoring data showed a large number of BGP updates from Rogers shortly followed by a complete drop in Rogers internet traffic to 0, indicating the entire Rogers network was not communicating with the internet.(16,17) This timeframe suggests errors associated with BGP updating (Figure 2).
Network issues already at this scale were compounded further when communication was disabled between executives, employees, and other maintenance workers, drastically affecting coordination and response times. External complications exacerbated the situation, including the rising of a seventh wave of COVID-19 and the timing of the outage being right before the weekend.(15,18) Additionally, as the network recovered, increased traffic to services associated with Rogers infrastructure may have overloaded and slowed down connections resulting in further delays.
This Rogers nationwide outage highlights gaps in the Canadian network system as well as the crucial importance of network connectivity to family medicine. Some family medicine clinics were able to continue operating through the Rogers network disruption if they were with other internet service providers, had backup networks with a second connection, or created phone hotspots if there was available cellular reception. However, these are overhead costs that may not have been feasible for smaller practices. Family physicians who were able to pivot to paper charting from EMRs would need to scan or rewrite documentation into the EMR when network connectivity was restored, an additional administrative burden in an overworked and understaffed office environment. Rogers faced a similar nationwide outage the previous year, albeit secondary to a different root cause related to errors in software updating, unrelated to issues with network updating.(19) More recently, the destructive effects of Hurricane Fiona caused lasting service interruptions in Eastern Canada affecting healthcare through delays in virtual care, transportation, and record access.(20) At the storm’s height, 138 of Bell’s towers lost power and 49 sustained long-term damage resulting in continued unreliable connectivity.(21) Without improved network resiliency and safety measures, service outages of any form will continue to leave family medicine practice, operations, and access especially vulnerable, whether from natural disaster, power outages, or internal updating procedures.(22)
This outage is a reminder that maintaining nationwide network service has multiple components that are vulnerable to complications. Updating or modifying these components requires careful oversight and effective fallback systems. While family physicians can prepare themselves for similar future occurrences by having backup networks, offline copies of data, or alternative communication and documentation methods, they should not bear this administrative or financial burden. For family physicians to be sufficiently supported, clear government policy oversight is required to ensure robust infrastructure and functional alternatives are in place. Disruptions of this scale have significant consequences for patient care and proper legislative intervention is needed to prevent similar impacts on healthcare from occurring in the future.
Network issues already at this scale were compounded further when communication was disabled between executives, employees, and other maintenance workers, drastically affecting coordination and response times. External complications exacerbated the situation, including the rising of a seventh wave of COVID-19 and the timing of the outage being right before the weekend.(15,18) Additionally, as the network recovered, increased traffic to services associated with Rogers infrastructure may have overloaded and slowed down connections resulting in further delays.
This Rogers nationwide outage highlights gaps in the Canadian network system as well as the crucial importance of network connectivity to family medicine. Some family medicine clinics were able to continue operating through the Rogers network disruption if they were with other internet service providers, had backup networks with a second connection, or created phone hotspots if there was available cellular reception. However, these are overhead costs that may not have been feasible for smaller practices. Family physicians who were able to pivot to paper charting from EMRs would need to scan or rewrite documentation into the EMR when network connectivity was restored, an additional administrative burden in an overworked and understaffed office environment. Rogers faced a similar nationwide outage the previous year, albeit secondary to a different root cause related to errors in software updating, unrelated to issues with network updating.(19) More recently, the destructive effects of Hurricane Fiona caused lasting service interruptions in Eastern Canada affecting healthcare through delays in virtual care, transportation, and record access.(20) At the storm’s height, 138 of Bell’s towers lost power and 49 sustained long-term damage resulting in continued unreliable connectivity.(21) Without improved network resiliency and safety measures, service outages of any form will continue to leave family medicine practice, operations, and access especially vulnerable, whether from natural disaster, power outages, or internal updating procedures.(22)
This outage is a reminder that maintaining nationwide network service has multiple components that are vulnerable to complications. Updating or modifying these components requires careful oversight and effective fallback systems. While family physicians can prepare themselves for similar future occurrences by having backup networks, offline copies of data, or alternative communication and documentation methods, they should not bear this administrative or financial burden. For family physicians to be sufficiently supported, clear government policy oversight is required to ensure robust infrastructure and functional alternatives are in place. Disruptions of this scale have significant consequences for patient care and proper legislative intervention is needed to prevent similar impacts on healthcare from occurring in the future.
Competing Interests
The authors declare they have no conflicts of interest. The authors alone are responsible for the content and writing of the article.
Anthony Li is a fourth-year medical student at the Queen’s University School of Medicine
Carolyn Tran is a third-year medical student at the Schulich School of Medicine and Dentistry
Adrian Yung is a graduate student in the Department of Computer Science at the University of Toronto
Alexander Thomas is a family physician pursuing fellowship training in sport and exercise medicine at the University of Ottawa
References
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11. Rogers outage a safety issue at Interval House of Hamilton on Hamilton Mountain. The Hamilton Spectator [Internet]. 2022 Jul 11 [cited 2022 Jul 10]; Available from: https://www.thespec.com/local-hamilton-mountain/news/2022/07/11/rogers-outage-a-safety-issue-at-interval-house-of-hamilton-on-hamilton-mountain.html
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14. Government of Canada I. Price Comparisons of Wireline, Wireless and Internet Services in Canada and with Foreign Jurisdictions: 2020 Edition [Internet]. Innovation, Science and Economic Development Canada; 2021 [cited 2022 Jul 10]. Available from: https://ised-isde.canada.ca/site/strategic-policy-sector/en/telecommunications-policy/price-comparisons-wireline-wireless-and-internet-services-canada-and-foreign-jurisdictions-2020
15. Charron J. “I’m frustrated”: Some Rogers customers in Ottawa without service for second day [Internet]. Ottawa. 2022 [cited 2022 Jul 10]. Available from: https://ottawa.ctvnews.ca/i-m-frustrated-some-rogers-customers-in-ottawa-without-service-for-second-day-1.5981327
16. Cloudflare’s view of the Rogers Communications outage in Canada [Internet]. [cited 2022 Jul 10]. Available from: https://blog.cloudflare.com/cloudflares-view-of-the-rogers-communications-outage-in-canada/
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21. Morse J. Phone and internet service restoration still a priority in P.E.I. after Fiona [Internet]. Atlantic. 2022 [cited 2022 Oct 16]. Available from: https://atlantic.ctvnews.ca/phone-and-internet-service-restoration-still-a-priority-in-p-e-i-after-fiona-1.6092854
22. Ryan H. Cell outages during storms like Fiona will continue unless regulations improve, advocate says | CBC News [Internet]. CBC. 2022 [cited 2022 Oct 16]. Available from: https://www.cbc.ca/news/canada/nova-scotia/cell-outages-in-storms-like-fiona-will-continue-unless-regulations-improve-advocate-1.6596539
