The telemedicine frontier: going the extra mile

V. Garshnek, J.S. Logan & L.H. Hassell

Dr V. Garshnek, a physiologist, and formerly Assistant Research Professor at the Space Policy Institute, The George Washington University, is now Project Manager of the AKAMAI Telemedicine Evaluation Initiative, Tripler Army Medical Center. 1 Jarrett White Road, Tripler AMC, HI, USA. Dr J. S. Logan is a physician and President of Logan and Associates, Norman, OK. USA, an international telemedicine consulting firm. Dr L. H. Hassell is a Colonel in the United States Army, a physician, and Project Director of the AKAMAI Telemedicine Evaluation initiative, Tripler Army Medical Center, Hawaii, USA.

We live in extraordinary times. In this century alone, we have witnessed the rapid emergence of technology and, with it, the ability to break crucial barriers that had previously hindered human progress. Currently we are standing on the edge of a barrier which is rapidly eroding-the physical distance barrier. Through telecommunications and computer technologies, such capabilities as real-time or stored multimedia information transfer, real-time interactive video and instantaneous acquisition of knowledge and expertise, are becoming reality. We have the means to electronically transport and make available the 'essence' of who we are anywhere at anytime.

At the present time, nowhere is this distance barrier eroding more rapidly than in medicine. Patients traveling miles to see a specialist for medical consultation, and medical documents and films being physically stored and transported are rapidly becoming antiquated modes of operation. Through telecommunications and information technologies medicine can now extend its reach regardless of physical distance through real-time or near real-time two-way transmission of information between places of lesser and greater medical capability and expertise. This capacity, known as Telemedicine, will revolutionize current clinical medical practice, especially for remote or geographically dispersed populations, and will profoundly alter the medical landscape well into the twenty-first century.

The use of telemedicine systems in settings such as hospitals, clinics, long-term care facilities, prisons, and home care is becoming well established and is evolving in effectiveness and efficiency. However, the purpose of this paper is not to discuss these more familiar settings but, rather, to focus on telemedicine at a bold 'frontier' beyond its current and common use. The new frontier is that of delivering specialty care on a planetary or 'global' scale and beyond Earth into the realm of space flight.

Telemedicine is the use of modern telecommunications and information technologies for the provision of clinical care to individuals at a distance and the transmission of information to provide that care. The main rationale for the development of telemedicine services has been the desire to provide health services 10 persons whose access to health care is restricted for one or another reason. It includes the diagnosis, treatment, monitoring, and education of patients using systems that allow ready access to expert advice and patient information no matter where the patient or relevant information is located. It involves a spectrum of technologies¹ including facsimile, medical data transmission, audio-only format (telephone and radio), still images, and full-motion video. Robotics² and virtual reality interfaces³ have been introduced into some experimental applications. Telemedicine is a process, not a technology and shifts the paradigm of transporting the patient to the site of the expert care giver to transporting expert knowledge to the health care provider closest to the patient (ie move the information not the patient).

Early expansion of telemedicine was affected by the cost and limitations of the technology. Recent technological advances-such as liber optics, integrated services digital networks (ISDN), and compressed vide~have eliminated or minimized many of these problems, fostering a resurgence of interest in the potential of telemedicine to improve the quality of; and increase access to health care, especially for those who live in remote or under-served areas. Today, the technology is not only better; it is also becoming signiFIcantly less expensive.

The telecommunications infrastructure provides the technology to move information electronically between geographically dispersed locations. Participating sites are linked through electronic networks. The telecommunication medium utilized by telemedicine programs is determined in large part by the available local infrastructure. These can include satellite, microwave link or terrestrial lines (either twisted copper phone lines or fiber optic cable).⁴ The use of advanced satellite links is unlikely to become common for medical desktop conferencing and consultation. Tools specifically designed for ISDN represent an inexpensive, but nevertheless powerful, terrestrial network which is already available in most industrial regions. Where ISDN is not available, satellite systems represent an attractive alternative since temporary links and manual dialing lead to major cost reductions compared with standard satellite links.

The bandwidth or bit rate of the transmission medium (terms used to refer to the amount of information that may be sent per unit of time) is a limiting factor on the type of telemedicine system that may be used. For example, narrow bandwidth systems, such as the ‘plain old telephone system’ (POTS) are relatively inexpensive to operate but lack the capacity to transmit full-motion video. Broad bandwidth networks, including fiber optic cable and many satellite systems, are capable of carrying sufficient data to permit the use of interactive, full motion video.

The medical systems infrastructure consists of the equipment and processes used to acquire and present clinical information and to store and retrieve data. Acquisition and presentation technologies include teleconferencing, data digitizing, and display (eg remote X-ray, laboratory tests); text processors (eg scanners, fax); or image processors (eg video cameras, monitors). Data storage and retrieval include storage devices (disks, tape, CD-ROM), along with technology to compress, transmit, and store data. Table l provides examples of typical telemedicine applications currently in use, modes of interaction, types of information transferred, and bandwidth requirements.

In general, each site has the basic equipment for communicating with other sites in its network and the specific applications it has established. The requirements for telemedical services are the same, independent of whether they need to be provided within a clinic (local area), between Clinics and general practitioners (regional or metropolitan area), or on a wide area (international/global scale).

Many nations have significant telemedicine activities in progress and include internal (domestic) as well as external (international) efforts. The most active nations include the United States, Australia, Canada, France, Germany, the UK, Greece, Italy, Japan, Netherlands, Switzerland, United Arab Emirates, Norway, Finland and Sweden. Although telemedicine has been practiced for decades, the majority of its applications have been in the developed world. Now that telemedicine has matured in effectiveness and efficiency with concrete medical impact, it is important and timely to ask whether telemedicine may have a role in developing countries. Developing countries face particular problems in the provision of medical services, which relate to the lack of capital, facilities and systems. Roads and transportation are inadequate and difficulties in transporting patients are often encountered. For countries with limited medical expertise or resources, telecommunications can provide a solution to some of these problems.

A number of challenges exist in international telemedicine development, which may slow the implementation and effective use of this capacity. These include the following: ⁵

1. Telecommunications

• Different technical standards
• Poor or non-existent telecommunications infrastructures
• National and international regulations governing telecommunications and equipment use

(2) Medical

• Medical cultural differences

• Differing medical approaches

• Differing medical standards

• Differences in medical technology and equipment

(3) Socioeconomic

• Political and bureaucratic barriers

• Differences in language and literacy

• Cultural differences in acceptability of medicine

• Differences in resources available for medical care

In addition, based on research thus far, and the responses to a questionnaire developed by a committee established by the International Telecommunication Union to study telemedicine, which gathered data with particular reference to developing countries, it is clear that much of the telemedicine activity undertaken around the world has depended on government subsidies. The situation is changing, however, and a trend towards commercial telemedicine provision is clearly discernable.⁶

One initial effort is the Satellite/HealthNet. Based in the United States, SateLife/HealthNet is an international non-profit organization which uses micro-satellite technology to provide health communication and information services in developing countries. SateLife began in 1985 and is an initiative of the Nobel Laureate group International Physicians for the Prevention of Nuclear War. It has joined with Atelier Temenos in France to provide island communities with e-mail and CD ROM availability via the HealthSat I and HealthSat 2 (LEO Satellites), at 0.25% of the cost of conventional geostationary satellites. SatelLifel HealthNet stations are also licensed in nine African countries, the Philippines and three countries in the Americas, linking remote practitioners and clinics regionally, as well as internationally with participating urban medical centers.⁷

The development of national telecommunications and telemedicine capabilities in underdeveloped countries can be enhanced by development of an international medical telecommunications network to facilitate communications among health care professionals globally and to improve their access to health care information. Such a network could stimulate the development of medical cooperation across cultural, political, and bureaucratic barriers and could facilitate the development of national telemedicine networks in underdeveloped countries. Such a global network could be built on a simple Internet infrastructure 'low' technology start which can be highly effective.

Global telemedicine will develop regardless of whether it is coordinated logically or not. It will require a concentrated effort to develop reliable national telecommunications capabilities in the underdeveloped countries where they are currently unavailable. Such systems should he developed through collaborative efforts and funding from multiple organizations (eg World Health Organization and other agencies of the United Nations such as the Pan American Health Organization, the Department of Humanitarian Affairs, the US Agency for International Development; and other international, and national, organizations with Interests in developing updated medical and communications technologies in underdeveloped countries).

Disasters are catastrophic events that overwhelm a community's emergency response capacity, threatening the health and safety of the public and the environment. Globally, a major disaster occurs almost daily. Although emergency medical services are an important part of disaster responses, populations affected by disasters require a complete range of health services. Disaster medicine has become more than a mass casualty response. It encompasses the entire spectrum of the affected population's needs, ranging from assessment of the medical requirements to rapidly coordinating routine and preventive health services.

There are three major time phases associated with disaster response. In the Pre-Disaster Phase, emphasis is placed on prevention and preparedness activities which lead to requirements for hazard and vulnerability assessments, human and material resource inventory, comprehensive planning and exercises to test plans, capabilities, and skills. In the Acute Post-Disaster Phase (hours to weeks) damage assessments and the implementation of emergency plans have priority. The Post-Disaster Rehabilitation Phase may extend for months or even years as infrastructure and various community activities are restored.⁸

While many information management and telecommunications technologies are currently employed in disaster response, there are few reports of telemedicine being utilized in disaster settings. The Pan American Health Organization (PAHO) has provided satellite communication ground stations to support disaster response. The longest and most extensive use of telemedicine was the NASA-Russia Space Bridge employed during the Post-Disaster Rehabilitation Phase after the devastating Armenian Earthquake of l988.⁹

The Space Bridge Project used satellite communications to provide medical consultation to several Armenian regional hospitals, linking them with four US medical centers. The program utilized two-way interactive audio with one-way full-motion video transmitted from Armenia to the United States. There were also separate data and fax transmission lines. Consultation was provided in the areas of neurology, orthopedics, psychiatry, infectious disease, and general surgery. In a separate link, consultation was also provided to the Russian town of Ufa, where a gas explosion during this same period of time caused a large number of casualties. Slow-scan black and white video was transmitted from Ufa to one of the Space Bridge sites in Armenia (Yerevan) which provided satellite uplink.'⁰

Over a 12 week period, the Space Bridge program was used to discuss the cases of 209 patients. According to data reported by Houtchens et al.,¹ the use of telemedicine was responsible for changes in the management of a large number of patients. For the 189 Armenian patients discussed, diagnoses were changed for 54 patients, new diagnostic studies were recommended for 70 patients, and treatment plans were changed for 47. During the attempted coup in the second half of 1993, NASA took advantage of a video-conferencing link in Moscow that was already in place to provide consultation regarding several casualties of small arms fire. This link was part of the USJ Russian Telemedicine Demonstration Project, which consisted of 18 different sessions dedicated to different medical specialties.

Evaluation of this entire Space Bridge experience has identified a series of important ‘disaster telemedicine’ needs for future consideration: ¹²

(1) need for precise protocols in both communications and clinical areas;

(2) need to intensively train and prepare users at both ends of the link;

(3) need for a new type of medical record generated by and compatible with telemedicine;

(4) need for vigorous qualitative and quantitative assessments of telemedicine applications;

(5) need to link telemedicine to a variety of information sources.

Telemedicine has been utilized on many different occasions over the past two decades; however, it has never before been deployed and tested on such a large scale as was demonstrated in the Space Bridge projects. These projects pioneered a global telemedicine disaster assistance system and demonstrated that the technology and ability to utilize it during a large-scale emergency situation are currently at hand. In addition, these projects clarified the value of such a system and the need to institutionalize this capability nationally and internationally so that it can be effectively activated on demand.

Telemedicine can significantly enhance efforts associated with the previously mentioned time phases identified for disaster response. For example, in the Pre-Disaster Phase, telemedicine could be employed in the education and training of health care personnel and the general community. Disaster planning and coordination could be facilitated and various types of exercises could be conducted and evaluated. In the Acute Phase of disaster, telemedicine capability could support disaster plan implementation and modification, assist with management of critical resources, and provide consultation from within and outside the disaster area, and provide assessment and survey data as the basis for relief and humanitarian assistance operations. In the Post-Disaster Rehabilitation Phase, telemedicine can provide a variety of more traditional medical consultations as demonstrated by the Space Bridge to Armenia and can continue to provide support to both resource management and continuing assessment activities. ¹³

Telemedicine can be utilized in disasters only within the constraints of local and regional infrastructure capabilities and, thus, must be compatible with and tailored to the level of sophistication which can be utilized and supported. Top down approaches are unlikely to be successful unless matched by intensive local area efforts, both of which must take into account the inherent cultural, technical, and political realities. These factors present the most significant obstacles to the rapid implementation of telemedicine capabilities in disasters and complex emergencies.

Although the application of telemedicine to disaster scenarios appears promising and logical, applying telemedicine technology to disaster settings is presently expensive both in terms of initial cost and investment of professional time and effort in the development, teaching and implementation of new practice paradigms and supporting protocols. It can only be employed effectively in disaster settings if it is also in frequent use in the routine delivery of health services. Leveraging a disaster medicine capability by employing it regularly in non-disaster settings should increase acceptance, and proficiency, reduce cost, and increase access to high quality health care. Extending the use of telemedicine to nonclinical areas (pharmacy, supply and equipment, administrative support) and to non-medical sectors of disaster management, increases the power of this leveraging. This parallel development of Disaster Medicine, Telemedicine, and provision of routine health care demands serious attention.'⁴

The United States armed services have long had an interest and involvement in both mobile health and telemedicine services. In fact, some of the most ambitious global applications of telemedicine and utilization of satellite technology can be found in the military.

Recent developments in data compression, fiber optics, satellite communications, computer inter-networking, information technology, advanced medical imaging and diagnostics have combined to provide the US military with the ability to establish a world-wide integrated health care delivery network. Various combinations of these technologies have been tested in Joint exercises, US Army Advanced Warfighting Experiments (AWEs), on board deployed naval vessels, in the peacetime Military Health Service System (MHS), and as part of the support for operations in Saudi Arabia, Kuwait, Somalia, Haiti, Cuba, Panama, Croatia and Macedonia.

Advanced telecommunications technology was used in conjunction with mobile health units during the war in the Persian Gulf"⁵ demonstrating that these two technologies can be integrated, even under difficult geographic and climatologic circumstances, with beneficial effect.¹⁶ Computerized tomography (CT) scanners were installed in transportable modular military hospital units and deployed in the Saudi desert just south of the Iraqi and Kuwaiti borders.'⁷ During Operation Restore Hope, beginning in February 1993, physicians of the 86th Evacuation Hospital in Mogadishu, Somalia, transmitted still, digitized images and voice messages from a portable 'Standard A' INMARSAT (International Maritime Satellite) terminal to Walter Reed Army Medical Center (WRAMC) in Washington, DC. Consultative systems at WRAMC were linked to both MEDLINE and the Composite Healthcare System (the Department of Defense medical computer network). A similar system has been deployed to Zagreb, Croatia and the Army's medical center in Landstuhl, Germany, since May 1993. The Navy's Fleet Hospital Six, which took over the United Nations peacekeeping operations in Zagreb, Croatia, from the Army retained the link to WRAMC and also established links to the Naval Medical Center at San Diego.

Recently, the US Department of Defense established a medicine network that serves US troops in Bosnia and other countries. The telemedicine segment of this project, known as Operation Primetime III, is designed to help Army physicians communicate with each other using real-time voice and video for consultation and diagnosis. The communications network in Bosnia is being supported by an Orion-built communications satellite orbiting over the area, thereby providing direct broadcast capability. Using commercially available technology, frontline physicians can transmit X-rays and other medical images to field hospitals for diagnostic support. These same links, which extend to deployed units and small clinics at forward areas in Bosnia, connects Army physicians in Bosnia with physicians at five regional military medical centers in the USA. The network also offers online medical information, patient administration systems, and information Systems. Operation Primetime was first established in 1993 to provide telemedicine support to medical units in Macedonia and Croatia. The operation was upgraded to Primetime 11 in 1995 with a 30-fold increase in communications bandwidth that substantially improved the transmission of medical images for diagnostic consultations. The telecommunications, advanced medical diagnostics and medical informatics provided by Primetime III Task Force has resulted in an integrated, world-wide system of telemedicine enabled healthcare delivery extending from the forward operating bases of Bosnia to the major military centers in Washington, DC, Texas, California, and Hawaii. Continental US based MHS Medical Centers are responsible for providing local telecommunications, video teleconferencing, teleradiology and clinical staff support necessary to provide continuous specialty and sub-specialty real-time interactive and store and forward teleconsultation support. The selection of medical centers positioned in varying time zones around the globe facilitate 24-hour, 7 days per week support without requiring additional medical staffing. This is a very exciting global telemedicine concept in that telemedical consultations literally 'follow the sun' around the Earth.¹⁸

The US armed forces are also engaged in a large-scale program of telemedicine research and development. This includes the distant physiological monitoring of deployed troops, and investigation of such technologies as telepresence,¹⁹ virtual reality, and telerobotic laparoscopic surgery.²⁰ The US Army has also experimented with telemedicine to provide care to persons living on remote islands in the Pacific Ocean.²¹

Another wide-area telemedicine project is AKAMAI, a tri-service project for electronic diagnosis and consultation, an effort headed by Tripler Army Medical Center in Hawaii. AKAMAI allows for Tripler (a tertiary medical center) to support a referral area of over one million square miles and a diverse military and civilian user group throughout the Pacific. The long-term goal of this project is to expand telemedicine into the Pacific Basin by establishing a Pacific-wide telecommunications system for medical information, including Picture Archiving and Communication System (PACS), telemedicine consultation, teleradiology imaging, digital patient records, and new technologies as they develop (eg telesurgery and telepathology).²²

The US Office of the Assistant Secretary of Defense Health Affairs is working with a number of federal agencies and industry to develop an infrastructure to fully exploit the potential for telemedicine and computer-based patient records globally throughout the US Military Health System. The goal is to have technology-based services that allow connectivity among military treatment facilities; interoperability among information systems at military treatment facilities; and commonality among the health care and related applications which run on these information systems. And, finally, to integrate these efforts to their fullest capacity, the Surgeon General of the Army has created a special project office for Advanced Technology and Telemedicine to encourage collaboration within the entire US Department of Defense.

Telemedicine is not a new concept to space flight. Since its very beginning space medicine has utilized communications and information processing technologies. In many aspects the operational boundary conditions in space medicine, such as remoteness, telediagnostics, and biotelemetry are characteristic of telemedicine applications on Earth.

Since the 1960s, in parallel, the United States and Russia served as pathfinders in the development of space telemedicine when they developed capabilities for remote medical monitoring and care for astronauts in their human space flight programs, beginning with Mercury and Vostok, through the current Space Shuttle and Mir programs. Medical conferences are held between the crew surgeon and crew members, and astronauts during extra-vehicular activity (EVA) are constantly monitored via telemetry. This type of medical monitoring has existed for decades. For example, during the Apollo lunar excursions, EKG, heart rate, oxygen consumption, heat production, suit carbon dioxide levels, and other physiologic and environmental variables were monitored by a biomedical team at NASA's Mission Control Center at the Johnson Space Center (JSC), Texas. Flight surgeons were on alert to catch potentially dangerous physiological conditions or events.²³

Currently the US Space Program (through NASA) has in place a training program that would enable astronauts who are not medically trained to be providers of remote telemedicine services (ie able to conduct a basic examination for consulting physicians on Earth). Complicating the provision of such services is the fact that the astronauts must learn to perform these tasks in a micro gravity environment. NASA has recently developed the capacity for private medical conferencing from orbiting spacecraft to Earth stations. Prior to this, telemedicine consultations had to be done via radio or video channels that were potentially open to the public. In the current system, the transmitted data are encrypted and transmitted to the Johnson Space Center, via White Sands Missile Base, New Mexico. These one-way (Shuttle to Earth) video and two-way audio signals are received in unscrambled form only by the chief medical officer in Houston, protecting the confidentiality of astronauts and allowing NASA to limit media coverage of medical problems in space.

Development is continuing for telemedicine applications to support US astronauts aboard the Russian Mir space station and the International Space Station at the turn of the century. NASA's first permanent, operational, international space telemedicine system will be established to support NASA's flight surgeons and astronauts training in several locations in Russia, including the Gagarin Cosmonaut Training Center in Star City, the TsUP (Mission Control) at Kalingrad, several sites in Moscow, and the Baikinor Cosmodrome in Kazakhstan. Utilizing NASA's Program Support Communications Network (PSCN), flight surgeons and astronauts in Russia will be able to obtain telemedicine consultations from the NASA Johnson Space Center (JSC) in Houston, Texas.²⁴

Telemedicine capability will be an important component in space crew health care onboard the International Space Station, especially in the prevention and early intervention aspects of disease and injury. In addition, in a medical emergency, telemedical capability can play an important 'lifeline' role in the rapid exchange of patient information and access to medical expertise and crucial instruction. However, if an emergency is life threatening and requires immediate medical treatment, the combined benefits of telemedicine and existing onboard medical capability may be limited, requiring medical evacuation to Earth.

In such a scenario, a crew rescue vehicle or 'ambulance' or even mission abort to return a crew member home may take hours, days, or even months depending on a Variety of circumstances (eg launch and/or landing feasibility, weather conditions, possibility of further patient injury upon reentry/landing, etc.). Given the consideration of passage of time for transport, potential of further injury during transport, etc., in certain cases the patient may indeed be better off treated inflight and/or the situation effectively managed until an appropriate mode of return to Earth is established. In order to provide patient stabilization and management in a crisis, the appropriate array of tools for adequate diagnosis and treatment must be on hand. Indeed, a future medically enhanced space station or facility could provide valuable learning experience for initiating greater crew medical autonomy, such as would be required for interplanetary flight where an 'ambulance' or mission abort may not exist as options (due to distance) in a medical emergency.

Granted, the overall space station experience is still in its infancy (in that so far, only a small population of individuals have flown for extended periods) and critical life-threatening medical emergencies requiring immediate evacuation or rescue have not occurred (astronauts, through selection, are extremely healthy), it is still likely that after the International Space Station becomes operational, a greater number of individuals will visit and work onboard. The possibility therefore exists that a life threatening medical emergency could occur, testing our wisdom and judgment in the types of onboard medical diagnostic and treatment capabilities initially provided. However, at this early stage, it is very difficult to plan for every possible medical emergency that might occur and space flight is still understood to be 'experimental' with definite risk attached to the occupation. In the future, especially in the more advanced and physically distant spaceflight scenarios, the medical provisions and expertise onboard and not necessarily the telemedical capability. may prove to be the most critical factors determining the life or death outcome of an individual in a medical spaceflight emergency.

 Conclusion

At this point in time, the claim that telemedicine will introduce revolutionary changes in global health care delivery and information access may seem premature, yet there are clear indications that dramatic changes have already occurred in the medical information infrastructures and vast networks already established. The information age is already upon us in health care. Telemedicine is bringing reality to the vision of an enhanced accessibility of medical expertise and a global network of health care available in any situation. The real question about the future of telemedicine is not whether it is here to stay but rather the extent to which we have the foresight to fully exploit it-building lifelines on Earth and as far as the human spirit dares to dream.

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Note: The views expressed in this article are those of the authors and do not necessarily reflect the opinion of the Tripler Army Medical Center or US Department of Defense.