Since 1994, a variety of telemedicine technology demonstrations and prototype telemedicine installations have been placed aboard U.S. Navy sea-going platforms. During the next fiscal year, the first fleet installations of a standardized Navy telemedicine suite will take place. This article is designed to familiarize IT professionals with basic telemedicine concepts and equipment.
What Is Telemedicine?
Telemedicine is the use of medical information exchanged from one site to another via electronic communications to provide improved health care and enhance education of the patient or health care provider. Put more simply, telemedicine involves the transfer of medical information over a distance.
The Navy Surgeon General's vision for the future of Navy medicine incorporated a number of strategic goals, two of which were directly responsible for telemedicine development. These goals were to:
Telemedicine was first deployed aboard an aircraft carrier for an extended deployment in 1994. Encouraged by a successful initial trial of transmitting digitized radiographs, subsequent deployments have fielded a variety of telemedicine tools, including computed radiology, medical video teleconferencing (VTC) and a wide array of video-enabled medical instruments. The USS George Washington recently completed a six month deployment in which she evaluated an advanced third generation telemedicine suite, which has now been proposed for fleetwide deployment on large-deck platforms. Telemedicine successes aboard carriers have led to demonstration projects aboard other vessels, including an attack submarine and an AEGIS cruiser.
The CHALLENGE ATHENA Project brings T1 bandwidth to deployed aircraft carriers and other large-deck ships, making telemedicine possible. The use of just a small portion of the bandwidth (64 kbps full-time, 128 kbps on request) has allowed the development of robust medical data and imagery transfer systems.
Naval bandwidth constraints have forced medical applications to become more efficient and rely less on live VTC sessions, instead emphasizing high quality still images which can be stored, compressed and transmitted at a later time using standard e-mail or FTP protocols. This is known as store and forward telemedicine.
Clinically, most telemedicine consults are for routine medical problems - not life or death emergencies. About 85 percent of medical teleconsults use a store and forward methodology. The remaining 15 percent of consults are performed with VTC - which seems the best medium for psychological evaluations, clinical examinations requiring physician/patient interaction and medical distance learning. Typical VTC usage is about 1-2 hours per week.
The MIDN Project
The Multimedia Integrated Distributed Network (MIDN), a telemedicine initiative, began in 1996 under sponsorship of the Composite Health Care System (CHCS) II Program headquartered at the National Naval Medical Center (NNMC) in Bethesda. CAPT Richard S. Bakalar, MC, USN, is the Functional Program Manager and head of the NNMC Telemedicine Department. The MIDN Project involves telemedicine links with two carrier battle groups, multiple medical treatment facilities, four regional clinics and various remote clinics worldwide. Extensions of this network are underway, supporting telemedicine installations on the USNS Comfort (TAH-20) during the exercise BALTIC CHALLENGE 98 and aboard the USS Bon Homme Richard (LHD- 6), which will be the first amphibious platform to receive a telemedicine capability. The MIDN Project also provides technical system engineering support, a virtual worldwide Internet help desk, clinical consultation support to DoD referring sites and the Navy/Marine Corps mission specific operational testbed to evaluate emerging telemedicine applications in real time.
The goals of the MIDN project are to:
Telemedicine Suite Components
The major telemedicine suite components are listed below:
Teleradiology
The teleradiology component of the telemedicine suite is based on a Computed Radiology (CR) processor, which captures the x-ray image on a phosphor plate instead of photographic film. The phosphor plate is scanned by an imaging laser and converted to a standardized digital file. A typical two-view chest x-ray results in a CR image file about 15 MB in size - it's available for review about 20 seconds after the plate is placed in the CR unit.
Unlike film, the phosphor plate is reusable and relatively insensitive to light, so no darkroom or film processor is required. CR technology also eliminates the need for using, storing and disposing of hazardous chemicals and waste products associated with conventional wet-processed x-rays. Digital radiological imagery significantly reduces patient radiation exposure and retakes due to poor exposures. Physicians are extremely comfortable with reading CR images and enjoy the digital enhancements possible with the system, including the ease of image retrieval (no more hunting for the x-ray jacket). Electronically stored x-ray images can be easily forwarded off-ship for further diagnostic analysis by shore-based medical experts using batch transfer telecommunications protocols.
Medical VTC
A standard PC-based PictureTel Live 200 system is located within the medical department. Five remote locations within the medical and dental departments will have the ability to conduct VTC sessions to support varied clinical requirements. Audio and video from any local or off-ship source can be distributed to any of the othershipboard VTC locations. A direct serial cable link carries the signal from the medical department up to the timplex unit in the ship's communications spaces.(See Figure 1.) In addition to clinical consultations, VTC sessions have been used to support family visits and baby-bonding between deployed Sailors and their newborn children. These visits demonstrate great potential for stress prevention for active duty personnel and their families, enhance personnel retention through improved morale and quality of life and promote wellness within our military families.
Medical Reference Library
Those ships with Internet access are able to bring medical reference resources to deckplate personnel using the Virtual Naval Hospital web page (http://www.vnh.org). A CD-ROM version of the Virtual Naval Hospital is also provided for those situations in which Internet access for deployed personnel is not available or operationally prudent. Both the Virtual Naval Hospital web page and CD-ROM version provide medical and non-medical personnel with the latest how to medical information arranged in a concise and easy-to-follow format.
Telemedicine Examples...
A worried Sailor reports to sickcall aboard ship with a new mole on his shoulder which seems to be enlarging. The ship's General Medical Officer evaluates the lesion and feels it is unlikely to be a cancer, but wants a dermatologist to evaluate the mole just to be sure. A corpsman, using a digital camera, takes several photographs of the mole and surrounding skin while the physician logs onto the TRICARE teledermatology web site and enters a brief patient history. The digital images are uploaded to the web site and the consult sent to the duty teledermatologist. Hours later, an e-mail from the dermatologist confirms that the mole is most likely a benign dermatofibroma which does not require surgical removal. The patient returns to duty, with his anxiety relieved by a specialist half a world away.
Results
During the USS George Washington's most recent deployment, over 3000 clinical x-rays and 60 telemedicine consultations utilizing 10 different medical specialties were completed. About half of the consults were for dermatology or psychiatric cases. Analysis of post deployment data confirmed that 20 medical evacuations were clearly avoided by the use of telemedicine, with a cost savings of approximately $88,000. There were other intangible benefits as well. The ship's hospital reported their inpatient census was up over 30 percent from previous deployments, in large part due to the fact that telemedicine consultations with stateside specialists allowed them to manage more patients onboard, shortening hospital stays and returning Sailors to duty faster. However, the biggest benefit is probably of inestimable value - the peace of mind for the patient and his family that a deployed Sailor or Marine has access to specialty medical care anywhere in the
world.Lessons Learned
The implementation of telemedicine has not been without challenges. Medical imagery software must be able to tolerate data drop outs which occur when data introduced because of faulty antenna tracking, atmospheric interference, ship's motion, etc. Limited bandwidth (compared to shore telemedicine operations) has placed emphasis on developing acceptable medical data compression algorithms for medical image transfer.
Other concerns include:
However, telemedicine involves more than just the addition of technological tools to the sickbay spaces. Researchers have learned that in order for telemedicine to be truly effective, they must change the mindset of deployed medical providers and make them realize they are not alone. Using telemedicine consults to their shore- based counterparts can be as easy as contacting the clinic at the local medical center while pierside in home port.
Fleet Telemedicine Suite Project
As part of the POM process, approximately $8.9M in funding was made available for FY-99 installation of telemedicine suites aboard carriers and large deck amphibious platforms. This project, led by SPAWAR PMW-154 in conjunction with the Navy Medical Logistics Command and Navy telemedicine developers, is working now to finalize the installation package. Final drawings, equipment specifications, and the Ship Alteration Request are in progress. A detailed Integrated Logistics Support package, which will address technical support, clinical protocols, user training and system administration training is being formulated as well. First installations are projected to begin in the April-May 1999 time frame.
The Future
Although this project will bring telemedicine support to large-deck ships, the medical personnel who might benefit the most from this technology are the Independent Duty Corpsmen who serve aboard smaller Navy ships and submarines. The barrier to placing telemedicine aboard these platforms has been the lack of sufficient bandwidth to support non-tactical applications. A small footprint telemedicine capability is under development as part of the Theater Medical Information Program - Maritime (TMIP-M), which has been proposed for deployment in late FY 00.
MIDN Project web site:
http://www-nmimc.med.navy.mil/midn/
CAPT Richard S. Bakalar, MC, USN
Executive Assistant to the Navy Surgeon General
for Telemedicine
Sean P. O'Brien
TMIP-M Project Manager
SPAWAR PMW-154
LT Morris Petitt, MSC, USN
TMIP-M Requirements Officer
OPNAV N62M