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Military telemedicine developments are a test for future applications

The BBI Newsletter - February 1, 1997

The most interesting and widespread applications of telemedicine are not in the commercial health care sector; rather, they are military applications. The military is an ideal test bed for telemedicine because legal issues surrounding the practice of medicine across state (or even country) borders often do not apply, and military application of the technology is in fact global in scope. The U.S. military has a medical beneficiary requirement to support the care of 8.5 million individuals who are in uniform, or dependents of those in uniform. These personnel are located at diverse sites scattered around the world - and even in space - where conventional medical services and diagnostic devices are limited. And, it is not yet as affected by the cost constraints of managed health care as are those serving the general populace.

The focus and objectives of the U.S. military have changed with the collapse of the Soviet military threat, and the U.S. now seems to have a policy of projecting limited military force into multiple theaters of operations around the world. Such objectives place great importance and pressure on logistical support, including medical support. Many of the Army's programs fall under the Army Medical Department (AMEDD) and its various subordinate groups. AMEDD was responsible for the use of telecommunications in the Gulf War and Somalia, providing medical support for deployed troops using digital radiology and other specialty consult services. The focus in military telemedicine has accelerated since the Gulf War and now includes the integration of distance learning, virtual reality and video conferencing applications.

How these digital battlefield elements fit into the overall military strategy for Force XXI was explored at the second annual National Forum on Global Telemedicine and its International Implications, sponsored by the U.S. Army Medical Research and Materiel Command (USAMRMC) in conjunction with Georgetown University Medical Center (Washington) in April 1996, and characterizes the type of civilian-military cooperation and dialog which is developing around telemedicine issues. By directive of Dr. Stephen Joseph, assistant secretary of defense for health affairs, the Telemedicine Test Bed (TTB) was established in 1994 to manage the rapidly expanding uses of telemedical technologies in the military. The Army was appointed as the executive agent for the triservices cooperation in this project, with the Army surgeon general as the CEO of the effort. The commander of medical research and materiel at Ft. Detrick (Frederick, Maryland) was the COO of the effort. This led to the Medical Advanced Technology Management Office (MATMO) at Ft. Detrick coordinating the telemed programs. The Telemedicine Test Bed's mission is to test telemedicine and information system technology intended to support the practice of military medicine in both war and peacetime.

The TTB is organized as a global interconnection of information technologies and facilities. It will include the development and deployment of a database about telemedicine projects operating and under way around the world, so that information and experience with telemedicine projects can be shared, and problems encountered can be avoided in new system designs. For interested readers, a list of 38 major projects, including contacts and their e-mail addresses, is available from Medical Strategic Planning Inc. (Lincroft, New Jersey).

One active group is the Army Materiel Command, which deals with medical readiness and the care of combat victims. It has three interesting projects related to telemedicine. The first is logistical support for battlefield trauma assessment and care, for which it is developing a "personal status monitor," or PSM. The PSM is supposed to access vital functions so a diagnosis can be made as to the degree of severity of a soldier's wounds. This is a necessary step in saving lives and focusing limited care resources on those soldiers who need care most urgently.

The PSM includes a small, wireless transceiver which sends data from several non-invasive biosensors that are worn by the troops. Vital signs telemetered at present include heart rate and waveform, blood pressure, body temperature, oxygen saturation and the onset of shivering. The data is sent to a field hospital or even back to Walter Reed Medical Center (Washington), where doctors with the necessary expertise determine who should be triaged first.

Patients who are triaged and removed from the battlefield can be taken to a "deployable digital medical treatment facility" (DDMTF), the high-tech MASH unit of the next century, which provides digital imaging (for X-ray images), wireless communications (again, back to stateside centers such as Walter Reed), and distributed video conferencing. The idea is to assist the medical personnel caring for patients with expert advice and consultation from doctors and specialists located remotely.

Imaging data is the most bandwidth-intensive application for telemedicine, and is proving to be a challenge for the Army to implement. The Army is working to increase bandwidth in current communication systems, and to replace current systems with shared bandwidth on demand, global networks via satellite and ground-based technologies, including fiber optic and wireless implementations of asynchronous transfer method (ATM) and Code Divison Multiple Access (CDMA) implementations of Ethernet networks across both radio and telephone links.

In cases where surgical personnel are not available on battlefield or forward deployment areas, or it is not possible to transport the patient to a surgical center, the Army will come to the soldier, with a Trauma Pod, a mobile OR of sorts which has robotic surgeons hooked up to real surgeons in a real-time, virtual reality link. The remote surgeons at Walter Reed can perform surgery on their battle field patients using their robot surrogates and assisted by field medical personnel. These "life-support trauma and treatment platforms" include ventilators, oxygen generators for breathing support, medicines, sutures, suction devices, infusion pumps - all the stuff normally found in a MASH unit.

All of these systems, from the initial telemetered medical assessment of the wounded soldier in the field to the data acquired at the DDMFT, go into an electronic medical record maintained for the patient and available by satellite link and the Internet to military medical personnel globally. The record includes: computerized radiology images, high-resolution still images, vital signs, assessments, treatments, and interactive video conferencing. It is a true paperless record. In initial experience at Walter Reed, medical consults constituted about 40% of the total consults, followed by surgical consults (36%) and radiology consults (21%). Other types of consults made up the remaining 3%. By practice, specialty dermatology accounted for 29% of the total, followed by radiology ([similar to] 21%), orthopedic surgery consults (16%) and various other types (55%). Most consults are routine in nature and handled in one day or less. Experience at other hospitals would be different as their medical missions are different, but these three plus psychiatry and medical education are among the most frequently implemented telemedical applications.

The number of consults at Walter Reed has been growing as U.S. military engagement sites have multiplied. Bosnia provided an excellent test bed for telemedicine concepts, and the frequency since then has escalated, with more support for consults in Somalia and Haiti than all other previous sites combined. Use of these services is split about evenly for U.S. military, UN members and local nationals, with a small number being used for U.S. citizens in foreign countries who are presumably unable to receive medical assistance there. Unlike some other military applications, telemedicine applications make more use of commercially available, off-the-shelf technology and products for audio and video, photography and computer workstations.

Walter Reed is but one site, however, and other services have other sites. Much work also is being done at Tripler Army Medical Center (Honolulu, Hawaii), Ft. Sam Houston (San Antonio, Texas), San Diego (California) Naval Air Station, Brooks Air Force Base (San Antonio), and various other Air Force sites, but the actual TTB is located at Ft Detrick. Often the services cooperate, as in the joint exercises of U.S. Army Advanced Warfighting Experiments conducted on-board deployed medical vessels and within the peacetime Military Health Service System. Real-time deployments of telemedical support systems have occurred in deployments in Saudi Arabia, Kuwait, Somalia, Haiti, Cuba, Panama, Croatia, and Macedonia.

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