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Introduction

An early form of telemedicine communication in the developing world was the radiotelephone. A series of ham radio operators would establish a schedule of time available for the long-distance communication between remote locations and more centralized locations. During the early 1960s, one of us (DAP) managed distant medical consultations between US military staff in Panama and distant military groups, missions and embassies from Mexico to South America using the Military Affiliate Radio System. At a prearranged weekly time, a radio operator would connect the various organizations together. Medical questions were discussed, which facilitated decisions regarding local medical care versus evacuation. However, radiotelephony was susceptible to problems caused by the weather and sunspot activity, resulting in loss of bandwidth and sometimes loss of signal. During the same period of the 1950s and 1960s, communications within the far-flung US-associated Pacific Trust Territories were handled in a similar manner.¹

Early telemedicine work at Tripler Army Medical Center

Tripler Army Medical Center (TAMC) was the test site for the Composite Health Care System, a database of the US Department of Defense. It was deployed in the late 1980s, and included modules for order entry, retrieval of radiology and laboratory results, pharmacy, patient administration and coding information. An email function was added in 1995, and this provided the basis for teleconsultations and referrals within the military health care system in Hawaii and ultimately military medical facilities in the Pacific. File attachments, however, were not allowed in the secure Composite Health Care System, which limited telemedicine to the written word only.

In 1993, telemedicine consultations with TAMC were begun from the US Army Kwajalein Atoll Missile Range in the Marshall Islands. There was an existing AT&T videoconference system at Kwajalein Atoll. About 150 consultations were conducted over 5 years, and a few unnecessary referrals to Honolulu were avoided.² The process, however, was difficult to schedule. Expensive computer and video hardware and costly maintenance with special technical support were required. By virtue of the proximity of the Ebeye Island to Kwajalein, a few Marshallese patients benefited from this demonstration project, but it was obvious that such a technology-dependent system was not practicable in the rest of the Pacific.

In 1995, at the inaugural meeting of the Pacific Basin Medical Association held in Pohnpei, the utility of the Picasso still-image telephone was demonstrated by a consultation on a patient in Palau, some 2400 km away. That consultation avoided the evacuation of the patient from Palau to Hawaii (saving at least US$20 000).¹ Four Picasso telephones were donated by AT&T to jurisdictions in the Western Pacific, and over 30 telemedicine demonstration projects were successfully carried out on the island of Pohnpei, between islands in Pohnpei State, and internationally between Alaska, Hawaii, Pohnpei, New Caledonia, Kosrae State and Palau. Several patients were transferred using this process. However, the cost of long-distance calls became prohibitive, and local health budgets could not continue paying such costs (US$5–10 per minute).³

Pacific Island Healthcare Project

At about the same time (1989–1990), a programme to benefit the graduate medical education needs of TAMC’s residents in training was developed. The Pacific Island Healthcare Project (PIHCP) was developed to facilitate the referral and treatment of indigenous peoples of the former Pacific Trust Territories, now referred to as the US-associated Pacific Islands (USAPIs). The USAPIs include three US territories (American Samoa, Guam and the Commonwealth of the Northern Mariana Islands) and three independent, freely associated states (the Republic of the Marshall Islands, the Federated state of Micronesia and the Republic of Palau) (Figure 15.1 and Table 15.1). The peoples of the USAPIs suffer from diseases such as tuberculosis, rheumatic heart disease, leptospirosis, dengue fever, pyomyositis and leprosy, as well as chronic diseases such as diabetes mellitus, obesity, hypertension, hyperuricaemia and cancer. In addition, there are surgically correctable congenital lesions, such as cleft lip/palate, congenital diaphragmatic hernia, Hirschprung disease and hypospadius.

The challenges of managing consultations with the time differences (five time zones and an International Date Line) and great distances (8000 km between Honolulu in Hawaii and the Republic of Palau) are formidable. The region is extremely remote (Figure 15.1). Some distant islands and atolls are 600–1300 km from the jurisdiction’s capital, reachable only by sailing canoe. Prior to the development of the web-based referral system, consultations from the jurisdictions came in the form of letters, long-distance telephone calls, faxes and even the diplomatic pouch. From 1988 to 1997, the PIHCP provided definitive care at TAMC for about 2500 patients from the USAPIs. The web-based system was established in 1997, and in 1998 we were able to demonstrate asynchronous consultations with TAMC.⁴

Figure 15.1 US-associated Pacific Islands, with an overlay of the continental USA (to scale) to demonstrate the distances invlolved

Since that time, email with attached images has been shown to be an acceptable medium for consultation for almost all patients. Several steps were needed to implement four test sites in Micronesia. First, a consultation web page was created with a request form to ensure that there was sufficient information to allow TAMC specialists to comment. Second, a web page was created to display all current or recent consultations received from the USAPIs. Third, a group of TAMC specialists was trained in the use of a web browser to access the consultations and comment on cases where appropriate. The use of a web-based system provided a flexible approach to patient management discussions. Four sites within Micronesia were selected as test sites: Chuuk, Pohnpei, Palau and Majuro in the Marshall Islands. Each location had relatively inexpensive Internet service providers (ISPs) and 24-hour access to the Internet. Each site was provided with:

• a desktop computer
  
  
• a digital camera (D-600L, Olympus)
  
  
• a flatbed scanner with transparency adapter (Scanmaker E6 Professional, Microtek)
  
  
• a digital video camera (DCR VX-1000, Sony)
  
  
• a printer.

In addition, two sites were provided with a digital otoscope and ophthalmoscope (American Medical Devices).

Training was conducted in two phases. First, a group of all interested clinicians at the annual Pacific Basin Medical Association meeting in Chuuk were allowed to test the equipment. Once the equipment had been installed at each site, small groups were trained. For many of the medical officers, this was the first opportunity that they had had to see or use a computer. It should be noted that five senior physicians in Yap, Pohnpei and Palau had access to the web page using their personal computers. Their involvement was important to the success of the programme.⁴

Clinical procedure

The first step in creating an electronic consultation is to gather digital images where appropriate. Even in cases where images do not support the consultation, an image of the patient helps to humanize the electronic process. Images are acquired using a digital still camera, digital video camera or digital medical device camera. Additional images can be acquired using the flatbed scanner (e.g. laboratory results, ECG recordings, photographs and X-ray films). Initially, it proved difficult to produce images of acceptable quality from X-ray films. However, in most cases, careful use of the digital camera to acquire an image on a light box proved satisfactory.⁵ Images are annotated using simple image editing software, with date, comments on area of concern and an identifying code as applicable.

Next, the history of the patient must be typed into the computer. This step is often completed before the connection to the Internet is made. The clinicians use a common word-processing program to type the medical history, and then copy and paste it into the website form; we do not use a rigid format for the history. Once complete, the clinician connects to the Internet and submits the case. Depending on the number and size of attached images, this process can take several minutes. The resulting electronic patient record is archived and can be retrieved via the website.

Once a new case is received, an automatic email notification is sent to the PIHCP Director. The Director queries the database to find the case. The information is protected by secure socket layer (SSL) encryption, which meets the current Health Care Financing Administration guidelines for secure clinical use of the Internet. The consultation is displayed as the provider types it in, with attached images displayed if included. The Director then comments on the case and forwards it to appropriate specialists as required. All comments are stored in the database, complete with time/date stamp and user information.

Specialists are notified of a new case via email. The email message contains a working diagnosis, a case number and a link to the PIHCP website. After reviewing the clinical data and images, the specialist can comment on the case or ask for further information or testing to be done. The remote provider is notified by email of the new comments, and reviews these on the website. If further information is required, he or she can enter the response on the web page. In this manner, a difficult case can be discussed using the website as a discussion group for a specific patient.

Figure 15.2 Numbers of PIHCP cases (n = 3039): (a) origin; (b) type. CNMI, Commonwealth of the Northern Mariana Islands

Results

By the end of 1999, we had installed 10 workstations in all of the jurisdictions of the USAPIs. More than 3000 consultations and referrals have been submitted in the nearly 10-year history of the telemedicine programme (Figure 15.2). The majority of the cases have come from the Marshall Islands, the Republic of Palau and Chuuk State. The US Congress provides US$2.5–5 million per year to the PIHCP for patient travel and medical care. After an initial investment of approximately US$300 000 to install the workstations and train the local providers, the PIHCP programme has been self-sustaining. The leadership of TAMC has supported the programme and integrated its administration into the hospital’s business plan. Administrative support is provided by TAMC’s Patient Administration Division and technical support is provided by TAMC’s Information Management Division. The Medical Director has provided the direction, leadership and oversight of the PIHCP as a labour of love.

We do not provide a list of indications for telemedicine. The decision to initiate a teleconsultation is left to the referring doctor. The numbers of patients accepted to TAMC for further evaluation and treatment are shown in Table 15.2. With the implementation of the web-based system in the late 1990s, there has been a drop in the number of patients brought to TAMC for evaluation and treatment. This has not been due to a decrease in the number of cases submitted to the PIHCP. It has been due to more accurate triage of those who would benefit from transfer to TAMC using the web system. In addition, the web-based system allows many patients to be treated locally with telemedical support from TAMC specialists. Both factors lead to improved health care for a greater number of patients. The costs associated with the care of those patients brought to TAMC are shown in Figures 15.3 and 15.4.

The PIHCP telemedicine system has had a significant effect on medical practice as reflected by the length of stay (Figure 15.5). Prior to the development of the web-based PIHCP system, the average length of stay for Pacific Island patients approached 30 days. Since implementation of the teleconsultation process, the length of stay has fallen, and is currently just over 5 days. This is a consequence of more appropriate triage of patients prior to transfer to TAMC, as well as improved coordination of care once the patient arrives.

Implementation of the web-based consultation system has had other advantages. It has allowed isolated practitioners to stay connected with their colleagues throughout the Pacific and be kept up to date with modern medicine. There has also been educational value for the residents in training at TAMC. Numerous publications have resulted from patient referrals.^5–10 Pacific Islanders have been restored to health, and have returned home to lead normal and productive lives.

Figure 15.3 Number of PIHCP cases and total costs

Figure 15.4 PIHCP: total expenditure for all islands. FY, financial year

Figure 15.5 PIHCP: number of cases accepted and length of stay

Pacific Asynchronous TeleHealth system

TAMC is the tertiary military medical treatment facility for the US military (active duty staff, retirees and dependants) in the Pacific region. TAMC’s area of responsibility includes US military bases in Korea, mainland Japan, Okinawa and Guam (Figure 15.6). These remote military health care facilities are often staffed by relatively junior physicians and have limited access to subspecialty care. Even if subspecialty care is available in the host nation, language and cultural limitations represent significant impediments to providing safe and effective care. A teleconsultation system capable of providing subspecialty services had the potential to improve both access to and quality of health care delivered.

TAMC’s asynchronous telemedicine for US military beneficiaries started in 2000, with the Electronic Children’s Hospital of the Pacific (ECHO-Pac) asthma intervention. Children with asthma were enrolled from military facilities in Guam, Okinawa, mainland Japan and Korea. Each child was cared for utilizing an asthma clinical pathway with advice from a paediatric pulmonary specialist via the website. All patients experienced an improvement in their asthma. There were fewer emergency room visits and fewer unscheduled acute clinic visits. At the same time, the primary care provider’s practice in caring for children also improved as a result of increased use of asthma education and planning.¹¹

In addition to the asthma intervention, ECHO-Pac included a general consultation capability modelled on the PIHCP. This feature was far more popular with remote health care providers than the asthma intervention. From October 2000 until April 2004, a total of 875 teleconsultations were submitted to the ECHO-Pac system from 14 different US military hospitals and clinics throughout the Western Pacific. These consultations included over 1700 images and more than 7000 clinical comments from numerous specialists.

Figure 15.6 US military health care facilities in the Pacific region, with overlay of the continental USA (to scale) to demonstrate the distances involved: Honolulu is closer to Atlanta (7230 km) than it is to Seoul (7320 km) or Okinawa (7480 km)

One of the difficulties with technology research is the lack of ‘measures of effectiveness’ for new initiatives. Technology is often pursued because it can be done, without asking whether it should be done and with no plan to measure whether the technology makes a difference. In 2004, the PacRim Teleconsultation Effectiveness Trial evaluated ECHO-Pac’s impact on access to specialty care, the quality of the care provided and the cost savings. A panel of 5 physicians evaluated 267 consultations over a 1-year period. The average time for the consultation to be reviewed and forwarded by the consult manager was 5 hours (SD 3), with a reply from a consultant in an average of 32 hours (SD 14). The diagnosis was modified in 15% of cases, the diagnostic plan was modified in 21% and the treatment plan was modified in 24%. Air evacuation to TAMC for further evaluation was reduced by 30%. Given the significant cost of moving patients (approximately US$5800 per case), use of the ECHO-Pac teleconsultation system demonstrated significant cost avoidance.¹²

As a result of the success of the ECHO-Pac teleconsultation system, TAMC launched the Pacific Asynchronous TeleHealth (PATH) system in 2004. PATH was created with a modular design to expand the capabilities to the care of both paediatric and adult patients. Subsequent modules have included Lightning Med (used by military health care providers in Afghanistan and Iraq) and a module for tele-auscultation development and testing.¹³ The secure website allows health care providers at medical treatment facilities throughout the Pacific region to submit cases for subspecialist input. Referring physicians provide clinical information, along with images, video and sound as necessary. At the TAMC, physician managers forward the case to the appropriate subspecialty for comment, and email messages notify all involved in a case when new information or comments have been added.

Differences from the Pacific Island Healthcare Project

Although PATH was modelled on the PIHCP website, it became apparent that the different patient and referring provider populations served would require some modifications to the teleconsultation process. For example, US military beneficiaries have both increased health care options and expectations compared with patients served by the PIHCP. Since use of PATH is not mandatory, referring providers can simply refer the patient for local specialty care (if available) or for air evacuation to TAMC or another tertiary military treatment facility. Our philosophy has been to simplify the teleconsultation process where possible, knowing that many health care providers will opt for the least time-consuming option when sending a patient for subspecialty care. As a result, the processes of teleconsultation submission, administration and multimedia handling have continued to change with technology innovations and provider needs.

Documentation and privacy requirements are demanding in PATH, which must comply with all US regulations. The results of teleconsultation must ultimately reside in the patient record, so we developed a system that allows the consultation notes to be printed onto standard US military health care forms for inclusion in the patient’s record. The security is sufficient to comply with the Health Information Portability and Accountability Act of 1996. The password encryption protocols are rigorous so as to ensure security. Although email is used to inform providers of new information regarding a specific case, no individually identifiable health information is included in the messages.

Documentation of services provided in PATH is important. Although few US insurance companies offer reimbursement for asynchronous telehealth, the Surgeon General of the Army grants appropriate workload credits for telemedicine. For this purpose, a billing module was created in PATH allowing for workload capture on the part of the subspecialist. Once a teleconsultation is entered into the PATH system, the patient administrators receive an email message informing them of a new patient requiring registration into the local hospital system. Once a subspecialty provider completes teleconsultation services in PATH, the billing module allows for easy coding of diagnosis. On completion, departmental coders are alerted of the billing form via email and can enter the data into the system. This streamlined approach reduces the extra work required of the consultant (approximately 10–15 seconds to complete and email the workload credit form) while documenting the workload provided by PATH. Accurate documentation is essential to continued funding of the PATH system.

Experience with PATH

Since its launch in October 2004, the number of consultations submitted to the PATH system has increased (Table 15.3). There has also been a 20% increase in the number of images submitted per teleconsultation in just over two years. Since the opening of the adult telemedicine module, nearly one-third of all consultations submitted have been for adult patients. This rapid growth verifies the demand for adult subspecialty teleconsultation services in the region.

The system is designed to accept all types of referrals. When a physician is registered in PATH, and during the consultation process itself, referring providers are reminded that it is not intended to be used for medical emergencies. Currently, there are over 600 registered users from 30 military hospitals and clinics throughout the Pacific. All of this activity has occurred despite the fact that PATH’s use is optional, and no formal system training occurs. Since most US military physicians serve for only one to two years in the Western Pacific, there is high turnover among PATH users.

As described above, the PATH system improves subspecialist access and quality of care while reducing health care expenditures from air evacuation or referral to host-nation specialists. Even for patients who are transferred to TAMC for further evaluation, PATH minimizes health care expenditures by reducing test duplication and coordination of efficient diagnostic and therapeutic options, resulting in a more rapid return to duty.

Challenges

Like many telemedicine systems, PATH was initially funded by research and development funds without a clear plan for financial sustainability. Once initial funding had been obtained, we sought funds from referring institutions based on the cost savings from avoided air evacuations. We chose this avenue because of the high cost of air evacuation (US$3000–6000 per patient), believing that the 30% reduction demonstrated in the PacRim Teleconsultation Effectiveness Trial¹² would make the system sustainable. Owing to the financial structure of the US military health care system, however, no single institution was responsible for these expenditures and, although each potential organization felt that PATH was a useful service, none was willing to contribute to its costs. Fortunately, the Army Surgeon General recognized PATH’s value and provided funds (approximately US$100 000 per year). Since the initiation of the workload capture function in late 2006, we anticipate that the revenue generated from PATH’s teleconsultation services will provide the necessary financial resources for future sustainability.

The US military’s transition to an electronic medical record (EMR) has resulted in further challenges for the PATH system. Since the clinical information needed for teleconsultation is already stored in a digital format in one of several computer systems, remote US health care providers have requested system interoperability to streamline the consultation process. In addition, the results of a PATH teleconsultation must find their way back to the patient’s EMR so that future caregivers have access to the information. At present, this is a manual process, albeit one under review.

The introduction of telemedicine has provided opportunities to expand PATH’s capabilities. We are currently experimenting with a variety of tele-auscultation devices for telecardiology. Although there was initial enthusiasm about using these devices, once the novelty wore off most were abandoned because of the time required and the lack of technical support available. We have learned that, although transmission of useful telehealth information may be possible with these devices, they must first be tested and integrated into PATH for seamless use prior to deployment. This is a challenging task, owing to the range of proprietary software and hardware, and the few interoperability standards.

Improved communications in the Western Pacific, by non-secure email, telephone or fax, has resulted in frequent consultations by health care providers outside the PATH system. Since these routes allow for easy, rapid consultation, some health care providers prefer this to utilizing the PATH system. However, such consultation routes do not meet privacy requirements, result in little, if any, clinical documentation, and fail to generate workload credit for the physicians involved.

Future work

We continue to develop the PATH system. For example, the tele-auscultation module allows remote digital stethoscopy. This includes a digital heart sounds recording system, which can be operated via a graphical user interface. Using this system, paediatric cardiologists can differentiate normal from abnormal heart sounds with a high degree of accuracy.¹³ We are also beginning to use the PATH system for tele-education. This will provide continuing medical education to staff distributed throughout the Pacific region.

Acknowledgements

The views expressed here are those of the authors and do not reflect the official policy of the Department of the Army, Department of Defense or the US Government.

Further reading

Mahnke CB, Mulreany, MP. PacRim Pediatric Heartsounds Trial: store-and-forward pediatric telecardiology evaluation with echocardiographic validation. In: Klapan I, Poropatich R, eds. Remote Cardiology Consultations Using Advanced Medical Technology – Applications for NATO Operations. NATO Science Series, I: Life and Behavioural Sciences, Volume 372. Amsterdam: IOS Press, 2006: 65–72.

Swinfen R, Swinfen P. Low-cost telemedicine in the developing world. J Telemed Telecare 2002; 8(Suppl 3): 63–5.

Tripler Army Medical Center. Pacific Island Healthcare Project (PIHCP). Available at: tamc-tmed.tamc.amedd.army.mil/pihcp.

Wootton R, Youngberry K, Swinfen R, Swinfen P. Referral patterns in a global store-and-forward telemedicine system. J Telemed Telecare 2005; 11(Suppl 2): 100–3.

References

¹ Yano V, Finau SA, Dever G et al. The PBMA and telemedicine in the Pacific: the first steps. Pac Health Dialog 1997; 4: 81–4.

² Delaplain CB, Lindborg CE, Norton SA, Hastings JE. Tripler pioneers telemedicine across the Pacific. Hawaii Med J 1993; 52: 338–9.

³ Person DA, Whitton RK. An Internet based consultation and referral network between Tripler Army Medical Center and hospitals in the Western Pacific. In: Proceedings of Pacific Medical Technology Symposium, 1998: 132–8.

⁴ Person DA. Pacific Island Health Care Project: early experiences with a web-based consultation and referral network. Pac Health Dialog 2000; 7: 29–35.

⁵ Ruess L, Uyehara CF, Shields KC et al. Digitizing pediatric chest radiographs: comparison of low-cost, commercial off-the-shelf technologies. Pediatr Radiol 2001; 31: 841–7.

⁶ Person DA. The Pacific Island Health Care Project: easing the cancer burden in the United States associated Pacific Islands. Pac Health Dialog 2004; 11: 243–7.

⁷ Person DA. The Republic of Palau and the Pacific Island Health Care Project (PIHCP). Pac Health Dialog 2005; 12: 132–40.

⁸ Hensel KS, Person DA, Schaefer RA, Burkhalter WE. An internet-based referral/consultation system for the US-associated Pacific Islands: its contribution to orthopedic graduate medical education at Tripler Army Medical Center. Mil Med 2005; 170: 214–18.

⁹ Belnap CP, Freeman JH, Hudson DA, Person DA. A versatile and economical method of image capture for telepathology. J Telemed Telecare 2002; 8: 117–20.

¹⁰ Meza-Valencia BE, de Lorimier AJ, Person DA. Hirschsprung disease in the US associated Pacific Islands: more common than expected. Hawaii Med J 2005; 64: 96–101.

¹¹ Malone F, Callahan CW, Chan DA et al. Caring for children with asthma through teleconsultation: ‘ECHO-Pac: The Electronic Children’s Hospital of the Pacific’. Telemed J E Health 2004; 10: 138–46.

¹² Callahan CW, Malone F, Estroff D, Person DA. Effectiveness of an Internet-based store-and-forward telemedicine system for pediatric subspecialty consultation. Arch Pediatr Adolesc Med 2005; 159: 389–93.

¹³ Mahnke CB, Abbas M, Mulreany MP. PacRim Pediatric Heartsounds Trial: asynchronous pediatric cardiology evaluation via tele-auscultation. Presented at the 2nd Annual Pediatric Telehealth Colloquium, San Francisco, CA, 6–8 September 2007.

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