Moving Images Not Patients

March 2005
By Cheryl Lilie

 
Larry Markins (r), technical consultant, Telemedicine and Advanced Technology Research Center (TATRC), and Lt. Col. Morgan Williamson, USA, radiologist, 31st Combat Support Hospital, Balad, demonstrate the teleradiology system that was deployed to Iraq in the summer of 2004.  

Remote medicine technology provides better access to specialty care for deployed soldiers in Iraq.

Soldiers in the Iraqi theater are receiving medical care from doctors thousands of miles away through telehealth programs and the use of the Internet and servers. Physicians using this capability can provide better continuity of care and better medical access, as well as reduce loss of duty time for soldiers deployed in Iraq. In addition, the telemedicine systems implemented in Iraq throughout 2004 and into 2005 have aided not only the soldiers receiving the care but also the doctors providing it. The technology not only keeps them safe from traveling through hostile environments but also allows more collaboration between other doctors in theater.

“The three big pillars for health care are cost, quality and access,” says Col. Ron Poropatich, USA, military liaison to the U.S. Department of Homeland Security and senior clinical adviser, Telemedicine and Advanced Technology Research Center (TATRC), Fort Detrick, Maryland. “Access to care can be really problematic. Telemedicine helps bridge that gap.”

Col. Poropatich deployed to Iraq for five weeks in the summer of 2004 under the U.S. Army Medical Research and Materiel Command. He and Larry Markins, a technical consultant from TATRC, took 1,500 pounds of equipment worth $400,000 to provide telemedicine capabilities in Iraq. They deployed to four sites to set up the equipment: the 31st Combat Support Hospitals (CSH) in Baghdad and Balad and the 67th CSHs in Mosul and Tikrit.

According to Col. Poropatich, one of the largest applications for telemedicine in Iraq is teleradiology, which has been in the country since October 2004. There are 63 teleradiology digital imaging and communications in medicine (DICOM) servers deployed worldwide, including in Iraq, Kuwait and Afghanistan. The DICOM server can convert files from any image capture device, such as ultrasound, computerized axial tomography (CAT), magnetic resonance imaging or plain film, into a standard so the images can be opened on one server. These servers bypass the proprietary nature of the different machines being used in Iraq. Two DICOM servers have been deployed to Iraq, and in January three more were sent to U.S. Army, U.S. Navy and U.S. Air Force sites in Kuwait.

The primary use of teleradiology in Iraq is to move CAT scan images from Baghdad or Balad to Landstuhl Regional Medical Center in Germany so the images can be archived. If a soldier is evacuated from Iraq to Germany, those CAT scans can precede the evacuation. This enables better continuity of care because the older studies will be available to compare to any new images. Prior to this process, the data was copied onto CD-ROMs, which were not always compatible with other systems. There was also the danger of losing the disc during the transfer.

Teleradiology is used to distribute images within the hospital as well. “With this equipment, we are able to take the digital X-rays—they only have filmless radiology over there—and, using this particular computer server for teleradiology, distribute them over the local area network at the combat support hospital,” Col. Poropatich says. “This capability allows doctors to distribute the images to the emergency room, the operating room or the physical therapy area, which makes it a lot easier to provide better patient care.”

Previously, doctors had to walk to the radiology trailer to view images. In addition, if a patient was in the trailer being X-rayed, the doctor would have to wait until this was done to go in and view the film, further delaying diagnosis and care to other patients.

Teleradiology also helped cut delays in treatment during mass casualty incidents. Previously, not only did the digital X-rays have to be viewed in one location, but also the machines in the radiology tent did not have printing capabilities. The physicians could look at the X-rays, but they could not give printouts to the patient or to other doctors. 

Although the Army provided the DICOM servers, other services also have purchased them, and coalition partners in Iraq are using them. In November 2004, at Tallil U.S. Air Force Base, Iraq, an Italian coalition doctor treated a Dutch coalition soldier with an eye injury, and he used the U.S. Army teleocular consultation system to obtain a second opinion from doctors in the United States.

A few pathology cases have used this technology. “The telepathology system is connected to the Armed Forces Institute of Pathology in Washington, D.C. The system runs over the Internet, and the pathologists at the institute can control a microscope, which allows them to magnify or move the image, or change the lens of the microscope,” Col. Poropatich explains.

Other telemedicine applications are managed through e-mail. “Essentially, what we have done is set up generic e-mail addresses—such as derm.consult@us.army.mil, eye.consult, burn.consult, trauma.consult—and we have Army specialists in burn, ocular and dermatology, for example, located in the United States answering these e-consults on a rotating basis,” the colonel notes.

An average of 50 dermatological consult requests come from Iraq and Kuwait a month. Of those, approximately 75 percent are from the Army, with the remainder being U.S. Marine Corps and Air Force personnel, Iraqi nationals and Iraqi detainees. A response from the United States on a dermatology case takes about four hours.

An ocular consult takes approximately six hours, although only about 15 ocular consults have been done since inception of the program in July 2004.

One of the main goals of the e-mail consult program is to prevent unnecessary evacuations. At least 17 air evacuations for dermatology have been avoided because of the program. “It’s a quality of care issue as well as a conserve the fighting strength issue,” the colonel says. “If someone gets evacuated to Germany as an ambulatory patient, it is about a three-week turnaround time, and that is a significant loss of duty time when you start adding them all up.”

There is one dermatologist in Baghdad, but he is deployed as a general medical officer with the 1st Cavalry Division in the red zone. He makes the trip once a week into the green zone and follows up with some of the clinic patients that used the teledermatology system. 

While consults for dermatology are sent to the United States, the dental consults are handled within the theater of operations. Dentists in Baghdad have a direct digital X-ray machine that can capture an image onto a laptop computer. The image is then attached to an e-mail and sent to someone within theater who can respond. “Dentists in Baghdad may be separated by only 10 miles, but it is 10 very dangerous miles of road to get there,” Col. Poropatich notes, “so the e-mail helps work around that issue.”

In-theater consults help not only the soldiers but also the doctors in Iraq. “You have to realize that a lot of the doctors over there are young, just out of training, and there are other senior doctors in theater who know more. So the younger doctors can send them e-mail with jpeg images attached and ask for assistance,” he relates.

The e-mail programs are easy to use, Col. Poropatich says. “There is no learning curve to using e-mail or sending jpeg image attachments,” the colonel states. “All we’re trying to do is make life easy and give them a single e-mail address to send it to.”

One of the biggest challenges is letting the medical team soldiers know that the service exists when units rotate, so the colonel has been meeting with the commands before they deploy. In December, he met with the division surgeons of the 44th Medical Command who would be going to Iraq in January to ensure they knew about the capabilities they would have when they arrived.

“When new units come in, you almost have to reinvent the wheel,” he says. “We try to identify the units going in and work with them so that when they show up in-country they are aware of the capability, but it continues to be problematic in the handoff.” 

Fixing the equipment in the theater of operations also has been a challenge. Sending the machines back to the United States is costly and time consuming. To improve efficiency, TATRC has developed a telemedical maintenance package that enables users of sophisticated equipment such as oxygen generators to make repairs in theater. The package was first deployed in January.

The biggest concern Col. Poropatich has for the telemedicine program in Iraq is obtaining dedicated bandwidth. He currently is working with Lt. Col. Robert Rhodes, USA, who is the signal liaison to the U.S. Army Medical Department. “Col. Rhodes is very instrumental in helping to crosswalk the requirements for doing telehealth with the signal community,” Col. Poropatich notes. Both colonels would like a dedicated T1 line at level 3 for the Combat Support Hospital and a half of a T1 line dedicated bandwidth at level 2, which would support forward-deployed surgical teams and troop medical clinics. “Right now the deployed teams and troop clinics do not have the capability to use bandwidth at level 2. Or if they do, it is only for a very brief period of time,” he adds.

Currently, video teleconferencing (VTC) telehealth is not occurring in the Iraqi theater. “It’s just a big bandwidth hog,” Col. Poropatich says. However, the capability has been available at the Army hospital in Bagram, Afghanistan, for approximately two years. A telemedicine system was deployed that can do teleneurosurgery and has been employed in a few cases, but it is used mostly for surgical mentoring. “It is full 384-kilobit-per-second VTC from the operating room,” he explains. “Doctors can zoom in on the patient’s head and send those images back to Walter Reed [Medical Center in the United States].” Col. Poropatich adds that in some cases when a neurosurgeon needed to be present and the patient was stable, the patient was flown to Baghdad.

Col. Poropatich is encouraged by the progress made in Afghanistan that increases the possibility of a telemedicine capability remaining in Iraq after the war ends and the rebuilding of the communications infrastructure. Currently, Iraqi surgeons outside of the Army hospitals do not have the capability, but as the infrastructure in Iraq improves, Col. Poropatich expects that the Iraqis will be at an adequate telecommunications level to use telemedicine. “I know that in Afghanistan there are projects going on in certain parts, with the U.S. Agency for International Development looking at telemedicine projects there,” he says. “And Afghanistan is two years ahead of Iraq, so I expect over time the capability will remain as the infrastructure builds to support it.

“To make the Army telemedicine program succeed in Iraq,” he explains, “there needs to be a telehealth consultation program in the United States. Before we can even think of doing this in an operational setting like Iraq. We train as we fight; we fight as we train, and we do.”

For the past 11 years, the telemedicine capabilities have grown, but the full potential has not been realized. “One of the key things for the future is standardizing multimedia electronic medical records that store pictures of CAT scans alongside documented text. It is going to be difficult because we need to standardize electronic medical records for all services,” the colonel notes.

A system to standardize medical records, called the composite health care system, or CHCS II, is under development. The hospital information system has been rolled out during the past year to a variety of sites. Col. Poropatich says that it will be some time before the system is mainstreamed but that it is going to be difficult to have telehealth grow without it.

 

Web Resources
Armed Forces Institute of Pathology: www.afip.org
U.S. Army Telemedicine and Advanced Technology Research Center: www.tatrc.org
U.S. Army Medical Research and Materiel Command: https://mrmc-www.army.mil
U.S. Army Medical Department: www.armymedicine.army.mil