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<title>Akamai and Pacmednet: Adventures in Telemedicine in the Pacific Region</title>
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<h1><b><font color="#004080">Akamai and PACMEDNET</font></b></h1>
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<p><font size="+2" color="#8080FF">Adventures in</font></p>
<p><font size="+2" color="#8080FF">Telemedicine in</font></p>
<p><font size="+2" color="#8080FF">the Pacific Region</font></p>
<p><i>By Donna Cunningham </i></p>
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<td width="235" height="21" valign="BOTTOM">&nbsp;</td>
<td width="362" height="21" align="RIGHT"><font color="#004080">Remote Clinic
in Numapitchuk, Alaska</font></td>
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<p>&nbsp;</p>
<p><b><font size="+3" color="#8080FF">T</font></b>he <a href="index.html">Pacific
Regional Program Office (PRPO)</a> headquartered at <a href="http://www.tamc.amedd.army.mil">Tripler
Army Medical Center</a> on Oahu, Hawaii, heads up several research and prototyping
projects designed to meet the needs of Department of Defense personnel in the
Pacific theater. Two of these projects are Akamai (a Hawaiian word meaning intelligent
or clever) and the Pacific Medical Network project (PACMEDNET). Both projects
prototype state-of-the art technology solutions designed to improve healthcare
for service men and women and their dependents. <br>
<br>
The lessons learned by <a href="akamai_main4.html">Akamai</a> and <a href="pacmed_main4.html">PACMEDNET</a>
can benefit healthcare communities who are looking for ways to preserve their
investments in existing systems while, at the same time, giving their user constituents
access to improved technologies and methods. <br>
<br>
The Akamai and PACMEDNET projects are prototyping generic infrastructures for
the Department of Defense that eliminate the need for developing multiple interfaces
on a single system to communicate with a variety of different systems. The goal
is to put technology in the hands of the medical communities and make it as
easy to use as surfing the Web. </p>
<p><br>
<font size="+2" color="#8080FF"><b>Akamai</b></font></p>
<p> In Alaska, where temperatures fall below zero and hundreds of miles separate
populated areas, remote clinics meet the basic healthcare needs of personnel
stationed in facilities far from Anchorage, Fairbanks, and other cities. At
times, personnel come to these facilities with conditions that require consultation
from a specialist. In these cases, evacuation of the patient can be an expensive
and possibly dangerous undertaking. Similarly, in Korea, where readiness is
vital, evacuation of personnel may not be practical. Telemedicine can help meet
the needs of patients and healthcare providers in these remote areas. The Akamai
telemedicine project is addressing these needs, enabling the generalist to consult
with specialists. The goal of this telemedicine project is to evaluate noncritical
patients and treat them without evacuating them. <br>
<br>
The <a href="T2P2.html">Tripler Telemedicine Prototype Project (T2P2)</a> portion
of Akamai is prototying a telemedicine system focused on supporting clinical
workflow between remote sites and medical installations. The prototype activities
include building a Webbased client workstation to support clinical consultations.
Specialists have collaborated to develop consulting data formats, which the
generalists fill in and send via the Internet to specialists. Images can be
sent as well. <br>
<br>
For example, if a soldier reports a sore knee, the generalist examines him,
fills in the data format, and sends the consult to Tripler. There, an orthopedic
specialist examines the consult and any xray or other image that has been sent
and renders an opinion, which is mailed back to the generalist. A videobased
help capability being created by the specialists enables the generalist to clarify
diagnostic procedures. If information is needed about past conditions, either
doctor can obtain a summary electronic patient record by utilizing PACMEDNET
technology.</p>
<p> <a href="T2P2.html">T2P2</a> is implementing two clinical formats: dermatology
(pigmented lesion) and orthopedics (knee pain). The T2P2 is also seeking to
answer questions about resolution of image display, security of Internet transmissions,
and incorporation of data in the form of objects. In conjunction with the PACMEDNET
project, Akamai is prototyping the exchange of data as DCOM objects and the
incorporation of those objects into the consult data formats. </p>
<p><br>
<font size="+2" color="#8080FF"><b>PACMEDNET</b> </font></p>
<p> Sometimes, however, patients need to be evacuated. Patients who are wounded
or who get sick in front-line positions need to be transported back to major
medical treatment centers and sometimes to Veterans Administration facilities.
The ability of a health care provider to obtain an electronic medical record
at the site of treatment and then transfer the record along with the patient
is important in providing improved medical care, particularly during emergencies.
</p>
<p><a href="pacmed_main4.html">PACMEDNET</a> makes use of state-of-the art technological
solutions to address problems associated with patient movement in the Pacific,
where large distances and multiple time zones offer special challenges. <a href="pacmed_main4.html">PACMEDNET</a>
began in March 1995 under the management of Air Force Lt. Col. Anthony Gelish.
An integrated project team consisting of SAIC as the prime contractor, GTE,
Northrup Grumman, and PRC, worked to develop and test a prototype during demonstrations
and exercises. </p>
<p><a href="pacmed_main4.html">PACMEDNET</a> has engineered several technological
solutions which have the potential for wider application outside of the Pacific
Region. These innovations include the Transportable Computer-based Patient Record
(TCPR) and an architecture that supports transmitting the record to other locations.
</p>
<p><br>
<font size="+2"><b><font color="#8080FF">Transportable Gomputer based Patient
Record (TCPR)</font></b></font> </p>
<p> Both the military and civilian sectors are in the process of defining what
should be contained in a Computer Patient Record. PACMEDNET prototyped a Transportable
Computer-based Patient Record (TCPR) which contains a summary of patient data
that is useful to move with a patient who is being evacuated. This data includes
information such as demographics, inpatient medications, allergies, inpatient
episodes, appointments, laboratory results, radiology data, immunization records,
and data from instruments such as the Mobile Medical Monitor (M3). </p>
<p><br>
</p>
<p><font size="+2"><b><font color="#8080FF">The System Architecture</font></b></font>
</p>
<p> The PACMEDNET project faced the challenge of moving from a hostcentric system
architecture to a more modular approach that would allow greater flexibility.
PACMEDNET sought to engineer a client server architecture to facilitate data
exchange between systems without adversely affecting those systems. These systems
include: CHCS, TRACES, DHCP, Medical Information Carrier (MIC), Mobile Medical
Monitor (M3), and offboard clinical systems, including the Akamai telemedicine
workstation.</p>
<p> PACMEDNET incorporates several architectural innovations including OffBoard
Server (OBS). OBS was designed to remove the host system burden of processing
incoming messages from several systems. The OBS resides on a hardware platform
compatible with the Windows NT operating system, and uses a relational database.
Software on the OBS extracts patient data from contributing systems, formulates
the record, and transmits it over a Wide Area Network (WAN) to a receiving facility.
</p>
<p>An Interface Engine (IE) also runs on the OBS to provide generic interfaces
with HL7 messages from multiple systems. The IE was originally designed as placeholder
technology. DoD anticipated procuring an off-the-shelf interface engine to provide
generic interface with HL7 messages from multiple systems. However, the procurement
did not meet the schedule needs of the PACMEDNET project. The IE that PACMEDNET
prototyped runs under the WindowsNT operating system on a PC and is a costeffective
government off-the-shelf product that could be implemented by multiple projects
within the DoD. </p>
<p><br>
</p>
<p><b><font size="+2" color="#8080FF">Master Subiect Index <br>
(MSI) </font></b></p>
<p> In order to gather data from different facilities about patients, information
about where they have received care is needed. The Master Subject Index (MSI),
a central component of the PACMEDNET system, fills this need. The MSI contains
three indices: the Master Patient Index, which stores locators for patient information
residing on CHCS and other systems; the Master Patient Locator which stores
locators for sites that a patient has visited for medical treatment; and the
Master Provider Index, which stores information about which health care providers
have access to patient information. One function of the MSI server is to provide
a requesting OBS with an index of locations where each patient has been treated,
allowing the patient's TCPR to be compiled from information found at these locations.
The MSI also determines if there are images available for the patients and on
what systems these images reside.</p>
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<font color="#FF80C0">The Mobile Medical Nonitor (M3) is a system comprised
of a ruggedized PC and FDA-certified medical instruments that allow heart
rate, blood pressure, and blood oximetry to be monitored remotely</font>
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<p><b><font size="+2" color="#8080FF">Medical Information Carrier (MIC)</font><font size="+2">
</font></b><br>
</p>
<p>The DoD is investigating portable electronic media for the capture and transport
of soldier information including medical data. PACMEDNET has successfully integrated
the ability to utilize a Medical Information Carrier (MIC). When the soldier
is brought to a treatment facility, the card is scanned and data is uploaded
from the card. Using the card to register the patient allows for faster and
more accurate processing than does registering the patient manually.</p>
<p>&nbsp;</p>
<p><font size="+2"><b><font color="#8080FF">The Mobile Medical Monitor (M3) </font></b></font></p>
<p>The Mobile Medical Monitor (M3) is a system comprised of a ruggedized PC and
FDA-certified medical instruments that allow heart rate, blood pressure, and
blood oximetry to be monitored remotely and automatically uploaded to a receiving
system. PACMEDNET prototyped the capability to capture and upload M3 data and
incorporate it into the TCPR. <br>
</p>
<p>&nbsp;</p>
<p><b><font color="#8080FF" size="+2">Theater Medical Data Store (TMDS) </font></b><br>
</p>
<p>Systems other than CHCS contribute to the TCPR. In some cases, these systems
do not have a permanent place to store data. This is especially true of instruments
to be used on the battlefield, such as the M3. This transient data is referred
to as &quot;orphan&quot; data since it has no parent system. The TMDS is the
&quot;orphanage&quot;, a home for the data. The TMDS can capture information
for a specific military engagement or location as well, giving the option to
isolate data relating to a specific military engagement. <br>
</p>
<p>&nbsp;</p>
<p><font size="+2"><b><font color="#8080FF">Transmitting the Record </font></b></font><br>
</p>
<p>The culminating activity of each phase of PACMEDNET is a demonstration in which
defense networks transport the patient record. The demonstrations and exercises
in which the PACMEDNET program has participated include: Tripler Army Medical
Center (August 1995), Joint Warrior Interoperability Demonstration (August 1995),
Cobra Gold Exercise (May 1996), Primetime 3 Phase 4, Ft. Gordon, Georgia (November
1996), and Kernel Blitz 97 (June-July 1997). <br>
</p>
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<blockquote>
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<font color="#FF80C0">The TCPR provides information such as demographics,
in-patient medications, laboratory results, and radiological data.</font>
</div>
</blockquote>
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<p>&nbsp;</p>
<p><b><font size="+2" color="#8080FF">Significant Results</font></b> <br>
</p>
<p>The goal of Akamai and PACMEDNET for the next year is to make medical consultation
accessible to remote areas on a regular basis rather than just during demonstrations
and exercises. The Akamai/PACMEDNET prototype will be used by sites in Korea
and Alaska as a model to assess and quantify the benefits of telemedicine. The
Alaska effort will analyze utilizing telemedicine in remote regions. The Korea
effort will assess utilizing telemedicine in a geographically distant area.
Using the Internet to move patient information, the Akamai and PACMEDNET capabilities
will be merged with other technologies to allow providers in these remote regions
to have access to consultants in Hawaii and other locations on the U.S. mainland.
The goal will remain to provide improved health care to the Pacific region while
prototyping cost-effective, state-of-the-art technological solutions. <br>
</p>
<p>&nbsp;</p>
<p><b><font size="+2" color="#8080FF">EuroCHCS</font></b> <br>
</p>
<p>The philosophy of the Akamai and PACMEDNET efforts has been to prototype technological
solutions as proofs-of-concept in the anticipation that subsequent efforts would
utilize elements of the prototype to solve real-world problems. This philosophy
has been borne out by the EuroCHCS project. </p>
<p>EuroCHCS took an early version of the PACMEDNET prototype and adapted it for
production use at European DoD hospitals. The three EuroCHCS Alpha sites are
the Army hospital, <a href="http://www.lrmc.amedd.army.mil/">Landstuhl Regional
Medical Center (LRMC)</a>, in Germany; the Air Force Hospital in Aviano, Italy;
and the Naval Hospital in Naples, Italy, making this a joint service effort.</p>
<p> <a href="http://www.lrmc.amedd.army.mil/">Landstuhl Regional Medical Center</a>
in Germany serves as a hub for medical operations in continental Europe and
so was selected for the location of the system's Master Patient Index (MPI).
As part of the EuroCHCS project, the hospitals uploaded patient demographics
information into the Master Patient Index (MPI). Off-board servers that function
as servers for the build of a patient's TCPR were installed at the three sites.
Users have the ability to generate TCPRs using either client-server functionality
or VT terminals. To enable the PACMEDNET prototype for production use, the system's
reliability, maintainability, and availability features were addressed.</p>
<p> The PACMEDNET features are used to transfer patient information between sites.
Users incorporated the functionality in unexpected ways. The system is used
locally to compile comprehensive synopses of patient information. Feedback from
the site has been extremely positive; approximately 20 TCPRs are generated per
day; approximately 3,000 were generated to date in the six months that the system
had been available. The prototype software will be incorporated into CHCS Version
4.6 so that the five clinical functional modules incorporated by the PACMEDNET
effort will become part of baseline CHCS. These functionalities include immunizations,
progress notes, problem lists, discharge summaries, and consults.</p>
<p> As the PACMEDNET prototype evolves, features being added will help European
sites accomplish their goals. A March demonstration in Washington D.C. showed
regional Master Subject Indices and a worldwide Master Subject Index. These
indices can link European, National Capital Area, and Pacific regional sites
so that Transportable Computer-based Patient Records can be exchanged between
these vital areas. The ability to exchange data with Veterans Affairs hospitals
and other disparate systems will also be demonstrated. </p>
<p>Input from current users of EuroCHCS, future users in Alaska and Korea, and
from those viewing the demonstration in March will be considered in the design
of the next iteration of the Akamai/PACMEDNET prototype. </p>
<hr size="1">
<i><a href="mailto:donna.s.cunningham@cpmx.saic.com">Donna Cunningham</a> is a
senior systems engineer of the Science Applications International Corporation.
The opinions expressed in this article are solely those of the author and do not
constitute an endorsement by Tripler Army Medical Center, the Army Medical Command,
or the Department of Defense. </i>
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