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<TITLE>The telemedicine frontier: going the extra mile</TITLE>
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<p>The telemedicine frontier: going the extra mile</p>
</font><font size=2>
<p>V. Garshnek, J.S. Logan &amp; L.H. Hassell</p>
<p>&nbsp;</p>
<b>
<p align="JUSTIFY">Telemedicine has the potential to have a greater impact
on the future of medicine than any other modality and will profoundly
alter the medical landscape of the twenty-first century. In the most remote
areas, it can bring high-quality health care where none is now available.
In global health care, it can enhance and standardize the quality of medical
care, including developing countries. In the realm of space flight, it
can provide a lifeline to medical expertise and monitoring. Through its
mobility, it can provide urgently needed health care In Instances of natural
disaster. However, a number of challenges exist in its coordination and
implementation on a global scale, specifically in the international and
remote disaster scenarios. In the area of spaceflight, telemedicine capability
will remain a consultation/information 'lifeline', but additional onboard
medical capability and expertise will become crucial complements as missions
become more advanced and remote from Earth. C 1997 Elsevier Science Ltd.</p>
<p align="JUSTIFY">&nbsp;</p>
</b>
<p align="JUSTIFY">Dr V. Garshnek, a physiologist, and formerly Assistant
Research Professor at the Space Policy Institute, The George Washington
University, is now Project Manager of the AKAMAI Telemedicine Evaluation
Initiative, Tripler Army Medical Center. 1 Jarrett White Road, Tripler
AMC, HI, USA. Dr J. S. Logan is a physician and President of Logan and
Associates, Norman, OK. USA, an international telemedicine consulting
firm. Dr L. H. Hassell is a Colonel in the United States Army, a physician,
and Project Director of the AKAMAI Telemedicine Evaluation initiative,
Tripler Army Medical Center, Hawaii, USA.</p>
<b><i>
<p align="JUSTIFY">&nbsp;</p>
<p align="JUSTIFY">&nbsp;</p>
</i></b>
<p align="JUSTIFY">We live in extraordinary times. In this century alone,
we have witnessed the rapid emergence of technology and, with it, the
ability to break crucial barriers that had previously hindered human progress.
Currently we are standing on the edge of a barrier which is rapidly eroding-the
physical distance barrier. Through telecommunications and computer technologies,
such capabilities as real-time or stored multimedia information transfer,
real-time interactive video and instantaneous acquisition of knowledge
and expertise, are becoming reality. We have the means to electronically
transport and make available the 'essence' of who we are anywhere at anytime.</p>
<p align="JUSTIFY">At the present time, nowhere is this distance barrier
eroding more rapidly than in medicine. Patients traveling miles to see
a specialist for medical consultation, and medical documents and films
being physically stored and transported are rapidly becoming antiquated
modes of operation. Through telecommunications and information technologies
medicine can now extend its reach regardless of physical distance through
real-time or near real-time two-way transmission of information between
places of lesser and greater medical capability and expertise. This capacity,
known as <i>Telemedicine, </i>will revolutionize current clinical medical
practice, especially for remote or geographically dispersed populations,
and will profoundly alter the medical landscape well into the twenty-first
century.</p>
<p align="JUSTIFY">The use of telemedicine systems in settings such as hospitals,
clinics, long-term care facilities, prisons, and home care is becoming
well established and is evolving in effectiveness and efficiency. However,
the purpose of this paper is not to discuss these more familiar settings
but, rather, to focus on telemedicine at a bold 'frontier' beyond its
current and common use. The new frontier is that of delivering specialty
care on a planetary or 'global' scale and beyond Earth into the realm
of space flight.</p>
<p align="JUSTIFY">&nbsp;</p>
<b>
<p align="JUSTIFY">Telemedicine defined</p>
</b>
<p align="JUSTIFY">Telemedicine is the use of modern telecommunications
and information technologies for the provision of clinical care to individuals
at a distance and the transmission of information to provide that care.
The main rationale for the development of telemedicine services has been
the desire to provide health services 10 persons whose access to health
care is restricted for one or another reason. It includes the diagnosis,
treatment, monitoring, and education of patients using systems that allow
ready access to expert advice and patient information no matter where
the patient or relevant information is located. It involves a spectrum
of technologies<sup>1 </sup>including facsimile, medical data transmission,
audio-only format (telephone and radio), still images, and full-motion
video. Robotics<sup>2 </sup>and virtual reality interfaces<sup>3 </sup>have
been introduced into some experimental applications. Telemedicine is a
process, not a technology and shifts the paradigm of transporting the
patient to the site of the expert care giver to transporting expert knowledge
to the health care provider closest to the patient (ie move the information
not the patient).</p>
<p align="JUSTIFY">Early expansion of telemedicine was affected by the cost
and limitations of the technology. Recent technological advances-such
as liber optics, integrated services digital networks (ISDN), and compressed
vide~have eliminated or minimized many of these problems, fostering a
resurgence of interest in the potential of telemedicine to improve the
quality of; and increase access to health care, especially for those who
live in remote or under-served areas. Today, the technology is not only
better; it is also becoming signiFIcantly less expensive.</p>
<b>
<p align="JUSTIFY">&nbsp;</p>
<p align="JUSTIFY">&nbsp;</p>
<p align="JUSTIFY">Telemedicine infrastructure</p>
</b>
<p align="JUSTIFY">The telecommunications infrastructure provides the technology
to move information electronically between geographically dispersed locations.
Participating sites are linked through electronic networks. The telecommunication
medium utilized by telemedicine programs is determined in large part by
the available local infrastructure. These can include satellite, microwave
link or terrestrial lines (either twisted copper phone lines or fiber
optic cable).<sup>4 </sup>The use of advanced satellite links is unlikely
to become common for medical desktop conferencing and consultation. Tools
specifically designed for ISDN represent an inexpensive, but nevertheless
powerful, terrestrial network which is already available in most industrial
regions. Where ISDN is not available, satellite systems represent an attractive
alternative since temporary links and manual dialing lead to major cost
reductions compared with standard satellite links.</p>
<p align="JUSTIFY">The bandwidth or bit rate of the transmission medium
(terms used to refer to the amount of information that may be sent per
unit of time) is a limiting factor on the type of telemedicine system
that may be used. For example, narrow bandwidth systems, such as the ‘plain
old telephone system’ (POTS) are relatively inexpensive to operate but
lack the capacity to transmit full-motion video. Broad bandwidth networks,
including fiber optic cable and many satellite systems, are capable of
carrying sufficient data to permit the use of interactive, full motion
video.</p>
<p align="JUSTIFY">The medical systems infrastructure consists of the equipment
and processes used to acquire and present clinical information and to
store and retrieve data. Acquisition and presentation technologies include
teleconferencing, data digitizing, and display (eg remote X-ray, laboratory
tests); text processors (eg scanners, fax); or image processors (eg video
cameras, monitors). Data storage and retrieval include storage devices
(disks, tape, CD-ROM), along with technology to compress, transmit, and
store data. Table l provides examples of typical telemedicine applications
currently in use, modes of interaction, types of information transferred,
and bandwidth requirements.</p>
<p align="JUSTIFY">In general, each site has the basic equipment for communicating
with other sites in its network and the specific applications it has established.
The requirements for telemedical services are the same, independent of
whether they need to be provided within a clinic (local area), between
Clinics and general practitioners (regional or metropolitan area), or
on a wide area (international/global scale).</p>
<b>
<p align="JUSTIFY">Table 1. Telemedicine interactions and Applications</p>
</b></font>
<table border cellspacing=1 cellpadding=7 width=727>
<tr>
<td width="30%" valign="TOP">
<p><b><font size=2>Purpose</font></b>
</td>
<td width="18%" valign="TOP"> <b><font size=2>
<p>Interaction Mode
</font></b></td>
<td width="18%" valign="TOP"> <b><font size=2>
<p>Information Transferred
</font></b></td>
<td width="18%" valign="TOP"> <b><font size=2>
<p>Minimum Bandwidth Required
</font></b></td>
<td width="18%" valign="TOP"> <b><font size=2>
<p>Applications (Examples)
</font></b></td>
</tr>
<tr>
<td width="30%" valign="TOP"> <font size=2>
<p>Diagnostic or Therapeutic consultation
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Real-time one-way or two-way interactive motion video
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Voice, sound, motion video, images, text
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Moderate to High
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Telepsychiatry, remote surgery, interactive exams
</font></td>
</tr>
<tr>
<td width="30%" valign="TOP"> <font size=2>
<p>Diagnostic or therapeutic consultation
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Still images or video clips with real-time telephone voice interaction
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Voice, sound, motion video, images, text
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Low to moderate
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Dermatology, cardiology, otolaryngology, orthopedics, etc.
</font></td>
</tr>
<tr>
<td width="30%" valign="TOP"> <font size=2>
<p>Diagnostic or therapeutic consultation
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Still images, video clips, text, ‘store-and-forward’ with data
acquired and sent for later review
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Sound, still video images, video clips, text
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Low
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Dermatology, cardiology, otolaryngology, orthopedics, etc.
</font></td>
</tr>
<tr>
<td width="30%" valign="TOP"> <font size=2>
<p>Medical education
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>One-way or two-way real-time or delayed video
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Voice, sound, motion video, images, text
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Full Spectrum: Low to High
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Distance education and training
</font></td>
</tr>
<tr>
<td width="30%" valign="TOP"> <font size=2>
<p>Documentation Administration
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Transfer of electronic text, image, or other data
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Text, images, documents, related data
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Low to High
</font></td>
<td width="18%" valign="TOP"> <font size=2>
<p>Health information networks, medical records
</font></td>
</tr>
</table>
<b><font size=1>
<p>*Bandwidth is the transmission capacity of a telecommunications link.
Conventional telephone lines have relatively little carrying capacity
(low bandwidth). High-capacity lines are required to transmit large amounts
of information (such as images) rapidly.</p>
</font></b><font size=2>
<p align="JUSTIFY">&nbsp;</p>
<p align="JUSTIFY">&nbsp;</p>
<dir>
<dir>
<dir>
<dir>
<dir> <b>
<p align="JUSTIFY">Telemedicine and developing countries</p>
</b></dir>
</dir>
</dir>
</dir>
</dir>
<p align="JUSTIFY">Many nations have significant telemedicine activities
in progress and include internal (domestic) as well as external (international)
efforts. The most active nations include the United States, Australia,
Canada, France, Germany, the UK, Greece, Italy, Japan, Netherlands, Switzerland,
United Arab Emirates, Norway, Finland and Sweden. Although telemedicine
has been practiced for decades, the majority of its applications have
been in the developed world. Now that telemedicine has matured in effectiveness
and efficiency with concrete medical impact, it is important and timely
to ask whether telemedicine may have a role in developing countries. Developing
countries face particular problems in the provision of medical services,
which relate to the lack of capital, facilities and systems. Roads and
transportation are inadequate and difficulties in transporting patients
are often encountered. For countries with limited medical expertise or
resources, telecommunications can provide a solution to some of these
problems.</p>
<p align="JUSTIFY">A number of challenges exist in international telemedicine
development, which may slow the implementation and effective use of this
capacity. These include the following:<sup> 5</sup></p>
<ol>
<sup> </sup>
<p align="JUSTIFY">
<li>Telecommunications</li>
<p></p>
</ol>
<ul>
<li>Different technical standards</li>
<li>Poor or non-existent telecommunications infrastructures</li>
<li>National and international regulations governing telecommunications
and equipment use</li>
</ul>
<p> (2) Medical</p>
<ul>
<li>Medical cultural differences</li>
</ul>
<ul>
<li>Differing medical approaches</li>
</ul>
<ul>
<li>Differing medical standards</li>
</ul>
<ul>
<li>Differences in medical technology and equipment</li>
</ul>
<p>(3) Socioeconomic</p>
<ul>
<li>Political and bureaucratic barriers</li>
</ul>
<ul>
<li>Differences in language and literacy</li>
</ul>
<ul>
<li>Cultural differences in acceptability of medicine</li>
</ul>
<ul>
<li>Differences in resources available for medical care</li>
</ul>
<p align="JUSTIFY">In addition, based on research thus far, and the responses
to a questionnaire developed by a committee established by the International
Telecommunication Union to study telemedicine, which gathered data with
particular reference to developing countries, it is clear that much of
the telemedicine activity undertaken around the world has depended on
government subsidies. The situation is changing, however, and a trend
towards commercial telemedicine provision is clearly discernable.<sup>6</sup></p>
<p align="JUSTIFY">One initial effort is the Satellite/HealthNet. Based
in the United States, SateLife/HealthNet is an international non-profit
organization which uses micro-satellite technology to provide health communication
and information services in developing countries. SateLife began in <i>1985
</i>and is an initiative of the Nobel Laureate group International Physicians
for the Prevention of Nuclear War. It has joined with Atelier Temenos
in France to provide island communities with e-mail and CD ROM availability
via the HealthSat I and HealthSat 2 (LEO Satellites), at 0.25% of the
cost of conventional geostationary satellites. SatelLifel HealthNet stations
are also licensed in nine African countries, the Philippines and three
countries in the Americas, linking remote practitioners and clinics regionally,
as well as internationally with participating urban medical centers.<sup>7</sup></p>
<p align="JUSTIFY">The development of national telecommunications and telemedicine
capabilities in underdeveloped countries can be enhanced by development
of an international medical telecommunications network to facilitate communications
among health care professionals globally and to improve their access to
health care information. Such a network could stimulate the development
of medical cooperation across cultural, political, and bureaucratic barriers
and could facilitate the development of national telemedicine networks
in underdeveloped countries. Such a global network could be built on a
simple Internet infrastructure 'low' technology start which can be highly
effective.</p>
<p align="JUSTIFY">Global telemedicine will develop regardless of whether
it is coordinated logically or not. It will require a concentrated effort
to develop reliable national telecommunications capabilities in the underdeveloped
countries where they are currently unavailable. Such systems should he
developed through collaborative efforts and funding from multiple organizations
(eg World Health Organization and other agencies of the United Nations
such as the Pan American Health Organization, the Department of Humanitarian
Affairs, the US Agency for International Development; and other international,
and national, organizations with Interests in developing updated medical
and communications technologies in underdeveloped countries).</p>
<p align="JUSTIFY">&#9;</p>
<b>
<p>Telemedicine and international disaster response</p>
</b>
<p align="JUSTIFY">Disasters are catastrophic events that overwhelm a community's
emergency response capacity, threatening the health and safety of the
public and the environment. Globally, a major disaster occurs almost daily.
Although emergency medical services are an important part of disaster
responses, populations affected by disasters require a complete range
of health services. Disaster medicine has become more than a mass casualty
response. It encompasses the entire spectrum of the affected population's
needs, ranging from assessment of the medical requirements to rapidly
coordinating routine and preventive health services.</p>
<p align="JUSTIFY">There are three major time phases associated with disaster
response. In the Pre-Disaster Phase, emphasis is placed on prevention
and preparedness activities which lead to requirements for hazard and
vulnerability assessments, human and material resource inventory, comprehensive
planning and exercises to test plans, capabilities, and skills. In the
Acute Post-Disaster Phase (hours to weeks) damage assessments and the
implementation of emergency plans have priority. The Post-Disaster Rehabilitation
Phase may extend for months or even years as infrastructure and various
community activities are restored.<sup>8</sup></p>
<p align="JUSTIFY">While many information management and telecommunications
technologies are currently employed in disaster response, there are few
reports of telemedicine being utilized in disaster settings. The Pan American
Health Organization (PAHO) has provided satellite communication ground
stations to support disaster response. The longest and most extensive
use of telemedicine was the NASA-Russia Space Bridge employed during the
Post-Disaster Rehabilitation Phase after the devastating Armenian Earthquake
of l988.<sup>9</sup></p>
<p align="JUSTIFY">The Space Bridge Project used satellite communications
to provide medical consultation to several Armenian regional hospitals,
linking them with four US medical centers. The program utilized two-way
interactive audio with one-way full-motion video transmitted from Armenia
to the United States. There were also separate data and fax transmission
lines. Consultation was provided in the areas of neurology, orthopedics,
psychiatry, infectious disease, and general surgery. In a separate link,
consultation was also provided to the Russian town of Ufa, where a gas
explosion during this same period of time caused a large number of casualties.
Slow-scan black and white video was transmitted from Ufa to one of the
Space Bridge sites in Armenia (Yerevan) which provided satellite uplink.'<sup>0</sup></p>
<p align="JUSTIFY">Over a 12 week period, the Space Bridge program was used
to discuss the cases of 209 patients. According to data reported by Houtchens
<b><i>et </i></b><i>al.,<sup>1 </sup></i>the use of telemedicine was responsible
for changes in the management of a large number of patients. For the 189
Armenian patients discussed, diagnoses were changed for 54 patients, new
diagnostic studies were recommended for 70 patients, and treatment plans
were changed for 47. During the attempted coup in the second half of 1993,
NASA took advantage of a video-conferencing link in Moscow that was already
in place to provide consultation regarding several casualties of small
arms fire. This link was part of the USJ Russian Telemedicine Demonstration
Project, which consisted of 18 different sessions dedicated to different
medical specialties.</p>
<p align="JUSTIFY">Evaluation of this entire Space Bridge experience has
identified a series of important ‘disaster telemedicine’ needs for future
consideration: <sup>12</sup></p>
<p align="JUSTIFY">(1) need for precise protocols in both communications
and clinical areas;</p>
<p align="JUSTIFY">(2) need to intensively train and prepare users at both
ends of the link;</p>
<p align="JUSTIFY">(3) need for a new type of medical record generated by
and compatible with telemedicine;</p>
<p align="JUSTIFY">(4) need for vigorous qualitative and quantitative assessments
of telemedicine applications;</p>
<p align="JUSTIFY">(5) need to link telemedicine to a variety of information
sources.</p>
<p align="JUSTIFY">Telemedicine has been utilized on many different occasions
over the past two decades; however, it has never before been deployed
and tested on such a large scale as was demonstrated in the Space Bridge
projects. These projects pioneered a global telemedicine disaster assistance
system and demonstrated that the technology and ability to utilize it
during a large-scale emergency situation are currently at hand. In addition,
these projects clarified the value of such a system and the need to institutionalize
this capability nationally and internationally so that it can be effectively
activated on demand.</p>
<p align="JUSTIFY">Telemedicine can significantly enhance efforts associated
with the previously mentioned time phases identified for disaster response.
For example, in the Pre-Disaster Phase, telemedicine could be employed
in the education and training of health care personnel and the general
community. Disaster planning and coordination could be facilitated and
various types of exercises could be conducted and evaluated. In the Acute
Phase of disaster, telemedicine capability could support disaster plan
implementation and modification, assist with management of critical resources,
and provide consultation from within and outside the disaster area, and
provide assessment and survey data as the basis for relief and humanitarian
assistance operations. In the Post-Disaster Rehabilitation Phase, telemedicine
can provide a variety of more traditional medical consultations as demonstrated
by the Space Bridge to Armenia and can continue to provide support to
both resource management and continuing assessment activities. <b><sup>13</sup></b></p>
<p align="JUSTIFY">Telemedicine can be utilized in disasters only within
the constraints of local and regional infrastructure capabilities and,
thus, must be compatible with and tailored to the level of sophistication
which can be utilized and supported. Top down approaches are unlikely
to be successful unless matched by intensive local area efforts, both
of which must take into account the inherent cultural, technical, and
political realities. These factors present the most significant obstacles
to the rapid implementation of telemedicine capabilities in disasters
and complex emergencies.</p>
<p align="JUSTIFY">Although the application of telemedicine to disaster
scenarios appears promising and logical, applying telemedicine technology
to disaster settings is presently expensive both in terms of initial cost
and investment of professional time and effort in the development, teaching
and implementation of new practice paradigms and supporting protocols.
It can only be employed effectively in disaster settings if it is also
in frequent use in the routine delivery of health services. Leveraging
a disaster medicine capability by employing it regularly in non-disaster
settings should increase acceptance, and proficiency, reduce cost, and
increase access to high quality health care. Extending the use of telemedicine
to nonclinical areas (pharmacy, supply and equipment, administrative support)
and to non-medical sectors of disaster management, increases the power
of this leveraging. This parallel development of Disaster Medicine, Telemedicine,
and provision of routine health care demands serious attention.'<sup>4</sup></p>
<p>&nbsp;</p>
<b>
<p align="JUSTIFY">Telemedicine and the military</p>
</b>
<p align="JUSTIFY">The United States armed services have long had an interest
and involvement in both mobile health and telemedicine services. In fact,
some of the most ambitious global applications of telemedicine and utilization
of satellite technology can be found in the military.</p>
<p align="JUSTIFY">Recent developments in data compression, fiber optics,
satellite communications, computer inter-networking, information technology,
advanced medical imaging and diagnostics have combined to provide the
US military with the ability to establish a world-wide integrated health
care delivery network. Various combinations of these technologies have
been tested in Joint exercises, US Army Advanced Warfighting Experiments
(AWEs), on board deployed naval vessels, in the peacetime Military Health
Service System (MHS), and as part of the support for operations in Saudi
Arabia, Kuwait, Somalia, Haiti, Cuba, Panama, Croatia and Macedonia.</p>
<p align="JUSTIFY">Advanced telecommunications technology was used in conjunction
with mobile health units during the war in the Persian Gulf"<sup>5</sup>
demonstrating that these two technologies can be integrated, even under
difficult geographic and climatologic circumstances, with beneficial effect.<sup>16
</sup>Computerized tomography (CT) scanners were installed in transportable
modular military hospital units and deployed in the Saudi desert just
south of the Iraqi and Kuwaiti borders.'<sup>7 </sup>During Operation
Restore Hope, beginning in February 1993, physicians of the 86th Evacuation
Hospital in Mogadishu, Somalia, transmitted still, digitized images and
voice messages from a portable 'Standard A' INMARSAT (International Maritime
Satellite) terminal to Walter Reed Army Medical Center (WRAMC) in Washington,
DC. Consultative systems at WRAMC were linked to both MEDLINE and the
Composite Healthcare System (the Department of Defense medical computer
network). A similar system has been deployed to Zagreb, Croatia and the
Army's medical center in Landstuhl, Germany, since May 1993. The Navy's
Fleet Hospital Six, which took over the United Nations peacekeeping operations
in Zagreb, Croatia, from the Army retained the link to WRAMC and also
established links to the Naval Medical Center at San Diego.</p>
<p align="JUSTIFY">Recently, the US Department of Defense established a
medicine network that serves US troops in Bosnia and other countries.
The telemedicine segment of this project, known as Operation Primetime
III, is designed to help Army physicians communicate with each other using
real-time voice and video for <i>consultation and diagnosis. The </i>communications
network in Bosnia is being supported by an Orion-built communications
satellite orbiting over the area, thereby providing direct broadcast capability.
Using commercially available technology, frontline physicians can transmit
X-rays and other medical images to field hospitals for diagnostic support.
These same links, which extend to deployed units and small clinics at
forward areas in Bosnia, connects Army physicians in Bosnia with physicians
at five regional military medical centers in the USA. The network also
offers online medical information, patient administration systems, and
information Systems. Operation Primetime was first established in 1993
to provide telemedicine support to medical units in Macedonia and Croatia.
The operation was upgraded to Primetime 11 in <i>1995 </i>with a 30-fold
increase in communications bandwidth that substantially improved the transmission
of medical images for diagnostic consultations. The telecommunications,
advanced medical diagnostics and medical informatics provided by Primetime
III Task Force has resulted in an integrated, world-wide system of telemedicine
enabled healthcare delivery extending from the forward operating bases
of Bosnia to the major military centers in Washington, DC, Texas, California,
and Hawaii. Continental US based MHS Medical Centers are responsible for
providing local telecommunications<i>, </i>video teleconferencing, teleradiology
and clinical staff support necessary to provide continuous specialty and
sub-specialty real-time interactive and store and forward teleconsultation
support. The selection of medical centers positioned in varying time zones
around the globe facilitate 24-hour, 7 days per week support without requiring
additional medical staffing. This is a very exciting global telemedicine
concept in that telemedical consultations literally 'follow the sun' around
the Earth.<sup>18</sup></p>
<p align="JUSTIFY">The US armed forces are also engaged in a large-scale
program of telemedicine research and development. This includes the distant
physiological monitoring of deployed troops, and investigation of such
technologies as telepresence,<sup>19 </sup>virtual reality, and telerobotic
laparoscopic surgery.<sup>20 </sup>The US Army has also experimented with
telemedicine to provide care to persons living on remote islands in the
Pacific Ocean.<sup>21</sup></p>
<p align="JUSTIFY">Another wide-area telemedicine project is AKAMAI, a tri-service
project for electronic diagnosis and consultation, an effort headed by
Tripler Army Medical Center in Hawaii. AKAMAI allows for Tripler (a tertiary
medical center) to support a referral area of over one million square
miles and a diverse military and civilian user group throughout the Pacific.
The long-term goal of this project is to expand telemedicine into the
Pacific Basin by establishing a Pacific-wide telecommunications system
for medical information, including Picture Archiving and Communication
System (PACS), telemedicine consultation, teleradiology imaging, digital
patient records, and new technologies as they develop (eg telesurgery
and telepathology).<sup>22</sup></p>
<p align="JUSTIFY">The US Office of the Assistant Secretary of Defense Health
Affairs is working with a number of federal agencies and industry to develop
an infrastructure to fully exploit the potential for telemedicine and
computer-based patient records globally throughout the US Military Health
System. The goal is to have technology-based services that allow connectivity
among military treatment facilities; interoperability among information
systems at military treatment facilities; and commonality among the health
care and related applications which run on these information systems.
And, finally, to integrate these efforts to their fullest capacity, the
Surgeon General of the Army has created a special project office for Advanced
Technology and Telemedicine to encourage collaboration within the entire
US Department of Defense.</p>
<p align="JUSTIFY">&nbsp;</p>
<b>
<p align="JUSTIFY">Astro telemedicine</p>
</b>
<p align="JUSTIFY">Telemedicine is not a new concept to space flight. Since
its very beginning space medicine has utilized communications and information
processing technologies. In many aspects the operational boundary conditions
in space medicine, such as remoteness, telediagnostics, and biotelemetry
are characteristic of telemedicine applications on Earth.</p>
<p align="JUSTIFY">Since the 1960s, in parallel, the United States and Russia
served as pathfinders in the development of space telemedicine when they
developed capabilities for remote medical monitoring and <i>care for </i>astronauts
in their human space flight programs, beginning with Mercury and Vostok,
through the current Space Shuttle and Mir programs. Medical conferences
are held between the crew surgeon and crew members, and astronauts during
extra-vehicular activity (EVA) are constantly monitored via telemetry.
This type of medical monitoring has existed for decades. For example,
during the Apollo lunar excursions, EKG, heart rate, oxygen consumption,
heat production, suit carbon dioxide levels, and other physiologic and
environmental variables were monitored by a biomedical team at NASA's
Mission Control Center at the Johnson Space Center (JSC), Texas. Flight
surgeons were on alert to catch potentially dangerous physiological conditions
or events.<sup>23</sup></p>
<p align="JUSTIFY">Currently the US Space Program (through NASA) has in
place a training program that would enable astronauts who are not medically
trained to be providers of remote telemedicine services (ie able to conduct
a basic examination for consulting physicians on Earth). Complicating
the provision of such services is the fact that the astronauts must learn
to perform these tasks in a micro gravity environment. NASA has recently
developed the capacity for private medical conferencing from orbiting
spacecraft to Earth stations. Prior to this, telemedicine consultations
had to be done via radio or video channels that were potentially open
to the public. In the current system, the transmitted data are encrypted
and transmitted to the Johnson Space Center, via White Sands Missile Base,
New Mexico. These one-way (Shuttle to Earth) video and two-way audio signals
are received <i>in </i>unscrambled form only by the chief medical officer
in Houston, protecting the confidentiality of astronauts and allowing
NASA to limit media coverage of medical problems in space.</p>
<p align="JUSTIFY">Development is continuing for telemedicine applications
to support US astronauts aboard the Russian Mir space station and the
International Space Station at the turn of the century. NASA's first permanent,
operational, international space telemedicine system will be established
to support NASA's flight surgeons and astronauts training in several locations
in Russia, including the Gagarin Cosmonaut Training Center in Star City,
the TsUP (Mission Control) at Kalingrad, several sites in Moscow, and
the Baikinor Cosmodrome in Kazakhstan. Utilizing NASA's Program Support
Communications Network (PSCN), flight surgeons and astronauts in Russia
will be able to obtain telemedicine consultations from the NASA Johnson
Space Center (JSC) in Houston, Texas.<sup>24</sup></p>
<p align="JUSTIFY">Telemedicine capability will be an important component
in space crew health care onboard the International Space Station, especially
in the prevention and early intervention aspects of disease and injury.
In addition, in a medical emergency, telemedical capability can play an
important 'lifeline' role in the rapid exchange of patient information
and access to medical expertise and crucial instruction. However, if an
emergency is life threatening and requires immediate medical treatment,
the combined benefits of telemedicine and existing onboard medical capability
may be limited, requiring medical evacuation to Earth.</p>
<p align="JUSTIFY">In such a scenario, a crew rescue vehicle or 'ambulance'
or even mission abort to return a crew member home may take hours, days,
or even months depending on a Variety of circumstances (eg launch and/or
landing feasibility, weather conditions, possibility of further patient
injury upon reentry/landing, etc.). Given the consideration of passage
of time for transport, potential of further injury during transport, etc.,
in certain cases the patient may indeed be better off treated inflight
and/or the situation effectively managed until an appropriate mode of
return to Earth is established. In order to provide patient stabilization
and management in a crisis, the appropriate array of tools for adequate
diagnosis and treatment must be on hand. Indeed, a future medically enhanced
space station or facility could provide valuable learning experience for
initiating greater crew medical autonomy, such as would be required for
interplanetary flight where an 'ambulance' or mission abort may not exist
as options (due to distance) in a medical emergency.</p>
<p align="JUSTIFY">Granted, the overall space station experience is still
in its infancy (in that so far, only a small population of individuals
have flown for extended periods) and critical life-threatening medical
emergencies requiring immediate evacuation or rescue have not occurred
(astronauts, through selection, are extremely healthy), it is still likely
that after the International Space Station becomes operational, a greater
number of individuals will visit and work onboard. The possibility therefore
exists that a life threatening medical emergency could occur, testing
our wisdom and judgment in the types of onboard medical diagnostic and
treatment capabilities initially provided. However, at this early stage,
it is very difficult to plan for every possible medical emergency that
might occur and space flight is still understood to be 'experimental'
with definite risk attached to the occupation. In the future, especially
in the more advanced and physically distant spaceflight scenarios, the
medical provisions and expertise onboard and not necessarily the telemedical
capability. may prove to be the most critical factors determining the
life or death outcome of an individual in a medical spaceflight emergency.</p>
<p align="JUSTIFY">&nbsp;<b>Conclusion</b></p>
<p align="JUSTIFY">At this point in time, the claim that telemedicine will
introduce revolutionary changes in global health care delivery and information
access may seem premature, yet there are clear indications that dramatic
changes have already occurred in the medical information infrastructures
and vast networks already established. The information age is already
upon us in health care. Telemedicine is bringing reality to the vision
of an enhanced accessibility of medical expertise and a global network
of health care available in any situation. The real question about the
future of telemedicine is not whether it is here to stay but rather the
extent to which we have the foresight to fully exploit it-building lifelines
on Earth and as far as the human spirit dares to dream.</p>
<p align="JUSTIFY">&#9;</p>
<p>&nbsp;</p>
</font><b><u>
<p>References</p>
</u></b><sup></sup>
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<p align="JUSTIFY"><sup>2</sup>Minsky. M.. Toward a remotely-manned energv
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<p><sup>6</sup>Wright, D. and Androuchko, L., Telemedicine and developing
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<p><sup>7</sup>Op cit. Ref. 5</p>
<p><sup>8</sup>Llewellyn. C. H., Public Health and sanitation during disasters.
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<p><sup>9</sup>Houtchens, B. A., Clemmer, T. P., Holloway. H. C., Kiselev.
A. A., Logan, J. S., Merrell, R. C., Nicogossian, A. E., Nikogossian.
H. A., Rayman, R. B., Sarkisian. A. E. and Siegel. J. H., Telemedicine
and International Disaster Response. <i>Prehospital and Disaster Medicine
</i>8 (1993) 57-66.</p>
<p><sup>10</sup>Op. cit. Ref. 9.</p>
<p><sup>11</sup>Op. cit. Ref. 9.</p>
<p><sup>12</sup>LIeweIlyn, C. H., The Role of Telemedicine in Disaster Medicine.
<i>Journal of Medical Systems </i>19 (1995) 29-34.</p>
<p align="JUSTIFY">Op. cit. Ref 12.</p>
<p align="JUSTIFY">Op. cit. Ref 12.</p>
<p align="JUSTIFY"><sup>15</sup>Cawthon, M. A.. Goeringer, F. and Telepak,
R. J. <i>et al., </i>Preliminary assessment of computed tomography and
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<p align="JUSTIFY"><sup>16</sup>Spiller, R. E.. Hellstein, J.. W. and Basquill.
P. J.. Radiographic support in highly mobile operations. <i>Military Medicine
</i>155 (1990) 486-9.</p>
<p align="JUSTIFY"><sup>17</sup>Op cit. Ref. 15.</p>
<p align="JUSTIFY">Garshnek, V., Floro, F. C. and Hassell, L. H., Telemedicine:
Breaking the Distance Barrier in Health Care Delivery. <i>American Institute
of Aeronaulics and Astronautics Student Journal </i>(in<i> </i>press).</p>
<p align="JUSTIFY"><sup>19</sup>Green, P.S., Hill. J. H., Satava, R., Telepresence:
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</i>57<i> </i>(1991) 192.</p>
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<p align="JUSTIFY"><sup>21</sup>Delaplain, C. B., Lindborg. C. E.. Norton,
S. A. and Hastings. J. E., Tripler pioneers telemedicine across the Pacific.
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<p align="JUSTIFY"><sup>22</sup>Garshnek. V., Moving information not patients:
The Department of Defense experience with tetemedicine in the Pacific.
Presentation to the Western Occupational Health Conference, Aston Wilea
Resort, Maui. Hawaii. October 1996.</p>
<p align="JUSTIFY">Johnston, R. S.. Dietlein. L. F. and Berry, C. A. (eds.),
<i>Biomedical Results of Apollo. </i>NASA SP-368. US Government Printing
Office. Washington. DC. 1975.</p>
<p><sup>24</sup>Op. cit. Ref. 5.</p>
<p align="JUSTIFY"><i>Note: The views expressed in this article are those
of the authors and do not necessarily reflect the opinion of the Tripler
Army Medical Center or US Department of Defense.</i></p>
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