Telemedicine in support of peacekeeping operations overseas: an audit.

BACKGROUND AND OBJECTIVE: Since 1993, the Department of Defense has augmented the medical support for Army units on peacekeeping operations in Macedonia through the medium of telemedicine. This project, known as Operation Primetime 1, was the first satellite-based telemedicine system deployed in support of remote primary-care physician in the U.S. military. Its declared aims are: (1) to improve the standard of care; (2) to reduce evacuations; (3) to support junior physicians in the field; and (4) to improve the military effectiveness of the deployed units. This paper audits the success in attaining those goals for the period January 1994 to April 1995. METHODS: A log was collated from the referring units and questionnaires completed by both referring and consulting physicians. The referring physicians were interviewed on their return from Macedonia, and a more detailed study was undertaken of cases in which a change in outcome was noted. Follow-up interview of consultants was not possible. RESULTS: A total of 53 consults were undertaken on 47 patients. The use of telemedicine affected the decision to evacuate 13 times (13/47), with a net reduction of 9 evacuations. Management of individual cases was changed in 30 of the 47 cases in which telemedicine was used. Physician confidence and military effectiveness were also improved. The level of utilization of the system was largely dependent on a training and sustainment program. Units and General Medical Officers who were trained in the clinical use of telemedicine and the technical sustainment of the equipment used the system; those who were not, did not. Most patients (45/47) were treated satisfactorily with a single consult. Telemedicine under these circumstances seems to be cost effective. The deployed sites chose the referral centers that provided the best service. CONCLUSIONS: Telemedicine is a valuable tool capable of augmenting medical support to deployed military units. A successful deployed telemedicine project requires an integrated support package that includes adequate provision for training and equipment sustainment at both ends of the link. Experience with telemedicine in Operation Primetime indicates the potential for substantial cost savings as well as cost-effective medical care. Further application of telemedicine should be encouraged. Successful deployment of telemedicine projects may hinge on an integrated support package.     

Tertiary telemedicine support during global military humanitarian missions.

OBJECTIVE: The U.S. military medical units face the challenge of delivering the latest medical knowledge and advances to remote areas of the world. This study details the tertiary care telemedicine support by Walter Reed Army Medical Center (WRAMC) for these humanitarian missions in several locations worldwide. METHODS: This study encompasses data from all clinical consults received at WRAMC, from the earliest deployment of a satellite-based system in February 1993 through February 1996. The analysis of the consultations include type of consult, medical specialty consulted, response time, and technology used. RESULTS: Two hundred forty consults were received from 12 remote telemedicine sites supporting military medical missions. The consults used a combination of "store-and-forward" technologies and interactive video conferencing systems. Establishment of a telemedicine service at WRAMC, including medical and technical support personnel, facilitated the delivery of telemedicine consultations. Several concurrent missions were supported. The distribution of consults included medicine (40%), surgery (36%), radiology (21%), and dentistry (3%). The most frequently consulted medical subspecialty was dermatology (29%) followed by orthopedic surgery (16%). Most consults were routine (88%). Ninety-four percent of the consults were completed within the predefined telemedicine response criteria (24 hours for routine consults and 3 hours for emergencies). CONCLUSION: The study illustrates the importance of a responsive telemedicine service at a tertiary facility supporting simultaneous medical missions. Access to the complete spectrum of medical and surgical specialties was essential to enhancing the delivery of medical care. The critical analysis and evaluation of this experience will assist in designing future prospective studies for evaluation of telemedicine.     

Telemedicine in the U.S. Army: case reports from Somalia and Croatia.

Recent advances in information systems technology improved the abilities of U.S. Army physicians in Somalia and Croatia to obtain clinical consults from U.S. Army Medical Centers in Germany and Washington, D.C. Through commercial satellite transmission of voice, facsimile, and high-resolution still, digital images, the Remote Clinical Communications System (RCCS) has expanded the Army Medical Department's means to provide better healthcare to our armed forces. This paper describes the RCCS technology and illustrates, through specific case reports, how this telemedicine system helped the Army Medical Department accomplish its mission during overseas deployments.     

A cost-effectiveness analysis of shipboard telemedicine.

BACKGROUND: The U.S. Navy is considering the installation of telemedicine equipment on more than 300 ships. Besides improving the quality of care, benefits would arise from avoiding medical evacuations (MEDEVACs) and returning patients to work more quickly. Because telemedicine has not yet been fully implemented by the Navy, we relied on projections of anticipated savings and costs, rather than actual expenditures, to determine cost-effectiveness. OBJECTIVES: To determine the demand for telemedicine and the cost-effectiveness of various technologies (telephone and fax, e-mail and Internet, video teleconferencing (VTC), teleradiology, and diagnostic instruments), as well as their bandwidth requirements. METHODS: A panel of Navy medical experts with telemedicine experience reviewed a representative sample of patient visits collected over a 1-year period and estimated the man-day savings and quality-of-care enhancements that might have occurred had telemedicine technologies been available. The savings from potentially avoiding MEDEVACs was estimated from a survey of ships' medical staff. These sample estimates were then projected to the medical workload of the entire fleet. Off-the-shelf telemedicine equipment prices were combined with installation, maintenance, training, and communication costs to obtain the lifecycle costs of the technology. RESULTS AND CONCLUSIONS: If telemedicine were available to the fleet, ship medical staffs would initiate nearly 19, 000 consults in a year-7% of all patient visits. Telemedicine would enhance quality of care in two-thirds of these consults. Seventeen percent of the MEDEVACs would be preventable with telemedicine (representing 155,000 travel miles), with a savings of $4400 per MEDEVAC. If the ship's communication capabilities were available, e-mail and Internet and telephone and fax would be cost-effective on all ships (including small ships and submarines). Video teleconferencing would be cost-effective on large ships (aircraft carriers and amphibious) only. Teleradiology would be cost-effective on carriers only. Telemedicine's bandwidth requirement is small-1% of a month's time. However, if the ships' medical departments need to resort to a commercial satellite, E-mail and Internet would be the only telemedicine modality generating enough monetary benefits to offset the costs.     

无线网络和移动设备在医院信息系统中的应用

本文主要介绍了无线网络和移动设备在远程医疗、医生查房、临床护理方面所具备的独特优势。无线网络和移动设备的使用,可以提高医护人员的工作效率,降低工作成本,避免了重复工作或错误的发生。该新型医疗技术充分发挥医院信息系统的效能,有效提高了医疗质量、服务质量和运营效率,从而提高医院的综合竞争力。     

Rural applications of telemedicine.

OBJECTIVES: To describe the status of telemedicine in rural America, the characteristics of health care facilities using telemedicine technologies to serve rural patients, the volume and scope of services delivered, the costs associated with this care, and the funding sources. METHODS: A screening survey was mailed to all 2472 nonfederal U.S. hospitals located outside metropolitan areas. Nonrespondents were interviewed by telephone. Those who reported some form of telemedicine capability, and all the telemedicine affiliates they named, became the sample for a detailed follow-up survey (N = 558) in January 1996. RESULTS: Ninety-six per cent of all rural hospitals responded to the screener survey, and 89% of the 558 identified telemedicine facilities responded to the detailed follow-up survey (total respondents = 499). In this cross-sectional study, two thirds of the telemedicine respondents (340) were using only teleradiology. Of the 159 telemedicine programs pursuing other clinical applications, 67% had been using telemedicine for 2 years or less. Telemedicine facilities have tried many clinical specialty applications, the most common being radiology, cardiology, and orthopedics. At this early stage of technology diffusion, reported utilization of the telemedicine systems for both clinical and nonclinical applications was very low, and the unit costs of equipment acquisition and operating expenses were corresponding high. Programs most commonly used hospital financial resources and federal grants and contracts for support. Telemedicine networks planned to grow from an average of nine facilities to an average of 13 facilities during 1996. CONCLUSIONS: Investment has been rapid in telemedicine, and the installed base reported in this survey was large, sophisticated, and growing rapidly. Nonclinical uses of the technology (e.g., meetings, training sessions, continuing medical education) were more common than clinical consultations, although the volumes of both were quite low. Investment and expansion to new sites were occurring in the absence of a favorable payor reimbursement environment and in spite of low volume at most operating sites, demonstrating optimism about the future of telemedicine and the potential for nonclinical applications.     

Effect of telemedicine on health outcomes in 87 infants requiring neonatal intensive care.

OBJECTIVE: This is an evaluation of a telemedicine system for the rapid interpretation of neonatal echocardiograms from a regional, level III neonatal intensive care unit (NICU). The use of telemedicine to support the cardiology needs of NICUs is increasing. However, there is very little published objective information regarding health outcomes or costs resulting from such telemedicine systems. The primary hypothesis tested was that the utilization of a telemedicine system for the interpretation of neonatal echocardiograms reduces the intensive care length of stay of low birthweight (LBW) infants. STUDY DESIGN: All infants who were admitted to neonatal intensive care at New Hanover Regional Medical Center during the first six months of the system were studied by the use of echocardiograms. They were compared with infants who were born in the same period of the previous year. The outcome measures were the intensive care length of stay, rate of transfer to academic medical centers, and mortality rate. RESULTS: A statistically non-significant reduction of 5.4 days in the intensive care length of stay (LOS) of low birthweight infants was observed (p = 0.37). The cost per echocardiogram transmitted was calculated at $33 compared to previous method of sending videotapes via overnight courier. CONCLUSIONS: While the sample size was inadequate to demonstrate improvements in health outcomes, the magnitude of the change and the low costs of the system suggest that this intervention is practical for obtaining rapid diagnostic and treatment support. Larger studies are warranted to confirm these findings and determine whether faster diagnosis and earlier initiation of treatment improve health outcomes of newborn infants.     

United States citizens studying medicine abroad. Their backgrounds and test performance

To acquire information about the characteristics of U.S. citizens who had recently studied medicine abroad, the Educational Commission for Foreign Medical Graduates (ECFMG) and the Association of American Medical Colleges merged independently collected data on a study group of 10,460 U.S. citizens who attended 359 medical schools in 75 foreign countries and who took their first ECFMG examination between 1978 and 1982. The study group was markedly heterogeneous: 21 percent were not U.S. citizens at birth, 32 percent did not have English as a native language, and 12 percent had two or more years of undergraduate college education in Puerto Rico. Sixty-seven percent resided in New York, New Jersey, California, Florida, or Puerto Rico, and 74 percent studied medicine in Mexico or the Caribbean. Forty-six percent passed the ECFMG examination on their first attempt, and 22 percent passed a subsequent examination. Only 45 percent had applied to a U.S. medical school, and 65 percent had taken the Medical College Admission Test. The means of the college grade-point averages, known for 39 percent of the study group, and of the scores on the admission test, known for 65 percent, were lower than those of both accepted and unaccepted applicants to U.S. medical schools in the 1976 and 1978 entering classes. The finding that 55 percent of the study group did not apply to a U.S. medical school does not support the widely held belief that most, if not all, U.S. citizens who attend foreign medical schools do so only after several unsuccessful attempts to gain admission to a U.S. school.     

Results of the second Clinical Skills Assessment Examination of the ECFMG

To test the hypothesis that the clinical skills of many foreign medical graduates entering residencies in the United States are deficient, the Educational Commission for Foreign Medical Graduates (ECFMG) administered a second, more extensive pilot examination called the Clinical Skills Assessment Examination. The test was constructed after identifying those clinical skills considered to be suitable for testing in a large-scale examination conducted at multiple locations. The test was given to 635 foreign medical graduates (including 53 U.S. citizens) who had been certified by the ECFMG and to a reference sample of 123 graduates of U.S. medical schools. All of the graduates took the test prior to their first postgraduate year of training. The results did not differ significantly from those of a previous test. The clinical skills of 28% of the graduates of foreign medical schools who took the examination were found to be inadequate when compared with those of graduates of U.S. schools. The conclusion reached was that a clinical skills examination is feasible for inclusion in the ECFMG certification process.     

Medical services of Croat people in Bosnia and Herzegovina during 1992-1995 war: losses, adaptation, organization, and transformation

During the 1992-1995 war in Bosnia and Herzegovina (BH), Croatian people in BH had 19,600 (2.6%) killed and 135,000 (17.6%) displaced persons, and 222,500 (28.9%) refugees. They lost around two thirds of both physicians and other health personnel, and were left with 8. 5% of prewar patient beds. Fortunately, the organized defence against Serbs was initiated in time and Croats defended the territories where they formed majority. The first defense unit established was the Medical Corps Headquarters (MCH), caring for soldiers and civilians alike. The MCH was soon incorporated in the Croatian Defense Council (CDC, armed forces of Croatian people in BH). The MCH had two chains of command. One went through the district commanders of medical services and their subordinated physicians to paramedics in military units, and the other directly to the commanders of 14 war hospitals. After its formation in 1993, the Ministry of Health took the jurisdiction over the civilian medical services and after the Washington Peace Agreement (April 1994) over the war hospitals, too, whereas the medical services within military units remained under control of the Ministry of Defense. Dayton Peace Agreement divided BH into the Federation of BH and Republic Srpska, each with their own army. The Federation of BH Army is composed of the CDC and Bosniac-controlled Army of BH, with overall numerical ratio 1:2.3 for Bosniacs, and organized in accordance with NATO standards. Military medical services are provided by the Logistics Sector of both Ministry of Defense and Military Corps Headquarters (Joint Command).     

北京大学的医学物理和工程研究

除了有六个附属医院外，北京大学与医学物理和工程研究有关的最早的单位是北京大学重离子物理研究所。这个研究所是1983年经国家教育部批准成立的，主要从事核技术及应用方面研究工作。1994年底因当时的国家科委和国家教委对基础性研究所改革试点的需要，经过国内同行严格评估之后批准建立了医学物理研究方向，开始了这方面的研究工作，开始了该领域的教学科研工作，包尚联是这个学科方向的发起者和具体组织者。为了建立和医学临床之间的合作关系并把重点放在肿瘤的诊疗上面，我们于1997年和北京大学医院联合成立了北京大学肿瘤物理诊疗技术研究中心。而北京医疗器械研究所是国内从事医用电子直线加速器的专业研究所，最近已经改造为企业，是国内的同等业内的领头企业。为了更好地和医疗工业的发展有机结合，北京大学的医学物理学科又于1999年左右开始和北京医疗器械研究所合作，并于2001春天经北京市组织的严格评估之后批准建立了北京市重点实验室：医学物理和工程。这个实验室的成立标志我们的研究方向和国民经济的紧密结合。至此，我们共有五个研究方向：核磁共振成像；核医学成像；医学图像处理；放疗物理和技术；电子直线加速器为主的医疗仪器的关键技术、工艺和整机的优化设计等工程研究和发展。     

Virtual polyclinic--consultant health service for rural areas and islands

The development of medical sciences and digital revolution in health care have made possible the creation of new models for hospital care and primary health care. Health care management usually does not follow all possible solutions of new computer technology. Croatian health system is based on large hospital centers in the mainland and small, poorly equipped remote medical units. The possibility of sharing medical information using telematic technologies brings all knowledge of the large, powerful hospital centers close to remote medical units. Working in a small, remote consultation office on the island Cres, the author A. M. became part of medical periphery far from the security of hospital on the mainland. After five years of the work on telemedicine projects for the islands, we have introduced a new medical practice concept of communication between remote medical units and clinical hospital centers in the mainland. The pilot project Virtual Polyclinic-Medical Consultation System for the Islands and Remote Areas is a good example of the possible new models in health care structure. Our experience indicates that organization of health care in remote areas depends not only on advanced technical solutions but also on team work and medical professionals.     

Implementation and evaluation of a telemedicine course for physician assistants.

Clinical telemedicine uses interactive video technologies and telecommunications networks to deliver medical consultations to distant patients and their primary care providers. Telemedicine provides real-time access to specialists whose services might not otherwise be available in rural or medically underserved areas. While recently there has been dramatic growth in the use of telemedicine, there is little evidence that telemedicine as a patient care delivery system has been incorporated into the medical school curriculum. The authors describe the current status of telemedicine in medical curricula and report on efforts at the University of Iowa to incorporate telemedicine into the curriculum of its Physician Assistant Program.     

The case of Powhatan Correctional Center/Virginia Department of Corrections and Virginia Commonwealth University/Medical College of Virginia.

OBJECTIVE: To implement a cost/benefit analysis of telemedicine subspecialty care provided between the Powhatan Correctional Center (PCC) of the Virginia Department of Corrections (Corrections) and the Medical College of Virginia campus of Virginia Commonwealth University (MCV/VCU). METHODS: We evaluated the costs and benefits of the implementation of telemedicine for HIV-positive inmates. Benefits included dollar savings in transportation and medical reimbursement. Costs included those of operating the telemedicine system and of medical care. Non-dollar benefits included implementing more consistent and timely treatment of inmates and reducing security risk. RESULTS: Over the 7-month study period, the total number of HIV consults by telemedicine was 165. The Department of Corrections was able to achieve transportation and medical savings of $35,640 and $21,123, respectively. The operating costs for the telemedicine services totaled $42,277. The net benefit, which is the difference between cost savings and total operating costs, was $14,486. CONCLUSION: Telemedicine increased access to care for HIV-positive inmates and generated cost savings in transportation and care delivery.     

Review of telemedicine projects in Taiwan

Taiwan is a heavily populated country, with a small land area and many mountains and isolated islands. Because medical resources are unequally distributed, high quality accessible medical care is a major problem in rural areas. Medical personnel are unwilling to practice in rural areas because of fear of isolation from peers and lack of continuing medical education (CME) in those areas. Telemedicine provides a timeless and spaceless measure for teleconsultation and education. The development of telemedicine in Taiwan began under the National Information Infrastructure (NII) Project. Distance education and teleconsultation were the first experimental projects during the initiation research stage. The cost and effectiveness of the hardware and network bandwidth were evaluated. In the promotion research stage, applications in different medical disciplines were tested to promote multipoint videoconference, electronic journals and VOD. Investigation of user satisfaction put on more emphasis on improving application functions. In 1998, a new Cyber Medical Center (CMC) international collaboration project was begun, integrating technologies of multimedia, networking, database management, and the World Wide Web. The aim of the CMC is to create a multimedia network system for the management of electronic patient records, teleconsultation, online continuing medical education, and information services on the web. A Taiwan mirror site of Virtual Hospital and two international telemedicine trials through Next Generation Internet (NGI) were done at the end of 1998. In the future, telemedicine systems in Taiwan are expected to combine the Internet and broadband CATV, ADSL, and DBS networking to connect clinics, hospitals, insurance organizations, and public health administrations; and, finally, to extend to every household.     

Health Care Utilization After Interdisciplinary Chronic Pain Treatment: Part I. Description of Utilization of Costly Health Care Interventions

Chronic musculoskeletal pain (CMP) is a significant burden for chronic pain sufferers, their medical and allied health treatment providers, and the U.S. medical system. The U.S. military has seen a significant increase in CMP with increased injuries stemming from military operations in Iraq and Afghanistan, and advances in care for CMP are sorely needed. Poor chronic pain treatment in the military has led to high levels of costly health care utilization with related costs estimated in billions of dollars. The functional occupational restoration treatment (FORT) trial, funded by the Congressionally Directed Medical Research Programs (Department of Defense), was the first formal, randomized trial of a novel interdisciplinary management program for CMP among active duty service members. Excellent clinical outcomes at posttreatment and long‐term follow‐up have been reported elsewhere. This paper examined patterns of health care utilization among FORT study participants for a period of 1 year before and after the study intervention or yoked, 3‐week control period. We examined the military's Armed Forces Health Longitudinal Technology Application, which went online in 2004, to identify costly health visits and procedures consumed by study completers. We then compared utilization rates between those who received the interdisciplinary FORT treatment and those who were randomized to treatment as usual. Our analyses revealed significant between‐group differences at posttreatment (controlling for pretreatment intervention use), with FORT participants receiving significantly fewer procedures including emergency department intervention, injections, and radio frequency nerve ablations. This paper precedes a follow‐up study of mediating factors for health care utilization after interdisciplinary treatment.     

A standardized patient enrolled in medical school considers the national clinical skills examination.

The National Board of Medical Examiners' recent decision to include a clinical skills examination as part of the licensing requirements for U.S. medical graduates has generated widespread discussion about the role of standardized patients in medical education. The author demonstrates that while specific clinical skills can and should be integrated into the medical school curriculum, any assessment of these skills using interactions with standardized patients must allow for a fuller range of responses and immediate, multifaceted feedback (content, process, and patient satisfaction) than would be allowed in the proposed Step 2 Clinical Skills. The presence of a national examination would pressure medical schools to adopt the very limited model of patient-physician interaction favored by the National Board of Medical Examiners. In addition, the author argues that the cost of registering for the examination and traveling to one of the few test sites on borrowed money is not justified to verify skills that may be reliably assessed locally.     

Primary-care delivery for sickle cell patients in rural Georgia using telemedicine.

BACKGROUND: Advances in newborn screening and pediatric management of sickle cell disease have resulted in patients living well into adulthood. For adults, preventive care and medication monitoring are crucial for optimal health maintenance. The Medical College of Georgia (MCG) in Augusta provides consultative services and comprehensive medical care to about 1200 sickle cell patients residing in middle and southern Georgia. An increase in the demand for clinical services in this patient population has resulted in expansion of sickle cell outreach efforts throughout the state. OBJECTIVE: A telemedicine clinic for adult sickle cell patients was established in order to meet the growing clinical demands. METHODS: An on-site outreach clinic was introduced in the target area. After 10 months of operation, a monthly telemedicine clinic was offered to patients as an option for routine medical follow-up. A clinic model was used, with scheduled appointments and a public health nurse assisting at the remote site. Phlebotomy and laboratory services enhanced the telemedicine encounter. RESULTS: Over a 12-month period, 52 encounters for 28 patients from 17 medically underserved counties were completed. All patients were African-American, and 89. 3% had Medicaid or Medicare insurance coverage or both. The clinic encounter time was 24 +/- 7.9 minutes (mean +/- SD), comparable to that for all telemedicine clinic encounters during the same period. CONCLUSIONS: The adult sickle cell population in rural Georgia accepts innovative health care delivery using telemedicine. Thus, the telemedicine sickle cell clinic has increased access to care for rural patients in underserved areas. For providers, it has allowed greater clinical productivity and diminished travel time to outreach clinics.     

Telecardiology through ubiquitous Internet services

PurposeImplementation of telemedicine in many clinical scenarios improves the quality of care and patient safety. However, its use is hindered by operational, infrastructural and financial limitations. This paper describes the design and deployment of a plug-and-play telemedicine platform for cardiologic applications.MethodsThe novelty of this work is that, instead of complex middleware, it uses a common electronic mailbox and its protocols to support the core of the telemedicine information system and associated data (ECG and medical images). A security model was also developed to ensure data privacy and confidentiality.ResultsThe solution was validated in several real environments, in terms of performance, robustness, scalability and work efficiency. During the past three years it has been used on a daily basis by several small and medium-sized laboratories.ConclusionsThe advantage of using an Internet service in opposition to a server-based infrastructure is that it does not require IT resources to set up the telemedicine centre. A doctor can configure and operate the centre with the same simplicity as any other Internet browser application. The solution is currently in use to support remote diagnosis and reports of ECG and Echocardiography in Portugal and Angola.     

智慧医疗在军事卫勤中的应用

随着物联网、大数据、云计算、人工智能等信息化技术在医疗领域的逐步深入,医疗行业的科技革命进入高潮,促进传统医疗模式向高效、全面、便捷的智慧医疗服务保障体系转变。而军队人员作为特殊群体,在遂行各类平时、战时、非战争军事行动时往往处于复杂特殊环境,远离保障中心,更需要通过建设智慧医疗加强军队卫勤力量,通过构建完善的军队智慧医疗服务保障体系,提高部队战斗力。本文总结概括智慧医疗近年来的发展现状,并阐述智慧医疗在平时、战时、非战争军事行动等多种特殊军事环境下的应用。