2. AIR FORCES REAL
TIME MEDICINE
By Dawn M. Yankeelov
During the past three years, the Air Force has developed a telemedicine capability.
Today, service personnel and their families from Alaska to Bosnia
are benefiting—and the process is just beginning.
A
fter a heavy air attack in a remote telemedicine. A “Star Trek” future of capabilities can be instituted to talk to
overseas location, military ser- medical care delivery, which has arrived specialists on the other side of the ocean.
vicemen are waiting for immedi- on U.S. Air Force bases and other For a modest five figure investment, add a
ate hospitalization. One is experiencing Department of Defense divisions, is put to video camera and high bandwidth with
internal hemorrhaging, another has use. High-tech telecommunications for supporting robotics controls to create real-
crushed bone fragments causing excruci- data transfer and combat control, which time interactive patient management.
ating pain, and still others are experienc- have led the way for high-tech medical This reality-based approach to
ing nausea from unknown chemical solutions, become lifesavers. medicine has not yet actually seen a
warfare. The nearest hospital is more than With a basic PC, a phone line, battlefield situation. However, it has
1,500 miles away.Enter the world of and a modem, simple store and forward entered the lives of thousands of

3. servicemen stationed on Air Force readiness, according to Dr.Benge.On bases
bases in the United StatesTelemedicine everywhere in the U.S., military physicians
training also began in October 1996 in will move to eliminate the need for sub-
Bosnia and Saudi Arabia to serve troops specialists in every location. “This will
already there. downsize the number of people and
The Department of Defense equipment required, avoid costly travel for
first cataloged success with telemedi- patients to the large medical centers, and
cine in 1993 when a serviceman’s save space ultimately,” Dr. Benge said.
severe skin rash wasdiagnosed from For example, digital radiology
Somalia. Doctors were baffled and used eliminates the need for expensive X-ray
telepathology to transmit a mic- film to be stored. Dr. Benge explained,
roscopic image of the rash to a derm- “Tons and tons of equipment, chemicals
atologist at the Walter Reed Army and water could be eliminated for this
Medical Hospital in Washington, D.C. specialty. The space needed to store X-ray
A microscope in Somalia was operated film could be reallocated.”
via computer tomake diagnosis and The environment benefits directly
treatment possible. just in the use of telemedicine in radiology
“Air Force medical services alone,because the U.S. Air Force can
have been involved for the last 3 1/2 eliminate the requirements to reclaim
years in Department of Defense dem- silver ions from water after developing
onstrations, trying t o prove or deter- film. It’s a near instantaneous payoff, Dr.
mine how best to utilize communica- Benge added.
tions for better patient management,” Telemedicine in the Air Force
Dr. Michael James Benge, Director of generally uses an interactive video system
Strategic Man- agement in the U.S. Air integrated with biomedical telemetry,
Force Surgeon General’s Office and except in areas where high bandwidth is
overseer of Air Force medical oper- cost prohibitive. Store and forward
ations,said. “It’s so dependent on image systems, that use “snapshots” instead of
capture. And in the early analysis, it’s real-time television, work as well. They
very profitable for all involved. allow a physician at a specialty medical
Through 2001, telemedicine complex or teaching hospital to examine
training will be completed for combat and treat patients at multiple

4. S POTLIGHTS
satellite locations, such as rural hospitals specialist can review any type of X-ray
and clinics. examination, including an MRI, CAT scan
Integrated into the video system, or ultrasound. Investments in equipment
and based on the requirements of the setup range from $15,000 for storage and
remote medical facility, are a number of forward to $200,000 per site for probes
diagnostic devices. The remotely con- and live television feeds.
trolled examination camera has a power- Telemedicine was unveiled for
ful zoom-focus capability that allows a broad military use in June 1995, when the
dermatologist to examine small details of Pentagon conducted a tri-service exhibit
a patient’s skin. An electronic stethoscope featuring live demonstrations of
permits a cardiologist to do a complete telemedicine in support of day-to-day
cardiological examination. Specific operations. At that time, then Secretary of
camera adapters and resolution capabili- Defense William J. Perry told the Air
ties enhanced by remote controlled optics Force News Service, “Telemedicine is
provides an ophthalmologist a clear view not just a new use of old technologies. It
of the retina at the referring site. A combines cutting-edge telecommunica-
Telemedicine’s enormous potential in the battlefield is demonstrated by this exhibition, in which an
attending physician assists a distant surgeon who uses electro-mechanical manipulators, lights and
television cameras to view the patient, communicate with the on-site physician and actually perform
some of the surgical procedures.

5. A corpsman examines battlefield casualties and prepares to administer first aid in this telemedicine simulation.
His helmet-mounted television camera and voice communications link allow him to transmit real-time images of
the wounds, plus his comments and questions, to a doctor located in a Mobile Medical Mentoring Vehicle, located
several miles from the battle area. Thus, the corpsman does not have to make difficult medical decisions alone.
tions systems with specialized medical equip- services to approximately 1 million people.
ment to project medical care in real-time Capt. Linda Eaton, now in charge of
anywhere in the world.” the fully operational program that began
During one international demonstra- several years ago, outlined the following
tion, doctors at the exhibit consulted via program goals:
satellite with doctors at the Air Force’s 60th • To improve access and quality care
Medical Group Hospital at Zagreb, Croatia, a rural bases;
about previous cases. Doctors also held live • To increase beneficiary and
teleconsultations with medical units in Haiti and provider satisfaction with health care
I Macedonia by satellite. delivery;
• To prepare providers for support of
TRICARE Southwest: An International deployed forces via teleconsulting;
Telemedicine Network • To improve and facilitate cross-
The first successful wide-scale service referrals;and
program implemented in the Air Force was • To be cost-effective or cost-
directed by Capt. Ken Bonner, now of MATMO neutral.
(Medical Advanced Technology Management “A paradigm shift must occur
Office). His success led to his current involve- through telemedicine training. Physicians are
ment with the efforts to set up telemedicine in not up to speed on their thinking about its
Riyadh, Saudi Arabia, where about 7,000 U.S. benefits, but through education the message
troops reside. “The Air Force realizes that you is getting out that this type of support is an
have to move information, not people. The important tool,” Capt. Eaton said.
delivery of quality health care is verbal, textual The plan is to have a telemedicine
and image-based,” Capt. Bonner said. network organized to function as a compre-
The TRICARE Southwest hensive system for the whole region, creating
Telemedicine Pilot Project is an approved a “virtual health care delivery system.” The
Department of Defense, Health Affairs (MHSS newly embraced technologies include digital
Proponent Committee), proof-of-concept compression, store and forward, automated
project initiated in Region VI. The region medical records, video e-mail and computer
covers Oklahoma, Arkansas and major portions networks. OC-3, DS3, and T1 bandwidth on
of Eastern Texas and Western Louisiana. The demand technology, coupled with the
Department of Defense medical plan in this DICOM standard for medical information
region is centered around two military medical interchange, supports the multimedia mix
centers-Wilford Hall Medical Center and necessary for gathering and analyzing
Brooke Army Medical Center. They provide information.

6. For example, doctor-to-doctor added. “The only difference is that you Dr. Reed oversees a pilot project
contact includes the transmission of can’t actually touch the patient.” between Offutt AFB in Nebraska and
medical records, transmission of medical The teleradiology and the Whiteman AFB in Knonoster, Mo. “We
images, video consultations and rules- telepathology system were the most are trying to help smaller facilities, like
based messaging. Doctor-to-patient supported at the program’s outset. At Whiteman, with low bandwidth to
contact includes remote patient monitor- Wilford Hall, eight telemedicine stations examine snapshots and answer ques-
ing, delivery of health information and have been established. Brooke Army tions,” Dr. Reed said. “You can’t make the
video consultations. Medical Center has a central suite and physician transmit. We haven’t gotten
Military treatment facilities telemedicine sites in cardiology, dermatol- over that speed bump. Physicians are not
involved with the TRICARE implementa- ogy, ophthalmology, surgery and pediat- used to using the technology. Our energy
tion include Corpus Christi Naval Hospital rics. Other specialists who have conducted of activation needs to be here to achieve
in Corpus Christi, Tex., Goodfellow Clinic telemedicine consultations from Wilford total success. The next generation of
in San Angelo, Tex., Dyess Hospital in Hall represented endocrinology, gastroen- doctors will be ready.”
Abilene, Tex., Ft. Polk Hospital in terology, ophthalmology, rheumatology The program’s first four months
Leesville, La., and Laughlin Hospital in and urology. When expanded to all the involved fewer than 50 patients but
Del Rio, Tex. Between 50-100 patients per region’s military installations, the proved the system’s premises. Total
month stand to be served by telemedicine TRICARE project could become the savings can climb well into five-figure
at each facility. Full program implementa- largest telemedicine network sums per specialty, according to military
tion is to occur in late 1997. “The patients models for Offutt AFB and Whiteman
seem to accept the technology. In most Air Force Surgeon General’s Office, AFB.
cases, they see a specialist on the screen Air Combat Command, Langley, VA Dr. Reed notes that telemedicine is
talking with them and the attending “Everyone thinks that the particularly useful for dermatologists and
physician,” Capt. Eaton said. “Downtime standard “Star Trek” real -TV transmis- ophthalmologists—an important point with
and costly travel is avoided. A typical sion approach is the only way to go, but the emphasis on eyesight for Air Force
specialist may be booked two to four we are using email and digital cameras to pilots, and the ongoing threat of chemical
weeks in advance. This changes the time do telemedicine. With essential ISDN and biological weapons in the Middle East.
frame in favor of the patient.” connections, we use store and forward “You don’t need video of retinas or ear
“All patients I’ve worked with capabilities to get the job done,” Lt. Col. drums or skin rashes. Photos work. Listen-
think it’s a great idea, “ Lt. Col. Dr. Gary Dr. Hadley Reed of Air Combat Com- ing to a heartbeat can also be had by email.
Gronseth, a Wilford Hall neurologist, mand said. An audio clip, for example,” he said.

7. TELEMEDICINE ... video teleconferencing suites at the five
Mental health patients can also primary medical sites in Alaska, even
be evaluated through telemedicine. “In the long-distance physical therapy manipula-
past, as much as three days would be lost tion and teledentistry were introduced.
to travel to see if a patient would require Real-world use included an oral surgeon
hospitalization through a psychiatric wanting the advice of an orthodontist
evaluation,” Dr. Reed said. before operating, a preoperative evalua-
Dr. Reed sees widespread tion for wisdom teeth extraction and a
implementation of telemedicine in the periodontic evaluation for gum disease
U.S. Air Force within 5-10 years. “People and treatment. “Over the first nine
do not realize that disease and non-battle months, 31 dental consults were per-
injuries are more of a concern in warfare. formed, saving more than 190 days and
Telemedicine can give near instantaneous $40,000 in travel expenses,” Col. Fred
tracking of the health of a force, if used Nolan, Jr. said.
efficiently.” Equipment choices supported the
use of low bandwidth, since high band-
3rd Medical Group, Elmendorf Air width circuits at 1.54 mbps and ISDN
Force Base, Anchorage, Alaska were not available. A pair of switched 56
In Alaska, telemedicine may Kbps data circuits was installed at each
serve approximately 40 percent of the location. The CLI Eclipse 8100 Model
population in the near future, since the was selected for video teleconferencing at
Department of Defense administers the 15 frames per second with full duplex
health care of active military, retired audio. The need for store and forward
military and dependents through an became apparent early in 1996, so
intricate partnership. Capt. Greg D. software and hardware under the name
Carson, clinical systems engineer for MD/TV was selected. An object camera
telemedicine in Alaska, claims tremen- was also available at all locations.
dous program success. “The reduced Col. Nolan reports that emer-
patient travel to Elmendorf from four gency orthopedic care has worked out, as
other program nodes is particularly in the case of a patient who had fallen on
welcomed based on the weather the duty, fracturing his little finger. There was
military faces here, in addition to the a question handled via telemedicine as to
distances between medical clinics,” he whether surgery would be required. “The
pointed out. human response to telemedicine in Alaska
The other Alaska sites involved has been very positive. Providers do
are Adak Clinic at Adak Naval Station, describe the need to reach out and touch
Kodiak Clinic at the U.S. Coast Guard the patient, but go on to state they put
Station in Kodiak, Eielson Clinic at their hands in their pockets. The initial
Eielson AFB, and Bassett Army Hospital shyness disappears quickly and the face-
at Ft. Wainwright. Involved with the DoD to-face relationships become a strong
healthcare initiative in the winter wonder- point,” he said.
land are Veterans Affairs and the Indian
Health Service. Overseas and Beyond
Air evacuations, particularly in Well into 1997, telemedicine will
Alaska, often may be risky, delaying become an integral part of the military
access to critical care or preventing it presence overseas, starting in Saudi
altogether. The state comprises 25 percent Arabia. Next, up to nine clinics will be
of all U.S. Iand acreage and covers the outfitted in nearby Kuwait, Oman and
same north-south distance as the entire Bahrain, at a cost of $50,000 per installa-
lower 48 states. It presents a challenge to tion.
provide specialty medical professionals INMAR-SAT-based systems,
from the 3rd Medical Group to Adak which can be set up anywhere, will
Clinic, at the Adak Naval Station some represent Phase II for DoD supporting the
1,500 miles away. Located in the Aleutian U.S. efforts in Bosnia. “People have not
Islands, Adaks NAS is the most remote put telemedicine into enough peacetime
site in the network. Meanwhile, the Coast care yet. We need to get our people into
Guard clinic on Kodiak Island is an air using this on a daytoday basis,” Dr.
flight from Anchorage, subject to extreme Benge, who oversees the ongoing
weather conditions, and is a free-standing telemedicine launch in the U.S. Air Force,
family practice clinic. said. “Telemedicine is very glamorous,but
With dedicated data circuits (56 it is still a concept trying to size itself and
Kbps), store and forward technology, and find itself, in terms of applications.”