Combat telehealth establishes tri-service theater connectivity

Team members are from left to right, Maj. David G. Ault, Maj. Erich Murrell, Master Sgt. David Gasper, of the 332 Expeditionary Medical Group; Maj. Sean P. Murphy and Col. Les Folio.  (U.S. Air Force photo)

Telehealth, specifically teleradiology, is becoming more commonplace across the globe. Forward deployed medical care in wartime is no exception.   In fact theater healthcare may help set examples for austere environments in other countries--including rural United States.

In March 2005, a team of four hand-picked active duty Air Force officers set out for a brief mission with a major impact: to provide a joint telehealth solution with connectivity from remote hospitals receiving war casualties back to large teaching institutions where wounded/injured patients may be transported. 

The team members were Col. Les Folio (Air Force Telehealth Office), Maj. Erich Murrell and Maj. Sean Murphy (Air Force Medical Support Agency), and Maj. Dave Ault (Air Force Medical Evaluation Support Agency).

From the onset, the evolution of this project was groundbreaking.  A landmark charter among the Army, Navy and Air Force was signed by each of the deputy surgeons general.

The charter started the PACS JSWG - Picture Archiving and Communications System Joint Services Working Group - that compelled the military to minimize redundancy, enhance provider’s practice and strive for standards-based technology and processes whenever possible with respect to diagnostic imaging. 

After a few meetings it was quickly agreed that forward deployed PACS and teleradiology would be of the highest of priorities.

As is often the case in medical practice, interim solutions proliferate as providers do whatever is in their power to best treat their patients.  This included doing montages of CT images to send via email (no patient data of course). 

Some took digital photos of dermatology lesions to get consults on perplexing cases where there was no dermatologist.  These solutions were novel, secure and compliant.  However, they served to demonstrate the need for a more uniform solution that can be replicated.

A small working group -- that quickly grew due to need -- emerged to assure similar decisions and processes would take place in the theater of operations in Southwest Asia.

Since the Army and the AF had experience with certain solution sets and were each having success in DICOM image distribution--common platforms were agreed upon. After an Army visit to the forward deployed units last year, much progress was made.  This was due to the personal connections established during onsite visits and through the telemedicine office of the Army and Air Force surgeon generals’ staffs.  

The enthusiasm for telehealth generated quickly and there was a clear path for follow-up once the assessments and educations were complete. This paved the way for other services to obtain compatible (similar) equipment, refine business rules and prepare follow-up visits to re-assess, teach, train, and install systems.

For example, questions from Iraq were forwarded to the team on how to send images, get remote interpretations, use equipment that was in place, and operate in an environment where low bandwidth (100Mbps or less) is commonplace. 

Other experts from other services (hundreds of support personnel from all walks of PACS world) collaborated in an effort to craft a telehealth strategy.  This dialogue included active duty, reservists, civilian contractors and vendors; whoever could answer the questions at hand. 

The AF team of four emerged from these emails, phone calls, and teleconferences as the most qualified to go in physically and optimize the telehealth capabilities at a key AF expeditionary hospital: Balad Air Base, just north of Baghdad. This large deployed hospital saw most of the casualties from the Fallujah battles, and continues to see trauma regularly. They have CT capability, limited ultrasound, and plain radiography with computed radiology.

The mission for the AF team was to virtually eliminate the need to over-image air evacuees -- both at Balad and at each subsequent echelon of care.

In order to connect the current system to the network, the LINUX servers needed to be exchanged with Solaris servers due to AF information assurance requirements. Secondary goals included proof of concept for future dynamic workload sharing, operational testing of bandwidth usage rates of teleradiology, and general telemedicine education for providers in a contingency setting.

Balad acquired a deployed teleradiology set from the Army when the Army transferred ownership of the hospital to the AF in 2004. External connectivity (for teleradiology) had not yet been established and was delayed due to Air Force security requirements that are different from the Army.

The Air Force team -- known sometimes as the Joint Expeditionary Telehealth Team or JETT -- focused on swapping out the teleradiology servers with AF approved systems and migrate the image archives seamlessly - all while hospital operations were in full force. Once swapped out, the base communications department allowed for connectivity across the LAN and out across the WAN for eventual connection and successful teleradiology over the Internet. 

In the short span of a few weeks the small team successfully swapped out the old servers for new AF approved ones; established teleradiology capability; added a diagnostic workstation with 3 MP flat panel monitors; and provided better visibility of images in the operating room for surgeons.

Presentations were made to the professional staff on teleradiology as well as other telehealth modalities available to them; for example, an Army-run teledermatology program facilitates continual access to a panel of experts that can discuss perplexing dermatology cases. 

This program is supported by AF dermatologists and allows providers to securely e-mail images and get consults within hours rather than days or months.  Other telehealth solutions mentioned included infectious disease and ocular consultations. There have been approximately 500 teledermatology consults since the Army started the process, saving roughly 11 air evacuations, and saving lives, from early melanoma detection, for example.

Visits to other bases provided more insight to theater telehealth, with lessons learned from other interim solutions that benefited those without dedicated teleradiology equipment.

Future directions include increasing archiving capability, more bases to be included in referral network and dynamic workflows so radiologists can share in interesting cases or help relieve each other depending on availability.  However, what is clear from the mission success of this AF Team is that telehealth in austere environments with relatively low bandwidth is clinically necessary and technically feasible.

NOTE: Folio will be a keynote speaker at the Defense Department R&D Conference in June.