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THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
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THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE CAPT Dennis A. Vidmar, MC, USN
Telemedicine has existed for longer than most people realize, but in many ways it is a new clinical modality. It will alter the delivery of dermatology care, especially to locations that are unserved or underserved by dermatologists who are in deployed military forces. A dermatologic office visit involves the transfer of information between the patient and the provider, allowing diagnosis and therapy. Such information is historic and objective. All consultations, whether “curbside,” telephonic, or televisual, involve the transfer of medical information. Dermatologists jokingly suggest that the referring provider “hold the rash closer to the phone.“ Teledermatology in its simplest sense is the interpretation of electronically transmitted images and clinical history to reach a diagnosis and provide recommendations for therapy. It indeed allows the referring provider to “hold the patient closer to the phone”. This article provides an introduction to selected principles of teledermatology, a history of their development and use by the Department of Defense (DoD), and a glimpse at some new DoD initiatives in teledermatology. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or Department of Defense.
DoD INTEREST IN TELEMEDICINE
The medical support of the US armed forces has always been a challenge because ground troops, aircraft, and ships are ”on the move” in combat operations, usually in austere environments. In addition, the armed forces are increasingly sent to many parts of the globe to support humanitarian, peacekeeping, and disaster relief missions. As such, the DoD has consciously nurtured telemedicine as a way to practice ”good medicine in bad places.” The prime mission of the DoD health care system is keeping every service member in good health and therefore on the job, anywhere in the world, to support combat operations or other missions such as peacekeeping. Telemedicine supports this goal by electronically bringing the specialist to the primary provider who directly cares for service members in an austere, remote, and isolated environment. Telemedicine creates an opportunity to provide more rapid, accurate diagnosis and therapeutic recommendations. In this way telemedicine maintains the health and the capability of service members to work by allowing faster return to duty and minimizing logistically burdensome, inconvenient, and expensive transportation to distant specialty care.
From the Departments of Military and Emergency Medicine and Dermatology, Uniformed Services University of the Health Sciences, Bethesda, Maryland ~
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DERMATOLOGIC CLINICS
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VOLUME 17 NUMBER 1 *JANUARY 1999
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Because dermatologic disease is one of the most common sources of morbidity and lost work days to armed forces,3O the DoD has wisely encouraged involving dermatology in telemedicine.
THE HISTORY OF TELEMEDICINE TECHNOLOGY AND ITS APPLICATION The first known use of telemedicine was in 1906 by Einthoven, who used it to transmit electrocardiograms 3 years before the invention of tele~ision.~ In 1924 Radio News magazine featured a cover illustrating a visual teleconsultation between a doctor and a patient at home. It took many years of technologic advancement to make Einthoven's experiments and Radio News' fanciful cover into a reality. Like any other modality in medicine, telemedicine has been heavily influenced by the availability and improvements of technology developed for nonmedical uses. The next sections trace the development of telemedicine technology from the heavy and cumbersome analog live television systems to the relatively light and flexible equipment of today. Some technologic principles and vocabulary will be introduced as a way to understand telemedicine systems. For additional background reading, Perednia's article on digital dermatologic imaging is highly r e c ~ m m e n dIt . ~is~ an excellent summary for the beginner. An important factor in the development of telemedicine has been the alignment of technology and clinical practice. For telemedicine to be viable, it has to play a role in continuing medical education, exchanging health care information, and improving health care delivery to the patient. Telemedicine has been used by dermatology and other clinical specialties for each of these functions.
Analog Signal Telemedicine The first use of visual telemedicine occurred in the 1950s, ' ~ O S , and '70s. It required a live television link between two wellequipped studios. The teleconsultations employed live video and audio with direct communication among the patient, referring pros, l9 Even dermatology vider, and c~nsultant.~, tested its effectiveness, albeit using blackand-white images.ls
These analog units required equipment, communications cables, links, and technicians that were solely dedicated to teleconsultation. This arrangement also required two teams of camera crew, sound crew, and other on-site technical support staff. At that time a twocamera studio cost $150,000 and a microwave uplink system to connect the studios cost another $30,000. Airwave transmission charges were also extremely high. Despite the good quality of the images and the advantages of live clinical interaction, the sheer expense, weight, and volume of equipment combined with its need for sophisticated technical support insured that telemedicine consultation, although possible, was not practical.
Digitized Videoteleconferencing (VTC) The development of digital television images in the early 1980s was the pivotal event that permitted the fruition of VTC and its logical use in medical teleconsultation. Some rudimentary knowledge of television transmission principles is necessary to understand the differences between analog and digital VTC. One can then appreciate the advantages, uses, and limitations of past and present VTC telemedicine systems. An analog television image is transmitted as a constant flow of electronic signals through a pipe of cables or airborne electromagnetic waves. These signals are processed for display on a monitor at a rate of 6 million Hz. Typical analog television signals are roughly the digital equivalent of about 90 million bytes(b)/sec or 90,000 Kilobytes(Kb)/ sec.I4 The pipe required to transmit such a large amount of information is large and is not easily shared with another transmission. The functional diameter of this pipe is referred to as bandwidth. In the early 1980s the development of the analog-to-digital converter compressor (CODEC) made VTC a reality in boardrooms, executive suites, and ultimately medical centers (Fig. 1).A CODEC transforms an analog television image into a digital image by converting the color of each tiny square (i.e., pixel) of a television image into a series of electronic binary code. By selectively sampling the continuous analog signals, the data transmission rate is reduced. A typical digital transmission rate for VTC within the US is about 128 Kb/sec, about 1/700th the rate re-
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Figure 1. Live videoteleconference between the National Naval Medical Center and the aircraft carrier USS George Washington.
quired for analog transmission. Another advantage is that signal digitalization allows several users to simultaneously use small individual portions of larger bandwidth. A CODEC works by digitalizing sequential frames of the analog signals. If the rate of sampling is large enough (e.g., 30 frames/s), the viewer perceives smooth motion, similar to viewing movie film. If the rate is too slow, a jerky motion is perceived. The CODEC and compression software further reduce the data flow by sensing and transmitting only the parts of the digitized image that have changed since the previous sampled frame. During times of very restricted bandwidth (i.e., less than 128 Kb/s), the received images are frequently distorted. This occurs because the data flow required to update the altered sections of the previous digitized frame with the new digitized frame may exceed the available bandwidth. Although the transmission site may partially compensate for this limitation by deliberately slowing the motion of the patient and primary care provider, it is a genuine nuisance that detracts from the consultation. The end result has been that the bandwidth required to perform VTC has been reduced to the point that it has become practical in many but not all telecommunications environments. To put this into perspective, a typical home computer modem using a typical residential
telephone line can reliably receive data at 28.8 Kb/sec to 56 Kb/sec. This rate of data flow will not support VTC; however, a digitized Integrated Services Digital Network (ISDN) telephone line receiving at 128 Kb/s can support VTC. Commonly used portable telecommunications ground stations (e.g., small microwave dish uplink to satellites such as International Maritime Satellite B) used by remote Army telemedicine sites permit data flow at 64 Kb/sec to 256 Kb/s, thereby supporting VTC. It is important to understand that the speed of data flow in telecommunication is only as fast as the slowest segment of any multistep link (usually the conventional home telephone line). The speed of data flow is very important to the military. The access to, size of, and reliability of bandwidth from an isolated austere location is problematic in peacetime, and becomes even more so during medical support of armed conflict using medical aid stations that are frequently and rapidly relocated. The advantages of VTC include the abilities to directly acquire a clinical history, ask follow-up questions, position the patient and camera for optimal clinical images, and interact with the referring provider (Table 1). The disadvantages, however, are numerous and are relevant to any highly mobile medical system. The detail (resolution) and color of
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Table 1. COMPARISON OF VTC TO STORE AND FORWARD TELEMEDICINE
Feature
VTC
Live interaction with patient and primary provider Ability to optimize clinical images by live interaction Need for large and reliable bandwidth Simultaneous temporal scheduling of patient, providers, and technicians Light, cheaper equipment Generally better-quality images Need for encryption Flexibility for location and time of consultant’s response
most VTC dermatology images, even those of a dermatoscope, are frequently inferior to still digital photography. The passage of the VTC signal through multiple relays and connections introduces an annoying delay of a couple of seconds in the receipt of both the audio and video signals. Newer VTC equipment, although smaller and lighter, is still significant in bulk, requires reliable external electricity, and is relatively fragile. The available datalinks may not be fast enough to support VTC. VTC also requires that the patient, primary care provider, telemedicine technicians, and consultant be available simultaneously for live interaction, a problem that is frequently underestimated. These disadvantages are particularly germaine to VTC in the armed forces. Military forces need equipment that is light, small, durable, and able to function without external electricity. Bandwidth is another concern. Access to large and reliable bandwidth from an austere, remote location is the exception rather than the rule. Even if bandwidth is available it is reduced or eliminated during periods of intense troop movement or hostile action when it is urgently needed by the battlefield commander to command, control, and coordinate his or her forces to fight and win. Lastly, the ability to have the patient, primary care provider, technicians, and consultant together at a specific moment during a fastmoving military operation is remote, if not altogether impossible. Store and Forward (SF) Applications
The next phase in the development of telemedicine required the development and expansion of internet services, lower-cost personal computers, and smaller, cheaper digital
Yes Yes Yes Yes No No No No
Store and Forward
No No No No Yes Yes Yes Yes
image acquisition devices (e.g., digital cameras). The internet is an ideal vehicle to exploit for SF telemedicine. It is a cheap, constantly expanding system capable of moving large quantities of information. Complex information can be transmitted using SF; it just can’t be done live. The use of electronic mail with attached complex data files (e.g., tables, graphs, images, and word processing files) has drastically altered the ways that businesses, institutions, and government manage their activities. It was easily adapted for telemedicine. Unfortunately, without encryption, the information is not reliably secure, which has serious implications for patient confidentiality. Most civilian internet users only have access to lower bandwidth connections (frequently older voice-grade telephone lines), making live VTC impossible. Nevertheless, these home-style telephone lines usually can support electronic mail and SF applications. SF telemedicine allows access to distant consultants by sending clinical history and still images via electronic mail. Electronic mail accounts are now ubiquitous, reasonably priced, and widely accessible using conventional or cellular telephones. This has clearly expanded the accessability of telemedicine. Other circumstances have encouraged the development of SF telemedicine. The availability of cheaper and smaller devices to acquire higher-resolution still images continues to accelerate. The movement of electronic image files from a camera to personal computers is easy and reliable. Software used to compress a large high-resolution digital image for rapid transmission with minimal loss of photographic fidelity (e.g., JPG) is accepted. Software that can encrypt a telemedicine consult for patient confidentiality and for direct
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
point-to-point transmission or electronic mail over the internet is commercially available and inexpensive. The medical community quickly saw the opportunity to use this technology and seized it. After all, how hard is it to electronically send representative clinical images and patient history to a distant consultant for review? Image-intense specialties such as radiology and dermatology saw this process as an ideal marriage of clinical need and technology. SF is a simple concept and is easy to do despite some pitfalls. The primary care provider distills a clinical history, takes still images with a digital camera, video camera, or other device, imports them into a personal computer, and encodes and transmits them to the consultant via electronic mail. The consultant opens the files on a personal computer after decoding, reviews the history and images, then replies to the requestor via electronic mail (Fig. 2). The advantages of SF are multiple (see Table 1).The equipment required for SF is small in size and weight as well as relatively inexpensive. Even moderately priced newer digital image acquisition devices (e.g., digital cameras) are easy to use and provide goodquality images. The files can be encrypted for confidentiality. The patient, primary care provider, technicians, and consultant do not have to be present at the same time. The clinical history and images can be transmitted
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at one time and reviewed in detail at another time. The bandwidth required for transmission is not large. Although it may take longer for a SF consult to be sent from a computer to the internet over a conventional telephone line than over a higher-speed link, it will still get to the consultant; however, SF has several disadvantages. The clinical history provided may be incomplete, inaccurate, or irrelevant. Asking immediate follow-up questions is impossible, because the clinical images may be of poor quality (e.g., out of focus, improperly illuminated) or not representative of the skin disease. Also, the images can take a long time to download to the consultant’s computer if the dataflow is slow (e.g., ”noisy” home telephone line). Lastly, the data in the consultation are not secure over the internet unless they are either encrypted or sent directly to their destination without the use of an intermediary server (e.g., America OnLine (AOL), Compuserve, etc.). TELEDERMATOLOGY AND DoD
DoD has assisted in funding some civilian telemedicine demonstration sites involving remote unserved or underserved populations. Partners have included National Cancer Institute (Bethesda, MD), Department of Health and Human Services (Washington, DC), and Children’s National Medical Center (Washington, DC), to name but a few.33This section
Figure 2. National Capital Area (NCA) teledermatologist responding to a store and forward consultation at home.
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will focus exclusively on the DoD’s direct involvement in teledermatology. The digital telemedicine systems used in the DoD include “roll-around” systems, systems that are integrated with personal computers, and complete teleconferencing studios. The vast majority of telemedicine systems at the DoD telemedicine consultation centers use ”off the shelf” commercial systems that have both VTC and SF capabilities. The rapid development of technology has spawned competing proprietary systems, formats, and technical standards. This has created problems of incompatibility between ”closed” architecture systems such as Apple computers (Cupertino, CA) and ”open” architecture systems such as IBM-based computers. An advantage of newer VTC systems is the ability to convert between television standards such as the phase alternative line (PAL) system and National Television Standard Committee (NTSC). DoD telemedicine supports the use of ”open” systems that have greater interoperability. Dermatology has figured prominently within military telemedicine. Rather than exhaustively review the experiences within the DoD, the following sections present some representative experiences and show some of the ”lessons learned” in teledermatology at the DoD. Tripler Army Medical Center Experience
In 1993 a telemedicine demonstration project began between Tripler Army Medical Center (TAMC) in Hawaii and Kwajalein Island in the South Pacific as a way to improve the clinical support of remote locations. The impetus behind this project was improving specialty care access of the islanders as well as reducing the one million dollar annual expense of transporting patients to Honolulu or Manila for consultation. A related goal was to provide continuing medical education (CME) to island medical personnel. This experience, summarized by Norton et a1,2I,22 included 250 patients over a period of 3 years. Forty percent of the consults were dermatologic. The consults were mostly completed using an early digital telemedicine system that provided live audio connections and slowly transmitted live high-quality color still images to a TAMC consultant. The communication links used an existing US Department of Commerce satellite (Peacesat) with connec-
tions to local telephone lines. Although the data connections were relatively slow, requiring sometimes several minutes to transmit one still image, the system was considered at the time to be satisfactory. The VTCs were coordinated in advance using electronic mail or fax. On the day of the consultation, the patient and referring physician travelled to the studio on Kwajelein for a VTC with TAMC. The consultant’s report was later forwarded to Kwajelein via electronic mail or fax. The provider on Kwajalein continued to manage the patient’s day-to-day care. Owing to occasional difficulties in scheduling, a few of the consults were videotaped beforehand. In these cases the consultant viewed the videotape and issued a report the next day. Although Norton’s summary of the Kwajelein experience does mention a reduction in off-island travel to specialty care, it was not possible to employ additional measures of effectiveness or analyse the clinical outcomes. Walter Reed Army Medical Center (WRAMC) Experience
For several years WRAMC has provided telemedical support to the US Armed Forces deployed in peacekeeping, humanitarian aid, and disaster relief missions worldwide. These missions have provided an opportunity to evaluate the practicality and clinical use of telemedicine. Gomez et a1 described 240 WRAMC telemedicine consultations from February 1993 to February 1996.12 The consultations originated from deployed forces in Haiti, Somalia, Macedonia, Croatia, Ivory Coast, Egypt, Panama, Germany, Kuwait, and several other sites. The referring providers usually used personal computer-based systems with both SF and VTC capabilities. The availability of only lowbandwidth communications from Somalia restricted those consults to SF only. The digital cameras that were used for many of the still digital photographs provided high resolution (usually 1524 X 1012 pixels) images in 24-bit color (millions of colors). The image files (4.5 Mb) were transferred to a personal computer. They were compressed using the Joint Photographic Experts Group (JPG) format with the final file size ranging between 170 Kb to 500 Kb. The clinical history and images were transmitted directly via modem to the WRAMC using combinations of commercial telephone lines or
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
satellite communications (e.g., INMARSAT B). The data transmission rates ranged from 2.4 Kb/s to 56 Kb/s. The VTC equipment required a minimum data transmission rate of 56 Kb/s. The dermatologic peripheral equipment included a dermatoscope and a camera. These peripherals were sometimes used to acquire still images for later SF transmission. The VTCs were videotaped. The quality of the VTC at the relatively slow rate of 56 Kb/sec was considered by many to be marginal. All of the dermatology consultations were answered from the WRAMC telemedicine suite. The consultant reports were forwarded to the referral site by electronic mail or fax after the cases were archived. Dermatology accounted for 29% of the telemedicine consultations. The WRAMC dermatologists found the high-resolution SF images to be of diagnostic quality. Only a handful of dermatology cases used VTC. A detailed list of dermatologic diagnoses was not provided. Walters3I critically reviewed the 114 WRAMC telemedicine cases that were received from February 1993 to March 1995. Thirty-nine percent of these cases were dermatologic. The most frequently asked questions in this series concerned additional recommendations for therapy. Interestingly, only 17% of the cases requested a confirmation of diagnosis or treatment. This stands in contrast to a commonly voiced criticism of telemedicine, which claims that teleconsultation only confirms the referring provider’s suspicion and does not add any value to patient care. Walters, however, also strongly defended the value of confirmation of diagnosis and therapy by stating that ”. . . the value of confirmation to a deployed health care provider should not be underestimated. Provider uncertainty rather than medical necessity probably causes many (unnecessary) patient evacuation~’’.~~ Walters also commented on the modalities used to provide telemedicine services. Ninety-one of the consults used still images. Of the WRAMC telemedicine cases in which the consultant requested additional still images, all were dermatologic. In several cases the consultant initially viewed live video images but requested supplementary still images because of the generally better image quality of SF. The cases were examined to discern the impact of the telemedicine consultations on the care provided at the remote site. Although
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in 30% of the cases there was a significant change in diagnosis, and in 32% there was a moderate change in treatment, this was largely confined to seriously ill (usually not dermatologic) patients. A detailed analysis of the telederrnatology diagnoses was not reported. Teledermatology Experience of the National Naval Medical Center and the Uniformed Services University of the Health Sciences
The National Naval Medical Center in cooperation with the Departments of Military and Emergency Medicine and Dermatology at the Uniformed Services University (Bethesda, MD) of the Health Sciences answered 89 teledermatology consultations from April 1996 to January 1998 (unpublished data). The cases originated from a wide variety of sources: aircraft carriers equipped for integrated VTC/SF telemedicine as well as units that only had digital cameras and access to electronic mail such as large amphibious ships, deployed Marine Corps units, regional primary care clinics, and even a submarine. A small number of cases were received from Army field units when Army telemedicine sites were briefly unavailable. All the cases were SF. The incoming case files were received by an integrated multimedia telemedicine system, and transferred to a dedicated file server. The consultant then signed on to the NNMC telemedicine server using a personal computer in the telemedicine suite, a clinical office, at home, or using a better-quality laptop computer virtually anywhere. The consultant transferred the history and image files to a personal computer and reviewed them, composed a reply, and archived it in the telemedicine server while forwarding the reply to the originator. This decentralized and flexible approach encouraged rapid responses, usually within 12 hours. In fact, one dermatologist answered a teledermatology consult while he was on a field exercise. In another case, a consultant rendered an opinion while he was in Germany. The only NNMC teledermatology cases that were reviewed using the perspective of cost effectiveness were 15 cases from the US Naval Academy at Annapolis, MD.’ The cases were analysed solely to determine whether
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teledermatology avoided the need for a patient to miss class and travel fifty miles to NNMC for a live dermatologic consultation. The primary purpose of these teleconsultations was to determine dermatologic fitness for certain types of specialized military occupations (e.g., aviation, submarine duty). The consultation was judged to be “effective” only if the patient did not ultimately require a live evaluation by a dermatologist for disposition. Of the 15 teledermatology cases only two eliminated the need for live evaluation. Unfortunately, the reason for the consults and the very narrow criteria for judging their success probably underestimated their value. The teledermatologist understandably felt uncomfortable (despite substantial experience in teledermatology), making a career-molding decision to qualify or disqualify a patient for special military occupations solely on the basis of a brief clinical history and a few still images. U.S. Army Teledermatology in the Balkans
The U.S. Army’s telemedicine support to peacekeeping operations in the Balkans continues at the time of this a r t i ~ l eThere . ~ are six field telemedicine units supporting this North Atlantic Treaty Organization (NATO) and United Nations (UN) peacekeeping mission. Each unit has lower bandwidth (56 Kb/s to 128 Kb/s) VTC capability as well as higherresolution digital still photography for SF via electronic mail. The primary consultation site is the Army Medical Center at Landstuhl, Germany. A preliminary audit of 47 VTC consults from the Macedonian base of Operation Joint Endevor was done by Navein et a1.20Twenty of these consults were dermatologic. The study determined that treatment plans were changed in 31 patients. The priority for referral to distant specialty care was altered in 13 patients. It was unclear whether any of these cases involved skin disease. “Lessons Learned” By DoD Teledermatologists The following observations are based upon my interviews with several DoD teledermatology consultants. They parallel my own experiences in telemedicine. Not surprisingly,
these observations also largely mirror the published experiences of the civilian teledermatology community. SF teledermatology using high-quality digital images appears to be as effective as VTC for the majority of teledermatology cases. The ability of the consultant to study in detail good-quality digital images usually outweighs the advantages of immediacy in VTC. The frequent disruptions in communication, audio/video time delays, generally poorer images, requirement to temporally coordinate the participants, and the need for higher-level technical support definitely detract from VTC. In addition, SF allows a provider in a remote location, with only rudimentary email, to obtain teledermatology consultation that had been previously available only via VTC . All of the surveyed DoD teledermatologists remarked on the inconsistant quality of SF images. Although some are breathtaking in fidelity, others are confusing or nearly useless. The most common complaints concerned lack of distant views showing lesional distribution or orientation, images that do not optimally sample the dermatologic disease, poor focus, inappropriate camera angles, and inability to correctly manipulate light sources to show surface texture, coloration, and topography. The clinical history provided to SF teledermatologists is sometimes scanty, inaccurate, or irrelevant. Although there is agreement in concept, there is still no agreement in DoD or civilian teledermatology concerning the optimal detailed content of a clinical history for a given type of dermatologic complaint. Also, although history templates have been developed by several DoD and civilian teledermatology providers, none has been widely accepted. As in the civilian sector, portions of DoD telemedicine cases are sometimes prepared by technicians who have uneven knowledge, expertise, and experience in condensing a clinical history and acquiring representative diagnostic quality images.29,32 The DoD consultants felt that technicians should have some rudimentary knowledge in medical history collation, imaging using standard clinical views, and the optimal use of lighting. Although some telemedicine sites such as the Oregon Health Sciences University (Portland, OR) and the DoD National Capital Region (Washington, DC) have written teledermatology manuals, they are only used by their own primary care referral sites. The DoD teledermatologists and the refer-
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
ral sites both noted difficulties with technical and logistical aspects of teledermatology. A standard system to archive teledermatology cases does not exist in the DoD as in the civilian sector. All sites reported some equipment incompatibility with other computer systems, as well as reliability and technical support problems. This was mostly experienced by the deployed isolated sites that had delayed access to spare parts, hardware, and troubleshooting services. These same sites had occasional disruptions in their e-mail service that reduced their ability to send SF cases and also lacked adequate bandwidth for VTC. Indeed, like so many other aspects of medical practice, logistics is the tail that wags the telemedicine dog. Lastly, the dermatologists were unanimously concerned over the impact of the teledermatology workload on themselves, their clinical staff, and their institution's day-today activities. If a provider is answering an electronic consult, he or she is not available at that moment to see clinic patients. Telemedicine activities also affect the time of the clinical support staff and consult managers who image, format, transmit, and archive the cases. COST-EFFECTIVENESS OF TELEDERMATOLOGY IN DoD
Determining the cost-effectiveness of a professional service or modality is one of the biggest challenges facing medicine. Dermatology has been struggling with this question in the context of managed care. Dermatologists in the DoD and the civilian sector do not have universally accepted outcome measures for clinical dermatology, let alone trying to create them for teledermat~logy.'~ As a result, valid and reproducible measures of cost-effectiveness for teledermatology have been elusive. Given this difficulty, it is not easy to show that teledermatology provides a positive and cost-effective influence on the outcome of a particular patient let alone deployed military units. A key element of cost-effectiveness research that is difficult to appraise is the full cost of teledermatology. Many early attempts to calculate the cost of telemedicine services frequently focused on facilities, equipment, network connections, and other similar things7; however, there are many other expenditures involved. A few studies have tried to be more
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inclusive.32What is the total administrative overhead needed to provide the service? What is the cost of the technicians required to process, image, transmit, and archive cases at both the primary care and consultant sites? How do telemedicine activities divert these personnel as well as the consultant and primary care provider from seeing live patients? One common measure is the effect of teledermatology in reducing the transportation of patients to a live dermatology evaluation. This is difficult in a military setting. Although the cost involved to transport a civilian patient may be easily the price of a multistep evacuation of a servicemember from a field location to a specialist is considerably harder to quantitate. In addition, the impact of lost work hours from a combat unit is difficult to assess. The only DoD study that considered several of these factors in the evaluation of telemedicine was that of the Center For Naval Analysis performed by Garcia et al.'O They evaluated such factors as potential telemedicine workload, potential reductions in patient evacuations and lost work days, cost-effectiveness of various configurations of telemedicine, and bandwidth requirements from a shipboard perspective. The results of their study are both interesting and thought-provoking. Although SF consultation was felt to be cost-effective on virtually all navy ships, VTC was deemed to be cost-effective only on aircraft carriers and large amphibious ships. Verifying the accuracy of diagnosis and therapeutic use of teledermatology is also problematic and requires study.4,15, 25, 26, 27 Does a teleconsultation eliminate the need for live dermatology consultation or reduce the number of primary care visits required for correct diagnosis, treatment, and resolution of the problem?23This lies at the very heart of the role of specialty care in all managed care systems, including the DoD. The answer at present is unclear. Every teledermatologist in the DoD can relate vivid anecdotes on how a teleconsultation has made a difference in individual cases; however, any wise medical manager or experienced clinical consultant will not fully embrace any new technology solely based upon anecdotes. Because of this and other reasons, teledermatology consultation is not usually reimbursed in civilian practice. .One indirect metric involves the acceptability of teleconsultation. Civilian data suggest that teleconsultation is well accepted by pa-
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tients and providers.’6 Unfortunately, these data are better used to ”showcase” telemedicine as a desirable service in a healthcare network rather than to actually demonstrate cost-effectiveness. In both civilian and military teledermatology there is as yet little published comprehensive data that evaluate the circumstances, situations, and environments where teledermatology actually makes a difference to many patient outcomes that fully considers all costs. The hard questions are now being asked.”, l7 Guidelines for the metrics of telemedicine research have been p ~ b l i s h e d Civilian .~ and DoD telemedicine projects are now incorporating these guidelines into studies to assess telemedicine, including teledermatology. SOME FUTURE DIRECTIONS IN DoD TELEDERMATOLOGY
The explosion of interactive World WideWeb (WWW) sites on the internet in the past
3 years has been stunning. Is this format adaptable to SF teledermatology consultation? Indeed it is! Two DoD sites are evaluating this medium: Tripler Army Medical Center (Honolulu, HI) and the National Capital Area (NCA) Teledermatology Consortium. The following discussion will use the NCA site to show the vast potential of World Wide Web-based consultative teledermatology. The dermatologists of the three DoD medical centers in the NCA are assisting WRAMC in the development of a SF teledermatology consultative WWW site. The Web site features multimedia pages that include clinical history, laboratory data, and scaleable clinical images in a “user friendly” format (Fig. 3). The website uses “off-the-shelf” hardware and software that meet DoD requirements for interoperability (Defense Information Infrastructure Common Operating Environment Standards). This system will be compatable with other future DoD computer systems. The teledermatology website is designed to
Figure 3. National Capital Area Telederrnatology Consultation Group worldwide web page. (Courtesy of Jorge L. Ribas, DVM, Vladimir Bedanov, PhD, Hon Pak, MD, and Mark Welch, MD, Washington, DC.).
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
be equally accessible to a remote site such as a ship at sea or deployed ground unit using e-mail as it is to a fixed primary care site with rapid and reliable connection to the WWW. An authorized provider in an isolated location that has only electronic mail service “fills in the blanks” on a consultation template and attaches the clinical images. Then the provider submits the automatically encrypted case via e-mail. Alternatively, a provider at a fixed primary care site with WWW access simply signs on to the site, completes a referral history template, attaches diagnostic images, and submits the automatically encrypted case while on-line. The consultant of the day signs onto the NCA teledermatology web site, opens the automatically decrypted case, and renders an opinion. The reply is automatically archived by the server and transmitted to the originator. The archived cases are available for later clinical review and use in cost-effectiveness research. The on-call dermatologist can reply to the consults from any location with WWW access. This could be at a clinical office, telemedicine suite, or in the case of a laptop computer with excellent graphics capabilities, virtually anywhere. When fully operational, the NCA will have a teledermatology system without borders. CONCLUSION
The DoD has been a leader in the development and use of advanced telecommunications for medical purposes, including dermatology. In this fashion, the DoD healthcare system is innovatively caring for servicemembers who work in peacekeeping, civil/humanitarian relief, and combat operations. As with any new modality, the niche of teledermatology is being defined in the DoD and the medical practice at large. Teledermatology will likely become an increasingly important part of the DoDs medical mission of providing “good medicine in bad places” anywhere in the world.
References 1. Bakalar RS: Business Process Reengineering: A Success Story From the US Naval Academy In Programs and Abstracts of the Healthcare Information Management Systems Society, San Antonio, TX, September 1997
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2. Bashbur R, Lovett J: Assessment of telemedicine: Results of the initial experience. Aviat Space Environ Med 65-70, 1977 3. Benschoter RA: CCTV-Pioneering Nebraska Medical Center. Educational Broadcasting 1-3, 1971 4. Bittdorf A, Fartasch M, Schuler G, et al: Resolution requirements for digital images in dermatology. J Am Acad Dermatol 37195-198, 1997 5. Calcagni DE, Clyburn CA, Tomkins G, et al: Operation joint endeavor in Bosnia: Telemedicine systems and case reports. Telemedicine Journal 2211-224, 1996 6. Chen W, Turner J, Crawford C: The process of elimination: Video compression in telemedicine. Telemed J 23741, 1996 7. Crowther JB, Poropatich R Telemedicine in the US Army: Case reports from Somalia and Croatia. Telemed J 1:73-80, 1995 8 Foote D, Hudson H, Parker EB: Telemedicine in Alaska: The ATS-6 satellite biomedical demonstration. National Technical Information Service (NTIS). US Department of Commerce. Springfield, VA, p 232 9. Framework for Evaluating Telemedicine. Zn Field MJ (ed): Telemedicine: A Guide to Assessing Telecommunications in Health Care. Washington, DC, National Academy Press, 1996, pp 200-207 10. Garcia FE, Stoloff PH, Thomason JE, et al: A CostBenefit Analysis of Shipboard Telemedicine. CRM 9766, Alexandria, VA, Center for Naval Analyses, 1997 11. Gardy M Telemedicine and economic realities. Telemedicine Journal 283-86, 1996 12. Gomez E, Poropatich R, Karinch MA, et al: Tertiary telemedicine support during global military humanitarian missions. Telemed J 2:201-210, 1996 13. Grigsby J: Sentenced to life without parole doing outcomes research. Telemedicine Today 4(4):4041, 1996 14. Jerant AF, Epperly TD: Fundamentals of Telemedicine. Milit Med 162304-309, 1997 15. Kvedar JC, Edwards RA, Menn ER, et al: The substitution of digital images for dermatologic physician examination. Arch Dermatol 133:161-167, 1997 16. Lowitt MH: User perceptions of teledermatology using interactive video. Telemedicine Today 4(4):2223, 1996 17. McLaren P, Ball CJ: Telemedicine: Lessons remain unheeded. Brit Med J 310:1390-1391, 1995 18. Murphy RL Jr, Fitzpatrick TB, Haynes HA, et al: Accuracy of dermatologic diagnosis by television. Arch Dermatol 1052333-835, 1972 19. Murphy RL Jr, Bird KT Telediagnosis: A new community health resource; observations on the feasibility of telediagnosis based on 1000 patient transactions. Am J Public Health 64:113-119, 1974 20. Navein J, Hagmann J, Ellis J: Telemedicine in support of peacekeeping operations overseas: An Audit. Telemed J 3907-214, 1997 21. Norton SA, Burdick AE, Phillips CM, et al: Teledermatology and underserved populations. Arch Dermatol 133:197-200, 1997 22. Norton SA, Floro C, Bice SD, et al: Telemedicine in Micronesia. Telemed J 2225-231, 1996 23. Perednia DA: Fear, loathing, dermatology, and telemedicine: Arch Dermatol 133:151-155, 1997 24 Perednia DA: What dermatologists should know about digital imaging. J Am Acad Dermatol 2589108, 1991 25. Perednia DA, Gaines JA, Butruille TW Comparison of the clinical informativeness of photographs and digital imaging media with multiple-choice receiver
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operating characteristic analysis. Arch Dermatol 131:292-297, 1995 26. Perednia DA, Gaines JA, Rossum AC: Variability in physician assessment of lesions in cutaneous images and its implications for skin screening and computerassisted diagnosis. Arch Dermatol 128:357-364, 1992 27. Phillips CM, Burke WA, Shechter A, et al: Reliability of dermatology consultations with the use of teleconferencing technology. J Am Acad Dermatol 37398402, 1997 28. Phillips CM,Murphy R, Burke WA, et al: Dermatology teleconsultations to central prison: Experience at East Carolina University. Telemed J 2:139-143, 1996
29. Vidmar DA. A plea for standardization in teledermatology: A worm’s eye view. Telemed J 2:173-178,1997 30. Vidmar DA, Harford RR, Beasley WJ, et al: The epidemiology of dermatologic and venereologic diseases in a deployed operational setting. Milit Med 161:382386, 1996 31. Walters TJ: Deployment telemedicine: The Walter Reed Army Medical Center experience. Milit Med 161~531-536,1996 32. Zelickson BD, Homan L: Teledermatology in the nursing home. Arch Dermatol 133:171-174, 1997 33. Zimnik PR: A brief survey of department of defense telemedicine. Telemed J 2:241-250, 1996
Address reprint requests to CAPT Dennis A. Vidmar, MC, USN Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda MD 208144799 e-mail: [email protected]
0733-8635/99 $8.00
+ .OO
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE CAPT Dennis A. Vidmar, MC, USN
Telemedicine has existed for longer than most people realize, but in many ways it is a new clinical modality. It will alter the delivery of dermatology care, especially to locations that are unserved or underserved by dermatologists who are in deployed military forces. A dermatologic office visit involves the transfer of information between the patient and the provider, allowing diagnosis and therapy. Such information is historic and objective. All consultations, whether “curbside,” telephonic, or televisual, involve the transfer of medical information. Dermatologists jokingly suggest that the referring provider “hold the rash closer to the phone.“ Teledermatology in its simplest sense is the interpretation of electronically transmitted images and clinical history to reach a diagnosis and provide recommendations for therapy. It indeed allows the referring provider to “hold the patient closer to the phone”. This article provides an introduction to selected principles of teledermatology, a history of their development and use by the Department of Defense (DoD), and a glimpse at some new DoD initiatives in teledermatology. The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Navy or Department of Defense.
DoD INTEREST IN TELEMEDICINE
The medical support of the US armed forces has always been a challenge because ground troops, aircraft, and ships are ”on the move” in combat operations, usually in austere environments. In addition, the armed forces are increasingly sent to many parts of the globe to support humanitarian, peacekeeping, and disaster relief missions. As such, the DoD has consciously nurtured telemedicine as a way to practice ”good medicine in bad places.” The prime mission of the DoD health care system is keeping every service member in good health and therefore on the job, anywhere in the world, to support combat operations or other missions such as peacekeeping. Telemedicine supports this goal by electronically bringing the specialist to the primary provider who directly cares for service members in an austere, remote, and isolated environment. Telemedicine creates an opportunity to provide more rapid, accurate diagnosis and therapeutic recommendations. In this way telemedicine maintains the health and the capability of service members to work by allowing faster return to duty and minimizing logistically burdensome, inconvenient, and expensive transportation to distant specialty care.
From the Departments of Military and Emergency Medicine and Dermatology, Uniformed Services University of the Health Sciences, Bethesda, Maryland ~
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DERMATOLOGIC CLINICS
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Because dermatologic disease is one of the most common sources of morbidity and lost work days to armed forces,3O the DoD has wisely encouraged involving dermatology in telemedicine.
THE HISTORY OF TELEMEDICINE TECHNOLOGY AND ITS APPLICATION The first known use of telemedicine was in 1906 by Einthoven, who used it to transmit electrocardiograms 3 years before the invention of tele~ision.~ In 1924 Radio News magazine featured a cover illustrating a visual teleconsultation between a doctor and a patient at home. It took many years of technologic advancement to make Einthoven's experiments and Radio News' fanciful cover into a reality. Like any other modality in medicine, telemedicine has been heavily influenced by the availability and improvements of technology developed for nonmedical uses. The next sections trace the development of telemedicine technology from the heavy and cumbersome analog live television systems to the relatively light and flexible equipment of today. Some technologic principles and vocabulary will be introduced as a way to understand telemedicine systems. For additional background reading, Perednia's article on digital dermatologic imaging is highly r e c ~ m m e n dIt . ~is~ an excellent summary for the beginner. An important factor in the development of telemedicine has been the alignment of technology and clinical practice. For telemedicine to be viable, it has to play a role in continuing medical education, exchanging health care information, and improving health care delivery to the patient. Telemedicine has been used by dermatology and other clinical specialties for each of these functions.
Analog Signal Telemedicine The first use of visual telemedicine occurred in the 1950s, ' ~ O S , and '70s. It required a live television link between two wellequipped studios. The teleconsultations employed live video and audio with direct communication among the patient, referring pros, l9 Even dermatology vider, and c~nsultant.~, tested its effectiveness, albeit using blackand-white images.ls
These analog units required equipment, communications cables, links, and technicians that were solely dedicated to teleconsultation. This arrangement also required two teams of camera crew, sound crew, and other on-site technical support staff. At that time a twocamera studio cost $150,000 and a microwave uplink system to connect the studios cost another $30,000. Airwave transmission charges were also extremely high. Despite the good quality of the images and the advantages of live clinical interaction, the sheer expense, weight, and volume of equipment combined with its need for sophisticated technical support insured that telemedicine consultation, although possible, was not practical.
Digitized Videoteleconferencing (VTC) The development of digital television images in the early 1980s was the pivotal event that permitted the fruition of VTC and its logical use in medical teleconsultation. Some rudimentary knowledge of television transmission principles is necessary to understand the differences between analog and digital VTC. One can then appreciate the advantages, uses, and limitations of past and present VTC telemedicine systems. An analog television image is transmitted as a constant flow of electronic signals through a pipe of cables or airborne electromagnetic waves. These signals are processed for display on a monitor at a rate of 6 million Hz. Typical analog television signals are roughly the digital equivalent of about 90 million bytes(b)/sec or 90,000 Kilobytes(Kb)/ sec.I4 The pipe required to transmit such a large amount of information is large and is not easily shared with another transmission. The functional diameter of this pipe is referred to as bandwidth. In the early 1980s the development of the analog-to-digital converter compressor (CODEC) made VTC a reality in boardrooms, executive suites, and ultimately medical centers (Fig. 1).A CODEC transforms an analog television image into a digital image by converting the color of each tiny square (i.e., pixel) of a television image into a series of electronic binary code. By selectively sampling the continuous analog signals, the data transmission rate is reduced. A typical digital transmission rate for VTC within the US is about 128 Kb/sec, about 1/700th the rate re-
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
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Figure 1. Live videoteleconference between the National Naval Medical Center and the aircraft carrier USS George Washington.
quired for analog transmission. Another advantage is that signal digitalization allows several users to simultaneously use small individual portions of larger bandwidth. A CODEC works by digitalizing sequential frames of the analog signals. If the rate of sampling is large enough (e.g., 30 frames/s), the viewer perceives smooth motion, similar to viewing movie film. If the rate is too slow, a jerky motion is perceived. The CODEC and compression software further reduce the data flow by sensing and transmitting only the parts of the digitized image that have changed since the previous sampled frame. During times of very restricted bandwidth (i.e., less than 128 Kb/s), the received images are frequently distorted. This occurs because the data flow required to update the altered sections of the previous digitized frame with the new digitized frame may exceed the available bandwidth. Although the transmission site may partially compensate for this limitation by deliberately slowing the motion of the patient and primary care provider, it is a genuine nuisance that detracts from the consultation. The end result has been that the bandwidth required to perform VTC has been reduced to the point that it has become practical in many but not all telecommunications environments. To put this into perspective, a typical home computer modem using a typical residential
telephone line can reliably receive data at 28.8 Kb/sec to 56 Kb/sec. This rate of data flow will not support VTC; however, a digitized Integrated Services Digital Network (ISDN) telephone line receiving at 128 Kb/s can support VTC. Commonly used portable telecommunications ground stations (e.g., small microwave dish uplink to satellites such as International Maritime Satellite B) used by remote Army telemedicine sites permit data flow at 64 Kb/sec to 256 Kb/s, thereby supporting VTC. It is important to understand that the speed of data flow in telecommunication is only as fast as the slowest segment of any multistep link (usually the conventional home telephone line). The speed of data flow is very important to the military. The access to, size of, and reliability of bandwidth from an isolated austere location is problematic in peacetime, and becomes even more so during medical support of armed conflict using medical aid stations that are frequently and rapidly relocated. The advantages of VTC include the abilities to directly acquire a clinical history, ask follow-up questions, position the patient and camera for optimal clinical images, and interact with the referring provider (Table 1). The disadvantages, however, are numerous and are relevant to any highly mobile medical system. The detail (resolution) and color of
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Table 1. COMPARISON OF VTC TO STORE AND FORWARD TELEMEDICINE
Feature
VTC
Live interaction with patient and primary provider Ability to optimize clinical images by live interaction Need for large and reliable bandwidth Simultaneous temporal scheduling of patient, providers, and technicians Light, cheaper equipment Generally better-quality images Need for encryption Flexibility for location and time of consultant’s response
most VTC dermatology images, even those of a dermatoscope, are frequently inferior to still digital photography. The passage of the VTC signal through multiple relays and connections introduces an annoying delay of a couple of seconds in the receipt of both the audio and video signals. Newer VTC equipment, although smaller and lighter, is still significant in bulk, requires reliable external electricity, and is relatively fragile. The available datalinks may not be fast enough to support VTC. VTC also requires that the patient, primary care provider, telemedicine technicians, and consultant be available simultaneously for live interaction, a problem that is frequently underestimated. These disadvantages are particularly germaine to VTC in the armed forces. Military forces need equipment that is light, small, durable, and able to function without external electricity. Bandwidth is another concern. Access to large and reliable bandwidth from an austere, remote location is the exception rather than the rule. Even if bandwidth is available it is reduced or eliminated during periods of intense troop movement or hostile action when it is urgently needed by the battlefield commander to command, control, and coordinate his or her forces to fight and win. Lastly, the ability to have the patient, primary care provider, technicians, and consultant together at a specific moment during a fastmoving military operation is remote, if not altogether impossible. Store and Forward (SF) Applications
The next phase in the development of telemedicine required the development and expansion of internet services, lower-cost personal computers, and smaller, cheaper digital
Yes Yes Yes Yes No No No No
Store and Forward
No No No No Yes Yes Yes Yes
image acquisition devices (e.g., digital cameras). The internet is an ideal vehicle to exploit for SF telemedicine. It is a cheap, constantly expanding system capable of moving large quantities of information. Complex information can be transmitted using SF; it just can’t be done live. The use of electronic mail with attached complex data files (e.g., tables, graphs, images, and word processing files) has drastically altered the ways that businesses, institutions, and government manage their activities. It was easily adapted for telemedicine. Unfortunately, without encryption, the information is not reliably secure, which has serious implications for patient confidentiality. Most civilian internet users only have access to lower bandwidth connections (frequently older voice-grade telephone lines), making live VTC impossible. Nevertheless, these home-style telephone lines usually can support electronic mail and SF applications. SF telemedicine allows access to distant consultants by sending clinical history and still images via electronic mail. Electronic mail accounts are now ubiquitous, reasonably priced, and widely accessible using conventional or cellular telephones. This has clearly expanded the accessability of telemedicine. Other circumstances have encouraged the development of SF telemedicine. The availability of cheaper and smaller devices to acquire higher-resolution still images continues to accelerate. The movement of electronic image files from a camera to personal computers is easy and reliable. Software used to compress a large high-resolution digital image for rapid transmission with minimal loss of photographic fidelity (e.g., JPG) is accepted. Software that can encrypt a telemedicine consult for patient confidentiality and for direct
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
point-to-point transmission or electronic mail over the internet is commercially available and inexpensive. The medical community quickly saw the opportunity to use this technology and seized it. After all, how hard is it to electronically send representative clinical images and patient history to a distant consultant for review? Image-intense specialties such as radiology and dermatology saw this process as an ideal marriage of clinical need and technology. SF is a simple concept and is easy to do despite some pitfalls. The primary care provider distills a clinical history, takes still images with a digital camera, video camera, or other device, imports them into a personal computer, and encodes and transmits them to the consultant via electronic mail. The consultant opens the files on a personal computer after decoding, reviews the history and images, then replies to the requestor via electronic mail (Fig. 2). The advantages of SF are multiple (see Table 1).The equipment required for SF is small in size and weight as well as relatively inexpensive. Even moderately priced newer digital image acquisition devices (e.g., digital cameras) are easy to use and provide goodquality images. The files can be encrypted for confidentiality. The patient, primary care provider, technicians, and consultant do not have to be present at the same time. The clinical history and images can be transmitted
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at one time and reviewed in detail at another time. The bandwidth required for transmission is not large. Although it may take longer for a SF consult to be sent from a computer to the internet over a conventional telephone line than over a higher-speed link, it will still get to the consultant; however, SF has several disadvantages. The clinical history provided may be incomplete, inaccurate, or irrelevant. Asking immediate follow-up questions is impossible, because the clinical images may be of poor quality (e.g., out of focus, improperly illuminated) or not representative of the skin disease. Also, the images can take a long time to download to the consultant’s computer if the dataflow is slow (e.g., ”noisy” home telephone line). Lastly, the data in the consultation are not secure over the internet unless they are either encrypted or sent directly to their destination without the use of an intermediary server (e.g., America OnLine (AOL), Compuserve, etc.). TELEDERMATOLOGY AND DoD
DoD has assisted in funding some civilian telemedicine demonstration sites involving remote unserved or underserved populations. Partners have included National Cancer Institute (Bethesda, MD), Department of Health and Human Services (Washington, DC), and Children’s National Medical Center (Washington, DC), to name but a few.33This section
Figure 2. National Capital Area (NCA) teledermatologist responding to a store and forward consultation at home.
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will focus exclusively on the DoD’s direct involvement in teledermatology. The digital telemedicine systems used in the DoD include “roll-around” systems, systems that are integrated with personal computers, and complete teleconferencing studios. The vast majority of telemedicine systems at the DoD telemedicine consultation centers use ”off the shelf” commercial systems that have both VTC and SF capabilities. The rapid development of technology has spawned competing proprietary systems, formats, and technical standards. This has created problems of incompatibility between ”closed” architecture systems such as Apple computers (Cupertino, CA) and ”open” architecture systems such as IBM-based computers. An advantage of newer VTC systems is the ability to convert between television standards such as the phase alternative line (PAL) system and National Television Standard Committee (NTSC). DoD telemedicine supports the use of ”open” systems that have greater interoperability. Dermatology has figured prominently within military telemedicine. Rather than exhaustively review the experiences within the DoD, the following sections present some representative experiences and show some of the ”lessons learned” in teledermatology at the DoD. Tripler Army Medical Center Experience
In 1993 a telemedicine demonstration project began between Tripler Army Medical Center (TAMC) in Hawaii and Kwajalein Island in the South Pacific as a way to improve the clinical support of remote locations. The impetus behind this project was improving specialty care access of the islanders as well as reducing the one million dollar annual expense of transporting patients to Honolulu or Manila for consultation. A related goal was to provide continuing medical education (CME) to island medical personnel. This experience, summarized by Norton et a1,2I,22 included 250 patients over a period of 3 years. Forty percent of the consults were dermatologic. The consults were mostly completed using an early digital telemedicine system that provided live audio connections and slowly transmitted live high-quality color still images to a TAMC consultant. The communication links used an existing US Department of Commerce satellite (Peacesat) with connec-
tions to local telephone lines. Although the data connections were relatively slow, requiring sometimes several minutes to transmit one still image, the system was considered at the time to be satisfactory. The VTCs were coordinated in advance using electronic mail or fax. On the day of the consultation, the patient and referring physician travelled to the studio on Kwajelein for a VTC with TAMC. The consultant’s report was later forwarded to Kwajelein via electronic mail or fax. The provider on Kwajalein continued to manage the patient’s day-to-day care. Owing to occasional difficulties in scheduling, a few of the consults were videotaped beforehand. In these cases the consultant viewed the videotape and issued a report the next day. Although Norton’s summary of the Kwajelein experience does mention a reduction in off-island travel to specialty care, it was not possible to employ additional measures of effectiveness or analyse the clinical outcomes. Walter Reed Army Medical Center (WRAMC) Experience
For several years WRAMC has provided telemedical support to the US Armed Forces deployed in peacekeeping, humanitarian aid, and disaster relief missions worldwide. These missions have provided an opportunity to evaluate the practicality and clinical use of telemedicine. Gomez et a1 described 240 WRAMC telemedicine consultations from February 1993 to February 1996.12 The consultations originated from deployed forces in Haiti, Somalia, Macedonia, Croatia, Ivory Coast, Egypt, Panama, Germany, Kuwait, and several other sites. The referring providers usually used personal computer-based systems with both SF and VTC capabilities. The availability of only lowbandwidth communications from Somalia restricted those consults to SF only. The digital cameras that were used for many of the still digital photographs provided high resolution (usually 1524 X 1012 pixels) images in 24-bit color (millions of colors). The image files (4.5 Mb) were transferred to a personal computer. They were compressed using the Joint Photographic Experts Group (JPG) format with the final file size ranging between 170 Kb to 500 Kb. The clinical history and images were transmitted directly via modem to the WRAMC using combinations of commercial telephone lines or
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
satellite communications (e.g., INMARSAT B). The data transmission rates ranged from 2.4 Kb/s to 56 Kb/s. The VTC equipment required a minimum data transmission rate of 56 Kb/s. The dermatologic peripheral equipment included a dermatoscope and a camera. These peripherals were sometimes used to acquire still images for later SF transmission. The VTCs were videotaped. The quality of the VTC at the relatively slow rate of 56 Kb/sec was considered by many to be marginal. All of the dermatology consultations were answered from the WRAMC telemedicine suite. The consultant reports were forwarded to the referral site by electronic mail or fax after the cases were archived. Dermatology accounted for 29% of the telemedicine consultations. The WRAMC dermatologists found the high-resolution SF images to be of diagnostic quality. Only a handful of dermatology cases used VTC. A detailed list of dermatologic diagnoses was not provided. Walters3I critically reviewed the 114 WRAMC telemedicine cases that were received from February 1993 to March 1995. Thirty-nine percent of these cases were dermatologic. The most frequently asked questions in this series concerned additional recommendations for therapy. Interestingly, only 17% of the cases requested a confirmation of diagnosis or treatment. This stands in contrast to a commonly voiced criticism of telemedicine, which claims that teleconsultation only confirms the referring provider’s suspicion and does not add any value to patient care. Walters, however, also strongly defended the value of confirmation of diagnosis and therapy by stating that ”. . . the value of confirmation to a deployed health care provider should not be underestimated. Provider uncertainty rather than medical necessity probably causes many (unnecessary) patient evacuation~’’.~~ Walters also commented on the modalities used to provide telemedicine services. Ninety-one of the consults used still images. Of the WRAMC telemedicine cases in which the consultant requested additional still images, all were dermatologic. In several cases the consultant initially viewed live video images but requested supplementary still images because of the generally better image quality of SF. The cases were examined to discern the impact of the telemedicine consultations on the care provided at the remote site. Although
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in 30% of the cases there was a significant change in diagnosis, and in 32% there was a moderate change in treatment, this was largely confined to seriously ill (usually not dermatologic) patients. A detailed analysis of the telederrnatology diagnoses was not reported. Teledermatology Experience of the National Naval Medical Center and the Uniformed Services University of the Health Sciences
The National Naval Medical Center in cooperation with the Departments of Military and Emergency Medicine and Dermatology at the Uniformed Services University (Bethesda, MD) of the Health Sciences answered 89 teledermatology consultations from April 1996 to January 1998 (unpublished data). The cases originated from a wide variety of sources: aircraft carriers equipped for integrated VTC/SF telemedicine as well as units that only had digital cameras and access to electronic mail such as large amphibious ships, deployed Marine Corps units, regional primary care clinics, and even a submarine. A small number of cases were received from Army field units when Army telemedicine sites were briefly unavailable. All the cases were SF. The incoming case files were received by an integrated multimedia telemedicine system, and transferred to a dedicated file server. The consultant then signed on to the NNMC telemedicine server using a personal computer in the telemedicine suite, a clinical office, at home, or using a better-quality laptop computer virtually anywhere. The consultant transferred the history and image files to a personal computer and reviewed them, composed a reply, and archived it in the telemedicine server while forwarding the reply to the originator. This decentralized and flexible approach encouraged rapid responses, usually within 12 hours. In fact, one dermatologist answered a teledermatology consult while he was on a field exercise. In another case, a consultant rendered an opinion while he was in Germany. The only NNMC teledermatology cases that were reviewed using the perspective of cost effectiveness were 15 cases from the US Naval Academy at Annapolis, MD.’ The cases were analysed solely to determine whether
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teledermatology avoided the need for a patient to miss class and travel fifty miles to NNMC for a live dermatologic consultation. The primary purpose of these teleconsultations was to determine dermatologic fitness for certain types of specialized military occupations (e.g., aviation, submarine duty). The consultation was judged to be “effective” only if the patient did not ultimately require a live evaluation by a dermatologist for disposition. Of the 15 teledermatology cases only two eliminated the need for live evaluation. Unfortunately, the reason for the consults and the very narrow criteria for judging their success probably underestimated their value. The teledermatologist understandably felt uncomfortable (despite substantial experience in teledermatology), making a career-molding decision to qualify or disqualify a patient for special military occupations solely on the basis of a brief clinical history and a few still images. U.S. Army Teledermatology in the Balkans
The U.S. Army’s telemedicine support to peacekeeping operations in the Balkans continues at the time of this a r t i ~ l eThere . ~ are six field telemedicine units supporting this North Atlantic Treaty Organization (NATO) and United Nations (UN) peacekeeping mission. Each unit has lower bandwidth (56 Kb/s to 128 Kb/s) VTC capability as well as higherresolution digital still photography for SF via electronic mail. The primary consultation site is the Army Medical Center at Landstuhl, Germany. A preliminary audit of 47 VTC consults from the Macedonian base of Operation Joint Endevor was done by Navein et a1.20Twenty of these consults were dermatologic. The study determined that treatment plans were changed in 31 patients. The priority for referral to distant specialty care was altered in 13 patients. It was unclear whether any of these cases involved skin disease. “Lessons Learned” By DoD Teledermatologists The following observations are based upon my interviews with several DoD teledermatology consultants. They parallel my own experiences in telemedicine. Not surprisingly,
these observations also largely mirror the published experiences of the civilian teledermatology community. SF teledermatology using high-quality digital images appears to be as effective as VTC for the majority of teledermatology cases. The ability of the consultant to study in detail good-quality digital images usually outweighs the advantages of immediacy in VTC. The frequent disruptions in communication, audio/video time delays, generally poorer images, requirement to temporally coordinate the participants, and the need for higher-level technical support definitely detract from VTC. In addition, SF allows a provider in a remote location, with only rudimentary email, to obtain teledermatology consultation that had been previously available only via VTC . All of the surveyed DoD teledermatologists remarked on the inconsistant quality of SF images. Although some are breathtaking in fidelity, others are confusing or nearly useless. The most common complaints concerned lack of distant views showing lesional distribution or orientation, images that do not optimally sample the dermatologic disease, poor focus, inappropriate camera angles, and inability to correctly manipulate light sources to show surface texture, coloration, and topography. The clinical history provided to SF teledermatologists is sometimes scanty, inaccurate, or irrelevant. Although there is agreement in concept, there is still no agreement in DoD or civilian teledermatology concerning the optimal detailed content of a clinical history for a given type of dermatologic complaint. Also, although history templates have been developed by several DoD and civilian teledermatology providers, none has been widely accepted. As in the civilian sector, portions of DoD telemedicine cases are sometimes prepared by technicians who have uneven knowledge, expertise, and experience in condensing a clinical history and acquiring representative diagnostic quality images.29,32 The DoD consultants felt that technicians should have some rudimentary knowledge in medical history collation, imaging using standard clinical views, and the optimal use of lighting. Although some telemedicine sites such as the Oregon Health Sciences University (Portland, OR) and the DoD National Capital Region (Washington, DC) have written teledermatology manuals, they are only used by their own primary care referral sites. The DoD teledermatologists and the refer-
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
ral sites both noted difficulties with technical and logistical aspects of teledermatology. A standard system to archive teledermatology cases does not exist in the DoD as in the civilian sector. All sites reported some equipment incompatibility with other computer systems, as well as reliability and technical support problems. This was mostly experienced by the deployed isolated sites that had delayed access to spare parts, hardware, and troubleshooting services. These same sites had occasional disruptions in their e-mail service that reduced their ability to send SF cases and also lacked adequate bandwidth for VTC. Indeed, like so many other aspects of medical practice, logistics is the tail that wags the telemedicine dog. Lastly, the dermatologists were unanimously concerned over the impact of the teledermatology workload on themselves, their clinical staff, and their institution's day-today activities. If a provider is answering an electronic consult, he or she is not available at that moment to see clinic patients. Telemedicine activities also affect the time of the clinical support staff and consult managers who image, format, transmit, and archive the cases. COST-EFFECTIVENESS OF TELEDERMATOLOGY IN DoD
Determining the cost-effectiveness of a professional service or modality is one of the biggest challenges facing medicine. Dermatology has been struggling with this question in the context of managed care. Dermatologists in the DoD and the civilian sector do not have universally accepted outcome measures for clinical dermatology, let alone trying to create them for teledermat~logy.'~ As a result, valid and reproducible measures of cost-effectiveness for teledermatology have been elusive. Given this difficulty, it is not easy to show that teledermatology provides a positive and cost-effective influence on the outcome of a particular patient let alone deployed military units. A key element of cost-effectiveness research that is difficult to appraise is the full cost of teledermatology. Many early attempts to calculate the cost of telemedicine services frequently focused on facilities, equipment, network connections, and other similar things7; however, there are many other expenditures involved. A few studies have tried to be more
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inclusive.32What is the total administrative overhead needed to provide the service? What is the cost of the technicians required to process, image, transmit, and archive cases at both the primary care and consultant sites? How do telemedicine activities divert these personnel as well as the consultant and primary care provider from seeing live patients? One common measure is the effect of teledermatology in reducing the transportation of patients to a live dermatology evaluation. This is difficult in a military setting. Although the cost involved to transport a civilian patient may be easily the price of a multistep evacuation of a servicemember from a field location to a specialist is considerably harder to quantitate. In addition, the impact of lost work hours from a combat unit is difficult to assess. The only DoD study that considered several of these factors in the evaluation of telemedicine was that of the Center For Naval Analysis performed by Garcia et al.'O They evaluated such factors as potential telemedicine workload, potential reductions in patient evacuations and lost work days, cost-effectiveness of various configurations of telemedicine, and bandwidth requirements from a shipboard perspective. The results of their study are both interesting and thought-provoking. Although SF consultation was felt to be cost-effective on virtually all navy ships, VTC was deemed to be cost-effective only on aircraft carriers and large amphibious ships. Verifying the accuracy of diagnosis and therapeutic use of teledermatology is also problematic and requires study.4,15, 25, 26, 27 Does a teleconsultation eliminate the need for live dermatology consultation or reduce the number of primary care visits required for correct diagnosis, treatment, and resolution of the problem?23This lies at the very heart of the role of specialty care in all managed care systems, including the DoD. The answer at present is unclear. Every teledermatologist in the DoD can relate vivid anecdotes on how a teleconsultation has made a difference in individual cases; however, any wise medical manager or experienced clinical consultant will not fully embrace any new technology solely based upon anecdotes. Because of this and other reasons, teledermatology consultation is not usually reimbursed in civilian practice. .One indirect metric involves the acceptability of teleconsultation. Civilian data suggest that teleconsultation is well accepted by pa-
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tients and providers.’6 Unfortunately, these data are better used to ”showcase” telemedicine as a desirable service in a healthcare network rather than to actually demonstrate cost-effectiveness. In both civilian and military teledermatology there is as yet little published comprehensive data that evaluate the circumstances, situations, and environments where teledermatology actually makes a difference to many patient outcomes that fully considers all costs. The hard questions are now being asked.”, l7 Guidelines for the metrics of telemedicine research have been p ~ b l i s h e d Civilian .~ and DoD telemedicine projects are now incorporating these guidelines into studies to assess telemedicine, including teledermatology. SOME FUTURE DIRECTIONS IN DoD TELEDERMATOLOGY
The explosion of interactive World WideWeb (WWW) sites on the internet in the past
3 years has been stunning. Is this format adaptable to SF teledermatology consultation? Indeed it is! Two DoD sites are evaluating this medium: Tripler Army Medical Center (Honolulu, HI) and the National Capital Area (NCA) Teledermatology Consortium. The following discussion will use the NCA site to show the vast potential of World Wide Web-based consultative teledermatology. The dermatologists of the three DoD medical centers in the NCA are assisting WRAMC in the development of a SF teledermatology consultative WWW site. The Web site features multimedia pages that include clinical history, laboratory data, and scaleable clinical images in a “user friendly” format (Fig. 3). The website uses “off-the-shelf” hardware and software that meet DoD requirements for interoperability (Defense Information Infrastructure Common Operating Environment Standards). This system will be compatable with other future DoD computer systems. The teledermatology website is designed to
Figure 3. National Capital Area Telederrnatology Consultation Group worldwide web page. (Courtesy of Jorge L. Ribas, DVM, Vladimir Bedanov, PhD, Hon Pak, MD, and Mark Welch, MD, Washington, DC.).
THE HISTORY OF TELEDERMATOLOGY IN THE DEPARTMENT OF DEFENSE
be equally accessible to a remote site such as a ship at sea or deployed ground unit using e-mail as it is to a fixed primary care site with rapid and reliable connection to the WWW. An authorized provider in an isolated location that has only electronic mail service “fills in the blanks” on a consultation template and attaches the clinical images. Then the provider submits the automatically encrypted case via e-mail. Alternatively, a provider at a fixed primary care site with WWW access simply signs on to the site, completes a referral history template, attaches diagnostic images, and submits the automatically encrypted case while on-line. The consultant of the day signs onto the NCA teledermatology web site, opens the automatically decrypted case, and renders an opinion. The reply is automatically archived by the server and transmitted to the originator. The archived cases are available for later clinical review and use in cost-effectiveness research. The on-call dermatologist can reply to the consults from any location with WWW access. This could be at a clinical office, telemedicine suite, or in the case of a laptop computer with excellent graphics capabilities, virtually anywhere. When fully operational, the NCA will have a teledermatology system without borders. CONCLUSION
The DoD has been a leader in the development and use of advanced telecommunications for medical purposes, including dermatology. In this fashion, the DoD healthcare system is innovatively caring for servicemembers who work in peacekeeping, civil/humanitarian relief, and combat operations. As with any new modality, the niche of teledermatology is being defined in the DoD and the medical practice at large. Teledermatology will likely become an increasingly important part of the DoDs medical mission of providing “good medicine in bad places” anywhere in the world.
References 1. Bakalar RS: Business Process Reengineering: A Success Story From the US Naval Academy In Programs and Abstracts of the Healthcare Information Management Systems Society, San Antonio, TX, September 1997
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Address reprint requests to CAPT Dennis A. Vidmar, MC, USN Department of Military and Emergency Medicine Uniformed Services University of the Health Sciences 4301 Jones Bridge Road Bethesda MD 208144799 e-mail: [email protected]