DOD gives patient care online

By Bill MurrayGCN StaffTelemedicine is helping Walter Reed Army Medical Center provide more cost-efficient care to soldiers and civilians, although some doctors remain skeptical of the technology, officials said.Applications have included real-time orthopedic consultations using videoconferencing, and using e-mail to get dentistry or dermatology advice, they said.The telemedicine center is working to overcome doctors' reluctance to use the technology, said Col. Ronald K. Poropatich, an Army physician and WRAMC's telemedicine director.'Telemedicine is underutilized because some physicians are reluctant to change from [exclusively] traditional practices and are only comfortable seeing patients face to face,' he said.Such doctors are also quick to abandon telemedicine when communications equipment is unreliable, Poropatich said.Telemedicine is the electronic transfer of medical information from a referring health care provider at one site to a consulting physician at another, he said. WRAMC, the Army's largest medical center, has provided telemedicine services for Northeast U.S. installations and for some overseas deployments since September 1995.Setting up a governmentwide patient record system is key to increasing the use of telemedicine, Poropatich said.'It's one of the big stumbling blocks to telemedicine adoption,' he said.Officials from the Bureau of Indian Affairs, Defense Department Health Affairs and Veterans Affairs Department are working to establish a common patient record system as early as 2010 through a Litton PRC contract, Poropatich said.'I think the warfighters have bought into the idea of using telemedicine far forward on deployments,' Poropatich said. 'When we deploy, we try to use the most low-cost means as we can.'E-mail, File Transfer Protocol and the Web, and videoconferencing over Integrated Services Digital Network and wireless communications are moderately expensive communications tools, Poropatich said. Satellite communications are the most expensive but least-used means, he said.WRAMC used telemedicine in 1993 during operations in Somalia, as well as in Kenya after the U.S. embassy bombing in Nairobi in 1998. WRAMC officials are also helping NATO officials develop telemedicine standards for far-forward deployments, Poropatich said.The Army has fielded its telemedicine needs for Kosovo and Macedonia out of Landstuhl, Germany, using 256- and 512-Kbps communications pipes.Telemedicine can also help the Army 'reduce [its] footprint during far-forward missions, because the service has to deploy fewer radiologists,' Poropatich said.WRAMC has slimmed down its deployable telemedicine workstation to a 117-pound package that costs $58,000 and can be shipped within hours, he said.WRAMC officials are helping the Army Special Forces administer basic battlefield treatment via handheld PCs running Microsoft Windows CE with diagnostic software, Poropatich said.The troops have electronic medical handbooks, and they can read and write to the 8K electronic dogtags known as Personal Information Carriers through a pilot that began in the Pacific in December.Despite warfighter acceptance, 'our main focus is on the peacetime environment in the Northeast United States,' Poropatich said. Service officials have focused on clinical consultations, distance learning and regional support for telemedicine.The 'Ask a Doc' program lets Army doctors in 72 clinical subspecialties get questions answered by service subspecialists within one working day. They can use text-based e-mail and the Composite Health Care System to find subspecialty e-mail addresses through a pull-down menu, Poropatich said.WRAMC officials handle 100 'Ask a Doc' consultations each month and fielded 1,668 such consultations between May 1, 1998, and Oct. 31, 1999, he said.Teledermatology, the most common telemedicine application, has helped Army officials resolve 51 percent of consultations at the referring site through videoconferencing. Teledermatology can cut the average wait for in-person care from 48 days to two days, Poropatich said.The Army uses asynchronous transfer mode technology to forward images that are password-protected, encrypted and stored on a dedicated server.After a dermatologist finishes an examination, a radiologist fills out a form using a browser and takes an image of the affected skin area. Subspecialists receiving the record can enlarge the image.The dermatology clinic at Fort Myer, Va., saved $45,000 in one year with teledermatology, Poropatich said.WRAMC offers 19 telemedicine subspecialties in its work with 11 military treatment facilities in the Northeast, he said.Orthopedics is the most common surgical consultation. The hospital also offers teledermatology consultations at 23 sites outside the continental United States.WRAMC officials participated in a Warfighter Information Network-Terrestrial demonstration at Fort Gordon, Ga., in November, which let doctors page other physicians using ATM switches, Internet Protocol routers and personal communication devices, Poropatich said.The WRAMC telemedicine directorate, which has 17 employees, uses teleconferencing products from ComputerLab International Inc. of San Francisco; PictureTel Corp. of Andover, Mass.; Polycom Inc. of San Jose, Calif.; Tandberg Data Inc., of Simi Valley, Calif.; and VTel Corp. of Austin, Texas. The directorate uses H.323 Internet and H.320 standards, said Daisy DeWitt, deputy telemedicine director at WRAMC.WRAMC officials are also working on echocardiology, sleep medicine, child psychiatry, pathology, surgery mentoring, simulation dentistry and nuclear medicine.Poropatich reported high patient satisfaction with WRAMC's child psychiatry telemedicine practice.'In some places like Fort Drum, N.Y., the closest child psychiatrist is more than 40 miles away,' he said. 'There is no alternative to telemedicine for such parents, unless they want to drive long distances. ' In telemental health, you need to see the movements of patients, which enable the doctor to see how the patients conduct themselves when speaking.'Home health care and critical care telemedicine and pharmaceutical work will increase this year, Poropatich said. At Fort Detrick, Md., he is researching next-generation technology in artificial intelligence, biosensors and knowledge management. He also predicted that simulation technology will help the Army better deliver advanced trauma care.WRAMC has loaded more than 80,000 pages about telemedicine into its Web sites, at and , which it uses for continuing education of doctors, soldiers and civilians.