Army Fields Advanced Telemedicine Network

LANDSTUHL, Germany—The Army is fielding the most advanced telemedicine system in history to provide medical care to U.S. forces deployed in Bosnia and Hungary for Operation Joint Endeavor.

According to Lt. Col. Tom Semarge, biomedical information systems officer for Landstuhl Regional Medical Center, "We're blazing trails here and writing new doctrine" with the Joint Endeavor telemedicine network, which he called "the most robust ever fielded."

The Joint Endeavor telemedicine network will use high-bandwidth circuits—up to 4 megabit/sec—to support such applications as telesurgery, telemedicine, telepsychology and teledentistry. The network will also extend the Defense Department's Composite Health Care System (CHCS) to field hospitals in Bosnia and Hungary.

Semarge said the Army wants to use telemedicine to "bring specialists to the patient rather than the other way around.... We're looking to provide the same standard of care everywhere."

Weather conditions in the region also served as an impetus for the telemedicine network, dubbed Prime Time 3. "Some months, due to the weather, you can only fly a med-evac [helicopter] four to six days out of the month," Semarge explained.

In a briefing on Joint Endeavor earlier this year, Army Surgeon General Lt. Gen. Alcide M. LaNoue said DOD's Somalia operation proved the potential of telemedicine, which the Bosnia operation will more fully realize. "What I see now [for Joint Endeavor] is the ability to move whatever information a practitioner or patient may have need of," LaNoue said. "Either to send it to the expert to get an opinion on it or to send it to the Library of Congress to find out the latest information [and] world literature on it."

Maj. Ray Bender, chief of support services at the Air Force Medical Systems Implementation and Training Division, said the deployment essentially amounts to an installation of the DOD peacetime hospital system platform into a battlefield environment. The deployment of CHCS in Bosnia means users need little or no additional training to operate the system in the field.

"When they go to the field, it's enough to sleep on cots in tents with snow blowing through without having to learn a new system on top of that," Bender said.

In Joint Endeavor, CHCS runs on Digital Equipment Corp. Alpha AXP 3000 workstations connected to a fiber-optic local-area network at Tazar Air Base in Hungary. The Alpha systems are equipped with TGV Software Inc.'s MultiNet TCP/IP software to provide Internet access to remote users.

Officials involved in Prime Time 3 emphasized they are not applying technology for its own sake. Aside from the potential for better health care for those serving in Bosnia, telemedicine serves the practical purpose of keeping doctors and patients out of harm's way by moving data, as opposed to people.

"It was determined that moving patients is too dangerous in this case because of all of the land mines in-theater," Bender said. "So we use technology to postpone that movement by providing more care in an austere environment. We can't have surgeons everywhere, but maybe we can have somebody who can perform procedures with help."

Dale Gareaux, the Landstuhl site telemedicine coordinator for Electronic Data Systems Corp., said the purpose of the network is "to project expertise...to provide people here who can help direct an operation there."

EDS is supporting Prime Time 3 through the Defense Medical Information System/System Integration, Design, Development, Operations and Maintenance Services contract.

The Army plans to roll out Prime Time 3 in three phases, Semarge said, with the third phase bringing for the first time advanced medical technology to infantry brigades operating out of isolated and primitive forward operating bases. While the Army has yet to receive funding for this final phase, Semarge said, "We're moving forward as if it was already done."

Phase I began in March, when high-speed circuits connected Landstuhl with the 67th Combat Surgical Hospital in Tazar and the 212th in Tuzla, Bosnia. Tazar rides a commercial E-1 circuit (2.049 megabit/sec), while the Tuzla hospital uses a 4 megabit/sec commercial satellite shot, with the circuits at both locations fed through a multiplexer from N.E.T. Federal.

These broadband circuits will allow a host of applications, Semarge said, including "diagnostic-quality video running at 30 frames per second and filmless radiology that will allow [the field hospitals] to send files back here. Since this is digital, it offers us better quality X-rays than film." The high-quality video enables telesurgery, Semarge said, through which a specialist at Landstuhl can assist surgeons in the field.

The data stream will also permit remote CAT scans and color ultrasound, Semarge said. "While most people know of ultrasound from its ability to `see' a baby in the womb, it's also a very good diagnostic tool if you have internal bleeding since it allows you to see into the body."

High-quality video will also support teledentistry applications, allowing a dentist at Landstuhl to remotely see into a patient's mouth and provide directions to a field dentist or dental assistant, Semarge said.

The wide bandwidth will also allow the extension of CHCS down to the field hospitals, Semarge said, allowing them to easily access patient records.

Phase II will tie the Tazar/Tuzla/Landstuhl sites through the Defense Information Systems Network (DISN) into a video bridge at the San Antonio (Texas) Army Medical Center. This will allow medics and doctors in the Tuzla field hospital to consult with specialists at a wide range of hospitals, including the Walter Reed Army Medical Center, Bethesda, Md.

Semarge said Phase II will also extend the Joint Endeavor telemedicine network to "two or three of the forward operating bases," bringing the advanced technology directly to grunts operating in the mud. Phase II calls for additional brigade base camps accessing the network—as many as 12 out of the 24 in Bosnia. This will require installation of commercial satellite downlinks and multiplexers to support the 512 kilobit/sec links planned for each of those bases.

At the brigade level, Prime Time 3 will support not doctors but physicians assistants—"people trained to do primary care who can use the network to tap into greater expertise. The purpose of putting the network into base camps is to try to avoid medevacs whenever possible," Semarge said.

The Army plans to equip the physicians assistants with a suite of off-the-shelf gear, including a consumer-type Canon video camera and an H1-8 VCR capable of recording and transmitting still-frame video back to a hospital in the rear. "This will help them handle trauma better," EDS' Gareaux said.

Eventually, Semarge said, the Army would like to transfer the whole Joint Endeavor telemedicine network to the joint Defense Advanced Research Projects Agency/Defense Information Systems Agency Asynchronous Transfer Mode (ATM) network being developed to support a number of users in the theater.

"Once we develop a mature environment, we believe ATM and bandwidth-on-demand is the way to go," Semarge said.

Lt. Col. Ed Gomez, a vascular surgeon at Walter Reed Army Medical Center, said a 384 kilobit/sec video connection lets doctors anywhere in the world assist in diagnoses of patients in Bosnia or any other battlefield scenario. "In Bosnia, we will probably see if we can bring together all of the expertise from our medical centers," he said. "We can bring in the different specialists together to work on a complex problem."

The Army also hopes that video teleconferencing will prove useful for "telepsychology" applications, such as group sessions of individuals suffering from stress related to the adverse conditions in Bosnia; such sessions could be led by psychologists at another location.

"We're fairly certain the field of mental health is very amenable to this [technology]," said Paul Zimnik, a psychologist with the Army's Medical Advanced Technology Management Office. "In the past, fields like radiology have been the leaders, but I think mental health will catch up and surpass that."