Col. Les Folio, MD

Telehealth, specifically teleradiology, is becoming more commonplace across the globe, and forward-deployed medical care in wartime is no exception. Theater healthcare may in fact help set an example for austere environments elsewhere, including rural U.S. regions.

In March, 2005, a team of four hand-picked active-duty Air Force officers set out for a brief mission with a major impact: to provide a joint telehealth solution with connectivity from remote hospitals receiving war casualties back to large teaching institutions where wounded patients may be transported. The team members were Col. Les Folio, Maj. Erich Murrell, Maj. Sean Murphy, and Maj. Dave Ault.

A landmark charter among the Army, Navy, and Air Force was signed by each of the deputy surgeons general. The charter called for formation of the PACS joint services working group, which required the military to minimize redundancy, enhance providers' practice, and strive for standards-based technology and processes in diagnostic imaging. After a few meetings, the working group quickly agreed that forward-deployed PACS and teleradiology would be of the highest priority.

As is often the case in medical practice, interim solutions had proliferated as providers did whatever they could to best treat their patients. This included assembling montages of CT images to send via e-mail (no patient data, of course, just interesting cases). Some practitioners took digital photos of dermatology lesions for consults on perplexing cases when no dermatologist was available. These solutions were novel, secure, and compliant, but they demonstrated the need for a more uniform solution that could be replicated.

A small working group (that quickly grew, due to need) emerged from the larger group to assure that similar decisions and processes would take place in the theater of operations in Iraq, Kuwait, and elsewhere. Because the Army and Air Force had experience with certain solution sets, and each was having success in DICOM image distribution, common platforms were agreed upon.

Much progress was made following an Army visit to the forward-deployed units last year, thanks to personal connections established during onsite visits and the efforts of the telemedicine office staff of the Army and Air Force surgeons general. Enthusiasm for telehealth spread quickly, providing a clear path for follow-up once the assessments were complete. This effort paved the way for other services to obtain compatible equipment, refine business rules, and prepare follow-up visits to reassess, teach, train, and install systems.

Questions from Iraq, for example, were forwarded to the team, who explained how to send images, obtain remote interpretations, use equipment that was in place, and operate in an environment with low bandwidth of 100 Mbps or less. Other experts from other services, and hundreds of support personnel from all parts of the PACS world, collaborated in an effort to craft a telehealth strategy. This dialogue included active-duty personnel, reservists, civilian contractors, and vendors-whoever could answer the questions at hand.

The Air Force team emerged from these e-mails, phone calls, and teleconferences as the most qualified to travel to and optimize the telehealth capabilities at Balad Air Base, a key Air Force expeditionary hospital just north of Baghdad. This large deployed hospital received most of the casualties from the Fallujah battles and continues to see trauma patients regularly. It has CT capability, limited ultrasound, and plain radiography with computed radiography.

A major mission for the Air Force team was to eliminate the need to overimage air evacuees at Balad and again at each subsequent echelon of care. To connect the current system to the network, the Linux servers had to be exchanged with Solaris servers in accordance with Air Force information assurance requirements. Secondary goals included proof of concept for future dynamic workload sharing, operational testing of bandwidth usage rates of teleradiology, and general telemedicine education for providers in a contingency setting.

Balad acquired a deployed teleradiology set from the Army when it transferred ownership of the hospital to the Air Force in 2004. External connectivity for teleradiology had not yet been established and was delayed by Air Force security requirements that differ from those of the Army. Our team's focus was to swap out the teleradiology servers with Air Force-approved systems and migrate the image archives seamlessly-all while hospital operations were in full force. Once they were swapped out, the base communications department allowed for connectivity across both the local area network and the wide area network for eventual connection and successful teleradiology over the Internet in a secure fashion.

In the span of a few weeks, the small team successfully exchanged the old servers for new Air Force-approved servers, established teleradiology capability, added a diagnostic workstation with 3-megapixel flat-panel monitors, and provided better visibility of images for surgeons in the operating room.

Presentations were made to the professional staff on teleradiology as well as other telehealth modalities available to them. An Army-run teledermatology program, for example, provides continual access to a panel of experts who can discuss perplexing dermatology cases. This program is also supported by Air Force dermatologists and allows providers to securely e-mail images and receive consults within hours rather than days or months. About 500 teledermatology consults have occurred since the Army started the process, saving about 30 air evacuations. More important, it has saved lives; for example, through early melanoma detection.

Visits to other bases provided more insight to theater telehealth, and lessons were learned from other interim solutions that benefited those without dedicated teleradiology equipment. Future directions include increasing archiving capability, adding more bases to the referral network, and establishing dynamic workflows so radiologists can share interesting cases and relieve one another. The mission success of this Air Force team has made it clear that telehealth in austere environments with relatively low bandwidth is clinically necessary and technically feasible.

Maj. Courtney Tripp, M.D., was one of two radiologists deployed to the Air Force Theatre Hospital at Balad Air Force Base at the time of our working group's visit for installation of servers and at the time of writing this article. The following is based on his description of the capabilities and potential benefits of the external connectivity.

Radiologists at Balad AFB provide diagnostic imaging services to 30,000-plus personnel and casualties received both directly from the field and from forward-deployed operating bases, some of which have imaging capabilities that include CT and radiography. In addition, the Air Force Theatre Hospital at Balad serves as the regional hub for air medical transport out of the country.

At the time of the working group's visit, the hospital did not have the capability to view previously acquired exams from the forward-operating bases. The ability to remotely view those exams and to make those done at Balad available to other bases would have greatly reduced the need for repeat imaging upon arrival to the Air Force Theatre Hospital and again at Landsthul Army Regional Medical Center in Germany. Additionally, this access would have allowed reliable comparison with old exams, thereby improving overall patient care.

"Following installation of the new servers and software, we can view the patient lists from some of the forward-operating bases and from Landsthul," Tripp said.

At the time of server installation, the ultimate goal of eliminating overimaging of air evacuees was still a work-in-progress. With the new servers in place and external connectivity established, that achievement appears to be in sight.

Dr. Folio is an assistant professor of radiology at the Uniformed Services University of the Health Sciences in Bethesda, MD. Dr. Tripp is chief of diagnostic imaging at Ehrling Bergquist Hospital, Offutt AFB, NE.

Col. Les Folio, MD

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