IWALT 2000 Panel – 2 Telemedicine and Tele- Education Remote Tele-Education as an Alternat

IWALT 2000 Panel – 2Telemedicine and Tele - EducationRemote Tele-Education as an Alternative to Telemedicine Aboard the Aircraft Carrier USSGEORGE WASHINGTONPanel Chair: Les Folio, D.O., M.P.H., M.Sc., M.A.S.; William Sneeder, M.D., M.P.H. Residents in Aerospace Medicine, USAF School of Aerospace Medicine, Brooks Air Force Base, TXlesfolio@AbstractPurpose: A method of Basic tele-education as an alternative to telemedicine on the aircraft carrier USS GEORGE WASHINGTON is described. Aircraft carriers are often deployed for months, with limited medical specialty services. This method was developed to increase access to images by specialists at the medical center where patients would be seen once at port. Methods: Radiologic images were imported into Word and PowerPoint with simple windows keyboard commands. Images were then e-mailed to various specialists for consultation. Results: The quality of the attachments for diagnosis was satisfactory to the consultants and replies were received within 24 hours. There was no apparent difference in image quality between Word and PowerPoint and both used comparable memory space. Conclusion: Telemedicine, teleconsultation and tele-education may be successfully implemented in remote environments such as carrier operations at sea, using PowerPoint with attachments.1. IntroductionThe USS GEORGE WASHINGTON (figure 1) is a Nimitz class nuclear powered aircraft carrier, capable of DICOM compatible computed digital radiography and teleradiology. Tele-education was employed using digital radiology and commercial satellite Internet access during a deployment with training competitive exercises.FIGURE 1. Nimitz class aircraft carrier USS GEORGE WASHINGTON at port. Telemedicine, teleconsultation and tele-education, herein collectively referred to as telemedicine are well-established applications of computer and communication interactive technology, especially in remote locations. Medical groups on aircraft carriers represent a unique form of remote medicine, with the technology able to overcome obstacles of the usual lack of specialties and expertise.Medical capabilities on the Nimitz class carrier USS GEORGE WASHINGTON include: Digital radiology, Ultrasound, acute care, ER, ICU, OR, aviation medicine, environmental health and up to 60 inpatient beds with flexible expansion capability in case of combat or other mass casualty situation. Full medical personnel compliment includes: two flight surgeons, a General Medical Officer, a Physicians Assistant, a General Surgeon, Anesthesiologist, nurse, psychologist, and approximately 46 enlisted corpsman. The USS GEORGE WASHINGTON was the prototype carrier to utilize digital radiography with successful application of basic Picture Archiving System (PACS) on a departmental Local Area Network (LAN). [1]2. Materials / MethodsRadiographs were viewed with a 21 inch Hitachi CRT 2000 x 2000 pixel resolution in an exam room setting with dimmed overhead fluorescent lighting aboard the GW. Various radiographs were copied by right mouse click on the desired DICOM raw image (without the patient data) for comparison. They were then pasted into Word and PowerPoint with the paste command (control-v shortcut). Several images were compared in vertically tiled windows to compare diagnostic quality differences. Each case was reviewed in combinations of both Power Point and Word, to evaluate loss of diagnostic ability compared to the DICOM raw images.The entire radiographic image was imported from the clipboard onto the first PowerPoint slide and detailed enlargements were made on subsequent slides. Appropriate sizing was used to fit the imported images using the mouse. Images imported into Power-Point werethen e-mailed to various specialists for consultation, with satisfaction on the receiving end with timely replies and advice.FIGURE 2. Radiograph file size comparison of DICOM raw data images verses images in PowerPoint and Word. The quality degraded slightly converting from the .img raw data file to the .jpg. However, unlike .img, .jpg files are fully compatible with computers unable to display DICOM images. DICOM Radiographic images are periodically archived onto economical read-write CD, while the current patients (50-100) x-rays were readily accessible on the 30-gigabyte hard drive. Archiving DICOM onto CD Write at one dollar per CD is economical and convenient for placing into a patient folder or filing teaching cases. This readily available technology is markedly improved over previous optical disc methods. [2] The larger hard allow several weeks of use without the need to archive.Digital radiological images and clinical photos were saved as PowerPoint jpeg files and attached to email sent via satellite to CONUS-based specialists (such as, the orthopedics department) at the Naval Medical Center Portsmouth, which is the GW’s referral hospital when in-port at Norfolk, VA. The digital photos and radiographs in this limited analysis were sent as educational cases without any patient name, identification number or any other personal identifiable information. Follow-up emails and phone calls were made to discuss the patients’ history and other data that had been sent in separate messages. 3. ResultsAlthough there was no appreciable difference in quality, Power Point allowed for more natural importing of images including sizing, manipulating and printing. This was also true on the receiving end of the images on shore-based medical facilities. These images had barely discernable differences on the CRT monitor. Images included studies such as a chest x-ray PA and Lateral, Tibia-Fibula, and a 4th metacarpal. Although possible, laser printout quality provided only fair reproduction of subtle radiological details. Diagnostic quality and detail did not seem significantly degraded on the full image DICOM versus PowerPoint; especially with select magnified images. All abnormalities were seen well on images that were sent by email as attachments, and seen on the receiving end to satisfactory detail. Although this is subjective, the concept was demonstrated and seemed acceptable based on consulted specialists feedback for the pathology presented. Responses by specialists were returned within 24 hours of the original email consult request, with advice on diagnostic modalities and treatment recommendations.4. DiscussionTelemedicine is an electronic way to provide a medical skill set (e.g. radiographic interpretation, etc) to an area (aircraft carrier) where that skill set would not otherwise be available. Alternative ways to provide the same service include: (1) put a radiologist at sea; (2) super-train onsite PCM's (Primary Care Managers) in radiographic interpretation. These alternatives are less preferable to telemedicine because they are not cost effective.Tele-education about a current case by consulting a specialist allows for learning to take place while benefiting the patient. Using images sanitized for patient information avoids the legalities of patient data and confidentiality issues and streamlines the patient care. The tele-education approach also allows the specialist to “triage” and schedule the higher priority patients based on radiographs they have actually seen. [3] Other considerations in methods of transmission were bandwidth availability, potential loss of satellite signal during long transmission times required for larger digital radiology files, and consideration of obvious priority reduction of finite communication network time and access available to medical services during contingency deployments and actual combat operations. There should be traditional backup systems in case bandwidth is unavailable especially since bandwidth is at a premium during operational maneuvers/war. To assure that the onsite PCM's do not become technology dependent on telemedicine they should continue to receive usual recurrent medical skills training.Internet access was limited and inconsistent on this deployment, so writing teaching cases to a web site was not performed. Instead, email attachments were used to send photos and radiographs, with replies sent from the referred specialists by replying to the email transmissions. One important limitation to this proof-of-concept study design, was a lack of quantifiable resolution differences in the .jpg and .img image formats. Further research is recommended in this area.5. ConclusionsThis exploratory research attempted to demonstrate the feasibility of an alternative to DICOM technology that is more widely available, with minimum diagnostic quality loss. It was found that email attachments of Lossy compressed radiographs imported into PowerPoint was the most efficient and universally accepted method of sending radiographs to specialists without DICOM capability during our trial period at sea. The authors conclude that the more widespread and faster availability of the images outweighed the minimal loss in resolution, however, more research is needed in resolution comparisons. Review of several DICIOM verses PowerPoint images failed to reveal significant loss of diagnostic quality in that the pathology of interest was evident on the .jpg images sent and received. Getting the knowledge to the provider in a timely manner through tele-eduation allowed for more definitive patient care while establishing a case dialog with the specialist that would ultimately be seeing the patient once ashore.Turn around time with email attachments to specialist with replys within 24 hours’ verses multiple day turn around with centers with DICOM compatibility. More importantly, the images were electronically delivered to the specialists that were going to be seeing the patients once reaching port. Usual security and confidentiality issues were avoided by performing the tele-consultation as tele-education. Providing the images in PowerPoint allow specialists to easily incorporate interesting cases into their presentations. Perhaps this could serve as additional incentives for specialists to continually evaluate interesting cases in remote areas such as deployed aircraft carriers and hospital ships.Our sailors and troops injured or ill at sea cannot afford to wait for medical services as facility technology catches up. They can get it now with just-in-time technology. Our goal was to develop an acceptable system interface between the more advanced radiology system available shipboard and translate it into a readable, compact imagery data set that could be received and evaluated in a timely manner using systems now commonly available to specialty consultants, at the same hospital where the patients would physically go when ashore.6. AcknowledgementsThe authors greatly appreciate the cooperation and support from all the members of the Medical Group on the USS GEORGE WASHINGTON. Special thanks to Dr. Solomon, the ship’s Chief Primary care physician and Dr. Rocereto, the ship’s Senior Medical Officer for their highly professional assistance with this project.7. DisclaimerThe opinions expressed are strictly those of the authors, and do not necessarily reflect the opinions or policy of the Department of Defense, the US Air Force or the US Navy.8. References[1] Folio, L., Sneeder, W., Solomon, C. Rocereto, P., Applied Telemedicine, Teleconsultation And Tele-Education Aboard Uss George Washington Aircraft Carrier; Aviation, Space and Environmental Medicine (Abstract), March 2000, pp. 165.[2] Folio, L ., Stokes, R.,Frankfurter, J.“From Film to Filmless: Military Experience with Teleradiology in Korea;” Applied Radiology, July 95.[3] Karpf, B., “Navy Telemedicine Sails ‘Off-The-Shelf,” U.S. Medcine, February 2000, pp. 2, 28.[4] Buntic, R.F., Siko, P.P., Buncke, G.M., et.al., “Using the Internet for Rapid Exchange of Photographs and X-Ray Images to Evaluate Potential Extremity Replantation Candidates,” The Journal of Trauma, Injury, Infection and Critical Care, Vol 43, No.2, August 97, pp. 342-344.Complementary papers in this session relating to tele-education technologies:1. Banks: “Continuing medical education via IT: a viable alternative for female rural and remote general practitioners, disenfranchised from travel based options by family responsibilities”2. Arnott, Davis: "Recording the Use of Computer Aided Learning in Veterinary Anatomy: Results for a Complete Year"3. Togno: “Policy on Using Information Technology to improve rural health care”。