Teleradiology Roundtable

THE WORD TELERADIOLOGY BY ITSELF IS ILLUSTRATIVE OF THE PARADIGM SHIFT IN NOT ONLY HEALTH CARE BUT VIRTUALLY ANYTHING ELSE YOU CAN IMAGINE. THE ABILITY TO USE TECHNOLOGY TO VIEW INSIDE THE HUMAN BODY IS ASTOUNDING WHEN CONSIDERED BY ITSELF, AND EVEN MORE SO WHEN COUPLED WITH AN ABILITY TO SEND THOSE IMAGES TO FAR-DISTANCE LOCATIONS. DIGITAL COMMUNICATIONS IS THE PARADIGM SHIFT MENTIONED.

The medical community has long recognized the value in being able to send images to other locations for second opinions, or perhaps, in some cases the first opinion. Every U.S. service has a team of forward-thinking individuals working the issues of teleradiology. These forward thinkers also recognize the value in not recreating the wheel and that by harnessing the synergies that each service can bring to the table, the benefits will come faster for everyone—to the ultimate benefit of the patient, whether on the battlefield or CONUS.

MMT recently posed a short series of questions to some of the key people working these issues to see how their responses were similar or dissimilar.

We had great dialogue with Dr. Les Folio, currently the radiology flight commander at the Air Force trauma hospital at Balad Air Base, Iraq; Air Force Lieutenant Colonel Timothy Lacy, currently the chief of telehealth in the Air Force Surgeon General’s Directorate for Medical Modernization; Ronald R. (Rob) Richardson, program manager for the Army PACS Program Management Office; and Dr. Stephen T. Sears MD, commander U.S. Navy and head of NNMC’s Department of Radiology and the Navy’s Diagnostic Radiology Specialty Leader

Q: What are the most significant challenges to improving the use of joint radiology in deployed environments?

Lacy: There are two primary problems from my perspective. First of all, because we do not yet have a standard HIS-RIS interface, and because the pace of clinical work and radiology can be quite rapid, we do not always get personal information inserted into the DICOM header of the study. This may not affect the study at the moment, nor affect the use of the study for immediate clinical use, but it does mean that when the study is sent back to Landstuhl and CONUS, the study may not match the patient’s indexed data, and will therefore be effectively lost even if it is in the PACS. Thus, many of the studies in theater are not available as a part of the patient’s longitudinal patient record.

The other primary problem is bandwidth. While the military is trying to solve this problem, bandwidth limitations and connectivity problems still place limits on our ability to transmit studies from the AOR to garrison.

Folio: If I were to prioritize the top three priority challenges to overcome; it would be bandwidth, bandwidth and bandwidth. After that, security [and rightfully so], business process and continued security updates are paramount.

I don’t think the issue is “joint” radiology since the telemedicine leads are joint and work together as a team. Our efforts have resulted in equipping our Army, Navy and AF deployed medical facilities with the same equipment, processes and interchanged ideas. We all happen to face the same challenges of bandwidth, money for bandwidth, bandwidth real estate on the shared lines out [we may have line bandwidth, but not the permission to use it].

Richardson: I believe the most significant challenge we face today can be summed up in two words—dedicated bandwidth. We simply don’t have sufficient bandwidth to effectively move images as required to support the clinical practice of radiology in the theater of operations. The advent of multi-slice computed tomography (CT) scanners, and the nature and extent of the injuries we see, has only exacerbated this problem. Information assurance issues associated with the use of disparate service network domains and the credentialing of users from other military services is a secondary challenge. I think the development of a DoD medical community of interest [COI] network would solve most, if not all of the interoperability challenges we currently face, and would greatly facilitate the movement of images intra- and inter-theater. I think the final challenge is really a “systems” issue. The utility of the data for primary interpretation is, to some degree, dependent upon the “quality” of the demographic information associated with the exam. We have state-of-the-art devices and systems that are not able to communicate effectively due to software licensing issues and clinical information systems without enterprise awareness. If not taken into consideration the end result could be that when the bandwidth and networking issues are fixed, text-based information may not move efficiently with the images.

Sears: Since 2001 when I joined the teleradiology effort within the Navy, I have come to greatly appreciate the efforts of so many people from all of the services who have worked for years jointly on teleradiology. We have seen many advances but still face many challenges. Advances in technology have improved our ability to process and display data, but the physical transmission of that data remains our most significant challenge.
 
The deployed environment, be it ship at sea or field hospital in an urban combat zone, poses significant communication challenges. Access to wide area networks can be unreliable and very bandwidth limited. There are special network security concerns and bandwidth allocation must be prioritized with respect to the underlying mission.

Inter-facility and inter-service differences in the approach to and application of network security procedures lead to additional difficulties in interconnecting medical facilities and facilitating the flow of data. There are a lot of really talented people in all the services working to create better uniformity and facilitate theses interconnections for all kinds of data and it will only be a matter of time until this problem is overcome.

Bandwidth is a problem today and will be a more significant challenge in the future. Once stable networks capable of carrying this data reliably from one treatment facility to another exist, the volume of data will expand well beyond our current levels. Along with the electronic medical record and the ever expanding amount of medical imaging, other telemedicine functions will expand as the potential benefits to the deployed service member is recognized.

Q: How would you characterize the use of and success of teleradiology in Iraq and Afghanistan today?

Sears: I would have to call this a “work in progress”. All of the services independently and more importantly jointly have learned a lot and developed significant capabilities through our experiences in Iraq and Afghanistan. Because of network reliability and availability issues, the function of teleradiology in the landbased deployed medical units continues to primarily be for the movement of patient data in support of the medical evacuation process. This in itself has a great positive impact on the individual’s health care. When the imaging data is available prior to the arrival of an injured servicemember, the receiving health care team can already be prepared to continue care without delay. Given that many of these patients are transferred from one treatment facility to another at least three or as many as six times from the time of injury to the time of discharge from a rehabilitation facility, the reduction in repeat imaging studies and the inherent reduction in radiation exposure also cannot be understated as a benefit.

Additionally, the Navy continues to utilize teleradiology services as we have for almost 10 years to support the medical departments of deployed aircraft carriers and large amphibious ships with primary radiology interpretation services. X-ray images from these ships can be transmitted to our major medical treatment facilities where radiologists are available 24/7/365. Final reports on imaging studies can be obtained as quickly as 20 minutes under ideal or urgent conditions or can require the use of CD-R and mail when network functionality is less than ideal. Before this was available, the ships medical officers would evaluate the images, determine treatment and then save the images for interpretation on their return to port; sometime six or more months later.

Folio: Our telehealth collegial relationships and joint efforts have built over the years. For example, I met Bob DeTreville [the previous Army teleradiology lead before Richardson] in 1994 [see the following article: http://www.medicalimagingmag.com/issues/articles/2005-08_02.asp as this nicely summarizes our  success] to have the first digitized radiology department in the Air Force at Osan Air Base, Korea; right around the same time the first civilian digitized filmless radiology department emerged at the VA in Baltimore under Dr. Siegle.

These relationships built to form the first official PACS Joint Service Working Group in 2003.

As witnessed in our joint panel at the battlefield conference, each of the services presented their successes and challenges. Together we have a powerful political leverage to obtain our objectives and overcome mentioned challenges.

When I led our joint PACS team to Iraq a few years ago, we succeeded in proving the joint transmission concept and were able to work with base security IT to overcome huge security issues with common medical and line IT backbone. To read me about this, readers should visit http://www.airforcemedicine.afms.mil/sg_newswire/apr_05/CombatTelehealth.htm

Since I am back in Iraq again at the time of this interview, I will continue to evaluate and recommend potential areas of improvement of our process deployed telehealth process.

I am now in a unique position to see the results of our telehealth efforts over the years. Since I am living it everyday in combat, I can tell you with some authority; that we are still not there. Just tonight I was discussing with other functional areas of the hospital here in Iraq what logical next steps we can take to make the RIS-HIS interface—that Dr. Lacy mentioned earlier— work to tide us over to the ultimate goal.

I sent you a photo of myself and one of our technologists, Technical Sergeant Ellwood Tegtmeier, and another photo of what I call the napkin phase of a potential answer to theater HIS-RIS issue. We use JPTA [Joint Patient Tracking Application] for our theater HIS, and it works like a charm. It does not yet talk to our theater RIS [Medweb] from a report standpoint, nor does it display images. I personally feel (along with others) that ICDB could join these two systems overnight. In theory—although we have tested with some success in isolation—ICDB could be the thin [or thick, with eventual order entry] client that providers go to for all HIS and RIS; but also the actual images, to include CT data—DICOM or mp4. Basically a provider anywhere in theater or CONUS can access any patient data and images; no matter where they were obtained, with one sign on.

Perhaps one of my greatest achievements while at modernization doing telehealth was hiring my boss while at the Pentagon [after he worked for me for a month, I decided he would make a great boss], worked my way down the political ladder to a position that did not even exist [AF telehealth lead], created a PAS code for it [so it existed], got an offer to teach at my current university [USU], hired my replacement [a psychiatrist], and got myself fired to take my new job. Dr. Tim Lacy [now the AF telehealth lead with an awesome team I am told that I helped create] must have read those 47 after-action/continuity binders because he got smarter on the topic and achieved more than I ever did [but I did hire him!].

My other major achievement while working for the Air Force surgeon general for modernization was developing a process to compress a gigabyte of CT data—chest, abdomen and pelvis, for example—to about 5 megabytes. We are now studying the quality degradation of 250:1 compression ratios from a trauma perspective at Walter Reed Army Medical Center as of this month. We—myself and the AF—currently have the patent pending on what I named DICOM2mp4 on the process of taking individual CT slices and creating a highly compressed mp4 movie—similar to mp3 music files.
 
Although there is some loss of quality, our hypothesis is that getting more studies quicker to experts and in-transit hospitals is worth it. We can still see the significant effects of trauma, even with the compression. My basic PACS TR [TeleRadiology] premise is acquire and interpret thin—high resolution, raw data, DICOM thin slice—archive and TR thick—compressed, save space for archived, with raw data relevant select images. I personally don’t want to see every renal angiomyolipoma or 3 mm lung nodule.

Now that the deployed bases [Army, Navy, Air Force] are loaded [with equipment] These joint foundations are leading us to the grand slam of deployed radiology. Only then will our final objective be achieved, and the words “telemedicine” and “teleradiology” go away, since it will be our everyday medical standard.

Richardson: I think that, despite the networking and bandwidth constraints addressed above, the deployment and use of teleradiology within the theater of operations has been widespread and generally quite successful. In fact, many in the Army radiology community object to the term “teleradiology” in the current operational context. What we’ve really done is apply current radiology business processes and practices to the deployed environment, so the “tele” piece is really an artificial distinction. All of the Level 3 medical treatment facilities in theater now have deployable teleradiology systems (DTRS) to support intra- and inter-facility distribution and viewing of images. All of the sites are generally able to provide echeloned support within theater and have “reach-back” capability to supporting hospitals in Europe and CONUS. This is not to say that the process is “easy or seamless.” A number of workarounds have evolved to deal with the network, bandwidth, and systems issues and the solution is far from perfect, but the capability is there. A number of different workgroups across the MHS are attacking the networking and bandwidth issues, and I think we’re really starting to see some headway toward resolution of those issues. We also work closely with all of the stakeholders to continually make incremental clinical enhancements to the DTRS system and to improve its interoperability with other systems and devices. In summary, “teleradiology” is in daily use, moving hundreds of exams in support of clinical operations. It could be better, but overall I’d call it a success.

Q: What do you see as the future of deployed teleradiology and are the technologies available today to get there?

Richardson: Radiology is fully embedded in theater clinical practice today. I think that the enabling technologies are available and in place now. The objective system will require full integration with all of the diagnostic imaging modalities, the Theater Medical Information System (TMIP), the Joint Patient Tracking Application (JPTA), and whatever other clinical information systems may be deployed in the future. I believe the bandwidth and network issues we have today can be addressed and resolved. Interestingly, the limiting factor may not be the technology at all, but rather related policy, doctrine and sustainment issues. So, while we have the technology in place today, there is no overarching policy which requires its use or, for instance, clearly articulates what should be archived, where, and for how long. Until teleradiology is fully integrated into doctrine and the clinical business practice in theater, we will likely have associated integration, support and training issues. The fact that “teleradiology” is not “doctrine” is almost certainly at the core of the dedicated bandwidth issue as those requirements are based on doctrinal systems and practices. All those issues aside, I think the future of deployed teleradiology is solid and it will be an enduring aspect of battlefield healthcare for all future operations.

Lacy: Teleradiology will be a part of military medicine for the foreseeable future. The technology is here today. We currently use equipment and the teleradiology system made by Medweb. This technology allows for compression and transmission of studies within the AOR and from the AOR to garrison. The primary limitations, as I mentioned earlier, are a lack of standards and bandwidth.

But the prefix “tele” will soon be a thing of the past. What we are trying to create is an extended Radiology Network that will connect all of our facilities in a seamless fashion. This is the future vision and the Air Force is currently trying to develop this technology. We are in the process of developing a service-oriented architecture that will allow us to “plug in” other applications and distribute workload throughout the enterprise. The other services are watching what we are doing, and if we are successful, our technology would be available for use by any service no matter which companies products they use. It will be “vendor neutral.” Radiology is radiology no matter where the images originate or are interpreted. What we hope to achieve is the rapid movement of medical information, whether it is verbal, textual or visual.

Sears: I believe the future for the word “teleradiology” is retirement. Once the network functionality and bandwidth availability problems are overcome, the practice of radiology across the world will be no different that the one within a medical facility. The images will be acquired and then transmitted to a viewing station where a radiologist will interpret them and pass the critical information to the physician and surgeons caring for the patient. Whether that radiologist is in the same building or even on the same continent as the patient will be immaterial; and thus it will just be called “radiology” again. This will never obviate the need for radiologists within deployed medical facilities as some procedure and studies must be physically performed by them, and there is little room for network failures or computer failures in the provision of trauma health care. The number of deployed radiologists may be decreased in the future while the availability of services including sub-specialty consultation will increase, and the stress level and working environment for those deployed radiologists will be markedly improved.

As many of my peers are quick to point out, there are commercial companies who can move medical imaging studies even bigger than the ones currently being produced in our deployed medical facilities halfway around the world to a radiologist and render an interpretation in less than an hour with availability that approaches 99 percent. The technology is already there. The difference between these commercial companies and the military services is environment of practice. While those commercial groups provide service from and to locations with reliable and frequently dedicated network bandwidth, our deployed medical units most often do not. Many groups within the military health care system are currently working to facilitate this flow of digital medical information in the form of images and the electronic medical record from the battlefield all the way to the Veterans Administration facilities. A continued joint approach to the solutions is critical to our success.

When I deployed with a Marine helicopter squadron in 1996, e-mail was newly available in the deployed environment. Just 10 years later, a sailor on an aircraft carrier in the middle of the Indian Ocean can send streaming video to his significant other in Oklahoma without it seeming out of the ordinary. In 10 more years, because of the efforts of many people, I believe that the practice of “radiology” in the military system will truly be a global one.

Folio: In my experience and opinion, the future should bring improved business processes, dynamic workload allocation and one common system that everyone will know and share into. All patients coming back from the theater will have all previous images from all hospitals encountered downrange. Ideally, dedicated medical IT infrastructure would provide us more control and less cross-line issues with the warfighting commanders. We fully understand that they need their satellite situational awareness to most effectively achieve their objectives.

Much of the technology is here today, however, we need to apply these and continue to leverage our corporate partners. Work-arounds, interim solutions and home grown successes such as JPTA and ICDB, may be our final destination since they are scalable.
 
Also, I am part of some patent applications and patents pending of emerging revolutionary remote diagnostics that will greatly assist the deployed radiologists and deployed areas without radiologists. Keep in mind that teleradiology, for example, is not to replace a radiologist; rather, act as a force multiplier to assist the deployed radiologist [and perhaps minimize the need for several, or at least centralize them] and those without locally. ♦

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