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An Overview of Telemedicine

Abstract
An overview of the current telemedicine program utilized by the United States Army will show many resulting benefits for all individuals using this concept. The civil healthcare system has adopted telemedicine and its benefits. The most widely debated topics of telemedicine today include “teleconsults versus in clinical diagnoses”, and supporting the conclusion, that telemedicine is comparable to clinical diagnoses in benefits.

Advancement of Medicine through Technology.
A Review of Telemedicine

It was a hot musky evening in southern Tikrit, Iraq. The convoy’s mission was supposed to be a short and simple drive through one of the hottest spots in Samara. After the convoy received small arms fire and came under attack from an improvised explosive (IED), which peppered the side of our vehicle with shrapnel we knew it would be anything short of simple. I just walked into the door of my Aid Station I established in the rubble of one of Saddam’s buildings when one of my buddies walked in. I was having a hard time hearing him as my ears where still ringing from the earlier explosion, but I sat him down and asked what was wrong. He told me he had developed a warty looking papule on the tip of his nose and was concerned about it. I suppressed my irritation at his ignorance of the day’s previous events from our convoy. He was complaining about having a wart on his nose. As a professional medic I looked at his aliment. He indeed had what appeared to be a wart on the right side of his nose.
I am a Combat Medic. I specialize in trauma cases, however, I know that I am no means qualified to diagnose or treat uncommon skin infections. This particular soldier would have to go to the nearest Combat Support Hospital (CSH). To get him there, however, would be a problem. There is the notion that nobody ever dies of dermatological cases. I knew the commander would laugh at me if I tried to put together a convoy to drive back through the dangerous roads of the city to get this soldier to the CSH. There would be no way I could convince Dust-Off (aero-medical evacuation) to pick this soldier up. The next convoy he could transport with would not be available out for about a week and a half. After I pondered what to do, I remembered one of my doctors telling me he had sent information via the Internet about a Leishmaniasis case he was working on to get a specialist opinion. I then took pictures of the patient and sent it out via email to a Dermatologist virtual hot line. This is a real-life example of the increasing use of telemedicine.
Medical consults via the Internet is not new at all. They fall under the general category of “Telemedicine” since the 90’s in both the military and civilian settings. Telemedicine is defined (McConnochie, 2006) as, “the use of medical information exchanged from one site to another via electronic communications for the health and education of the patient or healthcare provider and for the purpose of improving patient care” (e.58). Both the military and civilian sectors have benefited from telemedicine. Despite some concerns for patient privacy and different opinions of levels of quality of care, telemedicine has continued to thrive. One might be surprised to learn just how affective telemedicine is.
As outlined by Poropatich, De Treville, Lappan, and Barrigan in 2006 the United States (U.S.) Army first implemented telemedicine in 1992 throughout a deployment to Somalia by deploying a laptop computer, satellite technology and a handful of digital cameras, which deployed providers could consult non-deployed medical specialists. Since then the Army Medical Department (AMEDD) has continued to deploy its telemedicine program everywhere the U.S. Army has deployed. The program was deployed “in Croatia (1994), Haiti (1995), Bosnia (1995), Kosovo (1996), Kenya (1998), Afghanistan (2002), Kuwait (2004) and Iraq (2004).” In 1994, the AMEDD officially stood up an official office responsible for the “vision, research and development, and deployment capabilities of telemedicine.” This office’s official name is “Telemedicine and Advanced Technology Research Center (TATRC),” and is based out of Fort Detrick, Maryland. Since its establishment, the TATRC has provided deployed soldiers access to top medical specialty consults and cares, without which healing would not otherwise be possible (p.3).
As discussed (Poropatich, et al, 2006), research on the service TATRC provides, shows countless “unnecessary medical evacuations” where ultimately avoided, which resulted in saving of valuable resources, money, and time (p.3). The AMEDD organization is staffed by “77,000 soldiers and 28,000 civilians” and provides medical care for well over “5 million service members, retirees, and their family members” (p.2).
Even with this staff size, the AMEDD is stretched thin when it comes to providing specialty care. As outlined in the OTSG/MEDCOM policy memo 07-XXX (2007) the AMEDD is able of provide deployed medical providers access to specialty care in the subsequent twelve areas through telemedicine: dermatology, infectious disease, ophthalmology, burn-trauma, rheumatology, nephrology, cardiology, toxicology, internal medicine, neurology, preventive medicine and pediatric intensive care (p.8). By having access to this care, the report (Poropatich, et al, 2006) validated, as of February 2006, the teledermatalogy cases reviewed by the program had prevented over “50 unnecessary aero-medical evacuations [in Iraq, Kuwait and Afghanistan]” saved the military “potentially $1.0 million.” In addition, there where “seven documented cases” where, due to the teledermatalogy consults, soldiers which would have otherwise been misdiagnosed where “evacuated” to receive necessary treatment. The report goes on to state “since 2002 [through 2006]” the Tele-cardiology program based out of Brook Army Medical Center (BAMC) in San Antonio, Texas has “saved over $2.5 million” by providing “tele-cardiac echocardiography to outlying Army clinics” (p.4). Not only does the program save time and resources, but also it provides a shorter wait time for the same specialty service. Often a patient may have to wait days or even months before seeing specialty care provider in a clinical environment. However, as indicated by OTSG/MEDCOM policy memo 07-XXX (2007), by utilizing telemedicine the wait time for feedback “averages four hours” to a maximum of “24 hours” (p.5). One of telemedicine’s greatest benefits to the military is the ability to span the distance between patients deployed and healthcare providers.
To bridge this gap between patients and providers not only benefits the military but also patients in the civilian sector. In fact, from 1995 to June 2003, Congress authorized funds for over 500 telemedicine programs in civilian rural areas, which equaled $173 million (Hearing before the Committee on Agriculture House of Representatives 108th Congress, 1st session. 2003). Through telemedicine programs these rural areas have had access to “high quality health care services” which otherwise would not have been possible (p.2). In this hearing made to Congress, Thomas C. Dorr, the Under Secretary of Rural Development, went on to say, “[the] Telemedicine projects are providing new and improved health care services. They run the gamut from enhanced access to more sophisticated patient diagnostic and surgical procedures, to improved postoperative treatment. New advancements are being made in the telepharmaceutical and telepsychiatric arenas by providing health care options never before available to many medically underserved, remote, and rural areas” (p.4).
Telemedicine reaches far beyond just the rural areas of America. By providing continuous monitoring (Goldstien, 2000) of critically ill patients through telephone services and Internet services, civilian telemedicine services save an “average of $7.83 per patient for every dollar spent”. It also “resulted in 52% fewer urgent physician visits, 67% decrease in emergency room visits, and 36% reduction of health care costs (p.193). With further developments like the RTX3370 device created by the Swiss Centre for Telemedicine, physicians can monitor critically ill patients in the comfort of the patients home (Coverty, 2007, para 1). In 2001 86% of Internet users consulted telemedicine programs. Overall 37% of all Internet usage in 2005 was related to health information (Harrison, Lee, 2006, sect, 1).
One of the biggest benefits is the time in which patients can receive feedback. The average wait time to see a specialist can be a month, with only seeing the doctor for an average of ten minutes. However, with telemedicine the feedback can be instantaneous. With all of the benefits and usage of telemedicine there still is a concern for patient privacy and quality of care (Harrison, Lee, 2006, sect, 4).
The implementation of strict protocols and security measures can help protect patient privacy; the issue of quality of care in telemedicine is still an emergent concern. Because the Internet is not controlled by any organization, there is an equal or greater amount of fraudulent information as there is factual content. Deceptive information on the Internet may not have catastrophic results when one downloads a recipe, however faulty medical diagnosis from uncertified Internet sites can ultimately result in death. Which is why it cannot be stressed enough that telemedicine should only be used by trained medical providers, or under the guidance of said trained medical providers. It is argued that telemedicine could never compare to the accuracy in diagnosis versus in clinic visits. However, recent studies have produced unexpected evidence contradictory to this opinion.
In 2006, McConnochie published his findings (McConnochie, Conners, Brayer, Goepp, Herendeen, Woods, et al. 2006) on a study of telemedicine and acute childhood illness. The findings stated roughly, “85% of illness visits presented to primary care pediatric practices could be completed by means of telemedicine and simple office laboratory tests and albuterol administration.” The results reflect in the conclusion in a study taken of “492 cases (253 clinic visits, and 239 telemedicine consults)” showed the difference in “completion of treatment” between telemedicine (76.7%) and clinic visits (76.0%) was only 0.7% (sect, 3) in favor of telemedicine. A later study on teledermatalogy (Pak, Triplett, Lindquist, Grambow, and Whited, 2007) showed that out of 698 subjects (351 teledermatalogy, 347 clinical care) there was an “agreement rate of 96%” between the teledermatalogy consults and clinic visits (p.28-29).
Two days after I sent out the pictures of my patient’s nose, I received several emails from three Dermatologists in reference his case. They asked that I get some information from the soldier about possible previous outbreaks, and if he had any family history of tumors. After I emailed them the information the soldier provided me, I received almost instantaneous feedback; and was given guidance to send the soldier out to the CSH for a specific set of medical tests as soon as possible. I got him to the CSH the next day, and the tests showed the “wart” was not just an ordinary dermatology case, but a genetic disorder called Muir-Torre syndrome. Muir-Torre syndrome is an inherited “cancer syndrome” which consists of at least one “tumor” and a minimum of one internal “malignancy” (Horenstein, 2005). If it had not been for telemedicine, I would have told the soldier if his condition did not get worse, he would have to wait it out until we returned from the deployment. Luckily, with the consults I was able to coordinate for the soldier to fly back to Landstuhl, Germany to receive necessary medical treatment. He returned to duty a few short months later. I still hate to think of what could have gone wrong if he had waited till we returned to get his conditioned cared for. Thanks to telemedicine, even in a hot, dust, violent place like Iraq, soldiers are able to receive expert medical diagnosis from medical specialist within hours. This was just one case where technology’s influence on medicine is helping provide better health care.