"A Proposed MultiNational TeleConsultation Program A U'S' Army

1
"A Proposed Multi-National Tele-Consultation
Program - A U.S. Army NATO Cooperative
Endeavor"
COL Ron Poropatich, MD U.S. Army Surgeon General
Medical Informatics Consultant Deputy Director,
TATRC US Army Medical Research Materiel
Command Fort Detrick, MD
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Topics

• U. S. Army Tele-Consultation System for Deployed
  Forces
• USA/NATO TMED MOU in Afghanistan
• USA/Kosovo collaborations
• Conclusions

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Acknowledgements

• Chuck Lappan, Ret/USA - GPRMC
• David Lam, MD Ret/USA - TATRC
• Cynthia Barrigan, RN/MS - TATRC
• LTC Hon Pak - TATRC
• Dedicated Military Medical Personnel who support
  the consult support service on a daily and
  sustained basis

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Topics

• U. S. Army Tele-Consultation System for Deployed
  Forces
• USA/NATO TMED MOU in Afghanistan
• USA/Kosovo collaborations
• Conclusions

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Operational View OV-1

• Describe how the capability will be employed

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U.S. Army Teleconsultation program Background

• Email based system with JPEG image attachments
  no patient identifying information no patient
  privacy violations
• Utilizes theater providers personal digital
  camera routine Internet email access
• U.S. based medical specialists answer
  tele-consults 24x7
• Response time lt 5 hours (average for more than
  3000 consults)
• Strong favorable response from deployed providers

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Teleconsultation Program Business Practice
No
Consultant emails recommendation to the
deployed physician
Teleconsultation is routed to the appropriate spec
ialty group
Consultant retrieves and reviews teleconsultation
Copy furnished to specialty group confirms
teleconsultation is answered and enables
collaboration
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Locations Submitting Teleconsultations
Map as of 1 September 2007
http//www.cia.gov/cia/publications/factbook/refer
ence_maps/pdf/time_zones.pdf
Afghanistan
Italy - Sicily
Okinawa
Ecuador
US Australian Navy afloat
Egypt MFO Sinai
Pakistan
Belize
Kenya
Bosnia
Honduras
Kuwait
Philippines
Chad
Germany
Kyrgyzstan
Qatar
Continental US)
Hurricane Katrina
Turkey
Morocco
Iraq
Nepal
United Arab Emirates
Djibouti
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Current U.S. Army Tele-Consultation Clinical
Specialties in OIF/OEF
Burns-Trauma Cardiology Dermatology
Infectious Diseases Internal Medicine
Nephrology Neurology Occupational
Medicine Ophthalmology Pediatrics Preventive
Medicine Rheumatology Toxicology Urology Ortho
pedics
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Summary

• Program Summary
• 15 specialties with contact groups
  xxx.consult_at_us.army.mil
• 3,018 teleconsultations (April 2004 to September
  2007 42 months)
• 58 known evacuations prevented
• 97 known evacuations facilitated following
  consultants recommendation
• 904 different referring health
• care professionals
• 418 teleconsultations on
• non - US patients
• Average Reply Time

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U.S. Army Tele-Consultation Program Summary for
Deployed Forces April 2004 to
September2007
62 Dermatology 10 Infectious Diseases 5
Ophthalmology
By Specialty
66 Iraq 11 Afghanistan 6 Kuwait
By Location
53 Army 11 Marine Corps 8 Air Force 9
Non-Combatant
By Patient Branch
N 3018 consults
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Impact on Evacuations - Summary
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Teleconsultation Measures Of Effectiveness

• Relevant to deployed medical support
• Improved access to specialty care (demonstrated
  in all specialties)
• Avoided or facilitated medical evacuations due to
  second opinion consult
• Elevation of the quality of care by allowing
  rapid multi-specialty consultation (e.g.
  Infectious Disease Dermatology)
• Improved optimization of medical resources
  (consult management in theatre)

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Topics

• U. S. Army Tele-Consultation System for Deployed
  Forces
• USA/NATO TMED MOU in Afghanistan
• USA/Kosovo collaborations
• Conclusions

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US Army Medical Command Offer to NATO Forces

• Aim As a proof of concept, USA is offering this
  clinical capability at no charge to NATO/PfP
  forces deployed in Afghanistan.
• Objective A draft MOU/MOA Technical
  Arrangement has been developed and staffed
  nationally and within NATO. It is felt to be
  legally satisfactory.

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Afghanistan
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Draft Memorandum of Agreement Between U.S. Army
Medical Command NATO
 

• Draft Agreement considers
• Legal Issues (e.g. Liability/NATO SOFA/PFP SOFA)
• Patient Privacy/Security
• Finances
• Technical Arrangements
• Metrics for Demonstrating Effectiveness
• Clinical Supervision in Theatre
• Quality Assurance

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Draft Memorandum of Agreement Between U.S. Army
Medical Command NATO

• NATO participation is voluntary
• The U.S. will not charge for this support
• U.S. Army offer is for an interim basis (6-12
  months) and will assist NATO in establishing a
  NATO tele-consultation system, if desired
• NATO nations must provide computer/Internet
  access and digital cameras (which are commonly
  already in theater)

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Teleconsultation Metrics

• U.S. will maintain metrics on the NATO use of the
  system, which will allow regular reports to NATO
  on such items as
• Data usage on a monthly basis
• Number type of medical specialties consulted
• Response time for each consult
• Audit reports
• Individual case use analysis

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U.S. Army Responsibilities

• Permit access to the Teleconsultation System by
  NATO and PFP medical personnel deployed in
  Afghanistan
• Maintain a consultation management system which
  ensures that all teleconsultations are routed to
  an appropriate consultant, that a response is
  given in a timely manner (lt 8 hours) , and
  maintain appropriate metrics to document usage,
  successes, and problems
• Provide system description, instructions, and
  guidance on use of the system to NATO Medical
  Advisor, suitable for distribution to deployed
  NATO and PfP medical personnel

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NATO Responsibilities

• NATO Medical Advisor will
• Insure use of this system is incorporated into
  Operational Orders
• Publish and distribute the instructions and
  guidance provided by the U.S. Army to all
  deployed clinical providers in Afghanistan
• Insure that providers are trained in the use of
  the system

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U.S. Army MEDCOM/NATO MOU Status

• NATO approved in June 2007 the U.S. Army
  teleconsultation offer for NATO use in
  Afghanistan.
• US Army approval expected in September 2007
• NATO staffing to begin after US Army signature
  completed
• Deploy TMED system in FY08, Q2 to Afghanistan
  (tentative)
• Australia military in Afghanistan also interested
  in using the U.S. Army system

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Topics

• U. S. Army Tele-Consultation System for Deployed
  Forces
• USA/NATO TMED MOU in Afghanistan
• USA/Kosovo collaborations
• Conclusions

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U. S. Army Telemedicine Support to Kosovo
Kosovo Telemedicine Center in Pristina
Camp Bondsteel, U.S. Army
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Kosova Telemedicine Center (KTC)

• Inaugurated - December 2002 as an integral part
  of the University Clinical Center of Kosova
  (UCCK)
• Funded by the European Agency for Reconstruction
  - 1.5 million grant - Phase 1
• U.S. Department of State (Bureau of Educational
  and Cultural Affairs) provided (Oct. 2006) an
  850,000 grant to the Kosovo Foundation for
  Medical Development to further develop these
  programs (KTC as the major project partner)
  Phase 2
• KTC regularly provides on-line and VTC-based
  educational programs not only in Kosova, but
  throughout the Balkans, with recent effors in
  Albania and Macedonia
• KTC has an ongoing effort to further develop this
  capability throughout Kosovo involving
  development of 7 regional TMED centers - Phase 3

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MEMORANDUM OF UNDERSTANDINGBETWEENCAMP
BONDSTEEL FORWARD DEPLOYED CONTINGENCY MEDICAL
TREATMENT FACILITY(Task Force Medical Falcon
XIII, KFOR 8US ARMY ORGANIZATION)ANDTELEMEDICIN
E ASSOCIATION OF KOSOVO(Kosovo Telemedicine
Center)PRISTINA, KOSOVO
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U.S. Army MEDCOM MOU with KTCStatus

• MOU written being staffed with U. S. Army
  European Regional Medical Comand
• KTC requesting U.S. Army to augment their
  clinical needs via TMED
• Follow on planning scheduled - Balkans
  Telemedicine Conference in Tirana, Albania
  October 21-23, 2007

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Topics

• U. S. Army Tele-Consultation System for Deployed
  Forces
• USA/NATO TMED MOU in Afghanistan
• USA/Kosovo collaborations
• Conclusions

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Conclusions

• U.S. Army Medical Command has a long-standing
  history of supporting international TMED efforts
• Low cost simple TMED solutions are effective
• Military medical humanitarian support with TMED
  has demonstrated value
• NATO Balkans TMED involvement with the U. S.
  Army is increasing

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Back-up Slides
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NATO Telemedicine Capabilities

• Matrix developed assessing NATO TMED
  capabilities (approved March 2007)
• NATO nations invited to provide information
• 16 out of 26 nations responded
• Lithuania Belgium Romania
• Greece Finland France
• United Kingdom Netherlands Canada
• USA Italy Germany
• Czech Republic Spain Estonia
• Poland

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NATO Telemedicine CapabilitiesFindings

• A large percentage of the NATO Alliance nations
  have considered that telemedicine is now a vital
  part of the medical armamentarium, and have
  either fielded or are planning to field
  telemedicine capabilities to support their
  deployed troops
• A significant increase in fielded telemedicine
  systems demonstrated over the past several years.
• 5 nations felt that their national TMED
  capabilities could potentially be made available
  for NATO operations
• 2 nations reported negatively
• 9 did not feel able to comment on behalf of their
  nations

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NATO Telemedicine CapabilitiesFindings - 2

• Communications at role 1 are highly prevalent,
  with both voice and internet access being
  available in the majority of national systems.
  This would imply that telemedicine systems which
  are web-based can have a significant future
  impact and availability, even down to Role 1
  levels.
• Analysis shows a significant penetration, current
  and planned, of teleradiology, particularly at
  roles 2 and above.
• Most nations relying on Store and Forward
  technologies, rather than VTC for patient care.

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NATO Telemedicine CapabilitiesFindings - 3

• Most nations do not have any formal structure for
  their teleconsultation systems, nor any
  brokered or centralized TMED consult system in
  place (relying primarily on personal
  relationships with consultants in the home
  country to guide teleconsultation)
• Specialized Telemedicine (e.g. telepsychiatry,
  telemicrobiology, tele-medical maintenance,
  teledentistry, etc.) are still used only in a
  minority of reporting nations, but the technology
  to extend their use is now available if it is
  felt to fill a care gap
• Electronic health records (EHR) are now in use or
  planned in a minority of nations, and in a
  still-smaller group are such records
  interoperable with that nations civilian EHR

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NATO Telemedicine CapabilitiesRecommendations

• NATO COMEDS should recommend to the nations that
  Telemedicine capabilities be positively
  considered as a medical force extender and a
  positive asset to the quality of patient care,
  while assisting in reducing the size of the
  medical deployed footprint
• Planning for the use of Telemedicine capabilities
  needs to be included in all doctrinal medical
  planning documents
• Nations to be encouraged to ensure that their
  developmental and fielded telemedicine systems
  are in compliance with the interoperability
  requirements of STANAG 2517
• Availability of deployable telemedicine
  capabilities be included in future versions of
  the Defense Planning Questionnaire (DPQ) and
  incorporated into the Force Goals/Force Planning
  Process.