48-l Evolution of a Global Military and Civilian Telemedicine Network for the 21st Century: Near Future on Demand, Space Based Delivery of Multimedia Services John A. Evans, Special Advisor MILSATCOM Command and Control Systems Electronic SystemsCenter 50 Grifiss Street Hanscom AFB, MA 01731-1620, USA Frank Davidson, JD, DHL (Hon.), Co-Founder, Channel Tunnel Study Group Advisor, MIT Macro-Engineering ResearchGroup; Vice-Chancellor, The American Society for Macro-Engineering; and Member of the Board of Directors, The International Association of Macro-Engineering Societies Jay Sanders, MD, President American Telemedicine Association; and former Eminent Scholar of Telemedicine at the Medical College of Georgia; and founder and President of The Global Telemedicine Group Lieutenant General Thomas G. Mclnerney, USAF (Retired), President and CEO Business Executives for National Security; former Assistant Vice Chief of Staff of the US Air Force; and former Director of the NationaYDefense Performance Review William T. Brandon The MITRE Corporation Bedford, Massachusetts Abstract Lockard M. Row Advisor in Telemedicine The Medical Defense Performance Review Mont Vernon, New Hampshire (MDPR) was establishedin 1993 to help “reinvent” how health care is provided to the US military ser- vicemen and their dependents. One of the MDPR initiatives has been to rapidly insert video confer- encing, telemanagement and telemedicine tech- nologies to improve the quality and reduce the costs Paper presented at the AGARD AMP Symposium on “Aeromedical Support Issues in Contingency Operations”, held in Rotterdam, The Netherlands, 29 September - I October 1997, and published in CP-599. 48-2 of delivering that care from major and minor medi- adapt these kinds of networks to bring about cal treatment facilities, to wherever the need ex- healthier military and civilian communities. ists, e.g., to patient homes and to remote military communities. The technologies and the processes 19 Introduction now being reinvented have the potential to pro- vide excellent access to quality health care any- We are pleased to be here today at the Aerospace time, anywhere. Medical Panel Symposium. This paper updates our earlier work investigating the application of A major over arching issue is the need to facilitate video conferencing, telemanagementand telemedi- the evolution of high quality, financially self-sus- tine technologies to improve accessto health care, taining telemedical services. An earlier paper’ to improve the quality of care, and to reduce the provided an overview of the medical initiative of cost of health care in the military. We believe these the National Performance Review which stressed technologies have direct application to the prob- the initial testbed and initial interregional telem- lems that will be faced in the future to provide anagement deployment efforts. quality health care at reasonable, i.e., sustainable, cost. Secondly, this paper retrospectively synthe- This paper stressesthe more recent intraregional sizes critical success factors and projects future telemanagementand telemedicine efforts and syn- directions with the assistanceof the coauthors. thesizes key successfactors essential for evolving self-sustaining global telemanagement and tele- The opinions expressed are those of the authors medicine networks for the twenty-first century. and do not reflect the policy of the United States Finally, future directions are proposed which could Air Force. 48-3 20 Proiect Backpround Collaboration of the MDPR with the joint military and civilian community has been paramount U.S. Vice PresidentAl Gore establisheda National throughout the four years of the project. The Performance Review, the purpose of which is “to MDPR has been working with the Army Medical reinvent government*’both to improve government Advanced Technology Management Office , the services and to reduce the cost of providing these Naval Medical Information Center and the Office services2 Under the sponsorship of the National / of the Assistant Secretary of Defense for Health DefensePerformance Review, the Medical Defense Affairs to improve access to health care, to im- Performance Review was established under Lieu- prove the quality of health care, and to reduce the tenant General Thomas McInerney who brought cost of health care -goals that must be met in an in Brigadier General PeterHoffman to direct a two- environment of reduced resources in the military pronged effort. and civilian health care communities. Much of the current work being done by these and support- One prong of the effort was focused on develop- ing organizationswas presentedat the first National ing a medical provider workstation. This proto- Forum on Military Telemedicine in March of 199S4 type is being developed at Scott AFB, and is docu- and at the Telemedicine 2000 conference held in mented separately.3 June 1995.s An overview was presentedto a meet- ing of NATO Partnersfor Peacein September1995. The other prong of the effort was conceived as a And, more recently an overview was presented at joint civilian and military initiative with the Of- this summer’s Global Telemedicine and Federal fice of the Air Force Surgeon General as the ex- Technologies symposium at Williamsburg, VAn6 ecutive agent. This focused on a user-evaluated and user-guided, phased deployment of computer Because the ability to outsource military medical communication networks emphasizing group and services on a global basis has always been envi- desktop voice, data, image and video conferenc- sioned,718we have concurrentIy sought opportu- ing to support telemanagement and telemedicine. nities to work with best-of-breed military and ci- Concurrently, emphasis was given to inserting vilian leaders and facilities, ultimately contribut- high-value-added reengineered management and ing to healthier military and civilian communi- clinical processes based on collaborative experi- ties.9*10 For instance, from the beginning we ences with best-of-breed leaders of civilian tele- sought the guidance of and collaborated with best- medicine and newly-empowered military users of of-breed leaders in teIemedicine, such as Dr. Jay telemedicine. Sandersat the Medical School of Georgia, currently President of the American Telemedicine Associa- Thesebroad-based MDPR efforts recently received tion and coauthor of this paper. We collaborated the Vice President Gore Hammer Award for excel- with Jay at the First Congress of the Atlantic Rim lence in reengineering. This paper focuses on the in Boston, 1994.11.12,13This telemedicine pre- emergence of the network and its reengineered sentation and demonstration reported on the pio- managementand clinical processeswhich are cur- neering efforts of the US Army (Dr. Ed Gomez, rently being inserted and evolved worldwide. (See Walter Reed) and demonstrated a US Navy-devel- Figure 1, “MDPR Worldwide Operating Loca- oped, Joint Chiefs of Staff award-winning Multi- tions”) lingual Translator (Commander Lee Morin, Naval Medical Research Institute). 48-4 This collaborative activity has matured to the point between two or more locations. Most early suc- where joint presentations have been delivered at cessful systems were installed in government and Monaco, November 1995,t4315at the 100th Bos- large corporation conference facilities. The wid- ton Marathon, July 199616and at the Global Tele- ening acceptanceof this VTC technology has low- medicine and Federal Technologies Symposium at ered the cost of working and collaborating together Williamsburg, VA, July 1996.l7 Another milestone on common projects and issues from remote sites. was reached when a Collaborative Research and Development Agreement was struck between The fundamental components of video conferenc- Lahey Hitchcock Clinic and the Electronic Sys- ing systems are the basic video and audio capa- tems Center in July 1996.18 This agreement will bilities. Other audio-video capabilities are typi- enable the military medical regions within the US cally integrated into corporate VTC-equipped con- and Europe to import and leverage medical exper- ference rooms. These include graphic display sys- tise and reengineered clinical processes in ex- tems such as overheadviewgraphs and 35 mm slide change for providing Lahey with expertise in the projectors. Auxiliary video sources such as video deployment of global computer communication cassetterecorders and players as well as facsimile infrastructure. capabilities for the exchange of printed material are often also included. Thus, the MDPR initiative we focused on was in- tended: 1) to improve the medical management, Video conferencing technology is now being ex- acquisition, operational and support processes tended to the desktop in personal computer sys- within the Air Force medical community; 2) to tems. This has made the full range of capabilities promote collaboration among the other military found on personal computer systems (office auto- services, NATO, the United Nations, other coali- mation, engineering, computing, file transfer and tion partners, and the civilian health care commu- networking) inherent componentsof desktop video nities. This top-down and outreach approach has conferencing systems. Important among theseca- successfully extended the enabling technology pabilities is the ability to share computer applica- across regional medical organizations to evolve tions, allowing conference participants to work on incrementaIly to a true telemedicine system serv- a shared electronic copy of documents such as