Teleradiology is the new Army medical mule.
by Douglas Page © 2003
On a cold March morning in 2002 images of a U.S. soldier stationed in Bosnia diagnosed with a brain tumor were viewed first
by physicians at Landstuhl Regional Medical Center in Germany. Later that day a team of specialists at Walter Reed Army Medical
Center in Washington DC reviewed copies of the same images, then consulted with the Landstuhl doctors on the best treatment
plan for the patient, who was immediately medically evacuated to Walter Reed.
The images were bounced from Bosnia to Landstuhl to Walter Reed through the pipes of the military’s Deployable Radiology
(DepRad) system, a teleradiology network designed by the Imaging Science and Information Systems Center in Georgetown University
Medical Center’s radiology department. The service, originally intended to support U.S. troops stationed in Bosnia-Herzegovina,
was recently expanded to cover Camp Doha-Kuwait, since no radiologists are stationed there.
DepRad is part of an ambitious military medical mission of providing a world-wide, world-class, and occasionally portable,
HMO for 6.2 million troops, dependents, and retirees in both war and peace - a goal that costs some $20 billion a year (not
counting the $25 billion Veterans Affairs budget) and that increasingly depends on teleradiology for success.
"In support of this mission, the military has taken an aggressive approach toward digital radiology, which is a basic business
process decision that must be made by any medical
organization before any serious teleradiology effort can be undertaken," said Gary R. Gilbert, Ph.D., Chief Knowledge Engineering
Group, Telemedicine and Advanced Technology Research Center (TATRC), United States Army Medical Research and Materiel Command,
Fort Detrick, MD.
Army hospitals and clinics around the world are being equipped with computed radiography and networked PACS systems that
in many cases reach into forward deployed combat support hospitals and surgical treatment facilities in Afghanistan, Kuwait,
Iraq, Bosnia, Kosovo, and the Sinai.
The Army is now about 70% digital in its radiology environments, with the strategic intent to transition to completely
digital workflows and business practices by the end of 2006 or 2007.
"In the Pacific Regional Medical Command, we routinely interpret radiographs that are digitally acquired and electronically
sent to us at Tripler Army Medical Center, Honolulu, Hawaii, from Camp Zama, Japan," said COL James Breitweser, MD, Office
of the Surgeon General Radiology Consultant, and Chief of Tripler's department of radiology.
Another example is the Great Plains Regional Medical Command in Texas, where teleradiology is used to provide off-hour,
on-call, and consultative interpretation of studies obtained outside of Brooke Army Medical Center, Fort Sam Houston, Texas.
Staffing du Jour
The military sees teleradiology as the solution to the companion problems of a rapidly declining roster of military radiologists
and workloads that continue to increase from new modalities that produce far greater numbers of images.
"The Air Force had 147 radiologists in 1999, and expects to have as few as 48 by 2004," LTC Edward Callaway, MD, a radiologist
at Travis AFB, Calif., said last November at the Radiological Society of North American meeting.
While the military grooms residency programs in an attempt to attract new radiologists, military hospitals are forced to
shift workload offsite to compensate for the shortage of radiologists. Teleradiology is the mule.
"Due to dynamically changing staffing and clinical business practices, flexibility must be built into the technology solution
to provide the capability to modify workload transfer locations to fit the staffing du jour," said Robert E. de Treville,
Program Manager and Designated Approval Authority for Army DIN-PACS, Fort Detrick, Maryland.
In some forward locations several elements of the Army Medical Research and Material Command have deployed telemedicine
services that enables both local and remote storage and access of images.
Using software incorporated in radiology servers, Army medical commanders are now able to cross-level radiology workload
among many Army medical treatment facilities, including those forward deployed.
"Army radiologists located in a combat support hospital in Bagram, Afghanistan, not only send radiology studies to Landstuhl
or Walter Reed, but they can also be assigned studies from an Army hospital back home to read when their own workload is low,"
During February 2003 alone there were more than 1350 radiology studies containing over 15,300 images transmitted among
Landstuhl's teleradiology network for interpretation and/or
"Two hundred ninety two of those studies containing 5525 images were actually sent forward from clinics in Germany for
interpretation by Army radiologists in a forward deployed medical facility in Kosovo," Gilbert said. That represents workload
performed by a forward Army asset which would otherwise have had to be performed by an already overloaded Army radiologist
Outsourcing is In
When teleradiology-enabled workload leveling schemes fail to keep pace with demand for radiology services, the military
is finding it’s only remaining solution is to enlist the aid of the civilian sector through outsourcing. A new trend
is emerging where more and more examinations are being offloaded via teleradiology to civilian radiology groups for interpretation
and reporting - a practice fraught with security issues.
"Ensuring secure, encrypted communications between the government and these outsourced commercial providers is
critical, as is making sure that reports are entered back into the government's hospital information system, the Composite
Healthcare System (CHCS)," said de Treville.
An even more radical alternative to outsourcing military images to civilian radiologists is the new practice of insourcing
civilian radiologists to the military.
Fort Lauderdale-based Interim Physicians, a temp placement agency specializing in doctors, has begun staffing physicians
in the military on a temporary basis.
As of April, 2003, Interim had placed about 11 physicians with the military, including one radiologist at Fort Polk, La.,
and was attempting to place another radiologist at Maguire Air Force Base, New Jersey.
It’s About Time
Whether the images are read by military or civilian radiologists, implementing a digital radiology service model that teleradiologically
connects military installations allover the globe has dramatically improved the standard of care for patients by providing
overnight interpretation of images by radiologists at teleradiology hub facilities.
In Europe and Korea, there are over 30 remote military clinics too small to justify their own radiologists, that are nevertheless
responsible for providing healthcare to those soldiers stationed there. In the old film-based environment, imaging studies
acquired in these outlying clinics would be sent by courier to supporting military medical centers for interpretation, a process
that could take 21 days or more for reports to be returned.
In some cases, soldiers would be reassigned before their results came back. The films themselves frequently went AWOL.
Reports are now often returned within 24 hours, especially with the increased use of voice recognition dictation by radiologists,
de Treville said.
Teleradiology hub sites permanently archive images on their PACS so they are protected and available for future reference.
Firewalls in place at all locations protect medical devices, data, and networks from unauthorized access.
Bringing Good Things to Strife
All Army PACS vendors currently support teleradiology links between treatment facilities: IBM and GE in the Great Plains
Regional Medical Command; Agfa in the North Atlantic Regional Medical Command; GE and Medweb in the Southeast Regional Medical
Command; Siemens and Medweb in the European Regional Medical Command; GE and Medweb in the 18th Medical Command (Korea); and
GE in the Western Regional Medical Command.
Additionally, Medweb is being deployed to all of regional medical centers to support deployed units.
TATRC has worked closely with the Air Force Medical Evaluation Support Activity, also located at Fort Detrick, to test
and field new lightweight digital radiology and teleradiology systems designed to push digital medicine even farther forward
on the battlefield.
Just before Operation Iraqi Freedom, one of the 82nd Airborne Division's maneuver brigade medical companies was equipped
with a lightweight, "ruggedized" direct digital radiology system composed of a MinXray Model HF100H portable
medical x-ray unit and a newly FDA approved Varian Pax Scan 4030
Amorphous Silicon Digital X-Ray Detector that operates via a laptop computer, Gilbert said.
The brigade surgeon took the system to Kuwait and on into Iraq where it is still in use.
"As far as we know this is the first war-time use of direct digital radiology by a combat unit anywhere in the world,"