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The UK Defence Medical Services (DMS) deliver healthcare in the firm base, on exercise and on deployed operations, often in geographically remote locations. The military management of clinical uncertainty and informed clinical decision-making in the UK and overseas could be enhanced by better exploitation of contemporary telemedical technologies. Enhanced DMS health informatics could help mitigate the clinical risks associated with professional isolation, improve measurable positive patient outcomes and better inform the Chain of Command at tactical, operational and strategic levels.
The WHO defines telemedicine as:
‘the delivery of health care services, where distance is a critical factor, by all health care professionals using information and communication technologies for the exchange of valid information for diagnosis, treatment and prevention of disease and injuries, research and evaluation, and for the continuing education of health care providers, all in the interests of advancing the health of individuals and their communities’.1 From the first programme linking Norfolk State Hospital to the University of Nebraska School of Medicine,2 to early trials in deserts,3 Antarctica4 and space,5 telemedicine requires strategic investment. Bandwidth restrictions constrained early systems to asynchronous communication, where data were captured, stored and forwarded for interpretation at a different time. The internet now allows email, Voice over Internet Protocols (VoIP), cloud-based virtual offices, teleconsultations and teleconferences. With concurrent advances in imagery, biosensors, telemetry and diagnostic applications, healthcare in remote locations has never been so accessible.
This editorial explores some of the past and present uses of civilian and military telemedicine, and considers the potential future utility of an enhanced DMS telemedicine capability in support of the UK armed forces.
In low/middle-income countries, the adoption of telemedicine continues to be constrained by a lack of money, infrastructure and technical expertise.1 In developed countries, the principal barriers to telemedicine have been concerns about patient privacy and confidentiality. Today, however, the vast majority of telemedicine programmes comply with the US Health Insurance Portability and Accountability Act confirming that their security standards appropriately protect personal and organisational health data. In 2009, a survey of 114 countries showed 30% had a national telemedicine agency and 50% of the rest were establishing a telemedicine capability.1 The World Organisation of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians,6 the UK Royal College of General Practitioners,7 the Royal Australian College of General Practitioners8 and the Medical Council of New Zealand9 all acknowledge the telemedicine utility of open-source platforms such as Skype, Cisco Jabber and Google Hangout.
Within the UK, the National Health Service (NHS) ‘Digital First’ programme10 has identified ways in which telemedicine can reduce costs and unnecessary or missed face-to-face appointments. These include: on-line appointment booking and reminders; primary care triage; remotely delivered secondary care reviews and preoperative assessments and digital test results. Nevertheless, some clinicians and patients have reservations about the impact upon the doctor–patient relationship by the loss of ‘traditional’ face-to-face consultations. An early systematic review showed high levels of patient satisfaction,11 but a recent Cochrane review of 93 trials concluded the evidence on acceptability to patients and health professionals remained unclear.12 The Cochrane review indicated that telemedicine has similar or better health outcomes when compared with traditional consultations though.12 The ‘Whole Systems Demonstrator Programme’, a large-scale telemedicine trial in England, reduced emergency admissions by 20%, Accident and Emergency attendances by 15% and some chronic disease mortality by 45%.13 Telemedicine has also enabled remote specialist psychiatric evaluations and risk assessments; improved mental healthcare outcomes in primary care settings, especially when patients have co-morbid medical conditions; contributed to effective treatment for depression and anxiety disorders (especially cognitive behavioural therapy) and improved compliance and medication adherence.14
The four UK Departments of Health now consider telemedicine to be a vital capability in the move towards enhancing home-based care, and over 100 telemedicine pilots are underway across the UK.15–17 The NHS no longer regards telemedicine as a distinct capability, rather part of the inevitable technological advancement necessary to support contemporary healthcare provision. Such innovations may have utility for DMS patients in the firm base, and for those ‘Sick at Home’ distant from a military medical facility.
The US military medical services have proactively adopted telemedicine in both the firm base and on deployed operations. The US Army's Medical Department Telehealth Network (MDTN) is the world's most developed telemedicine capability. Developed in 1992, it now spans over 50 countries and supports mental health services (55% of its total usage), cardiology, dermatology, infectious diseases, neurosurgery, pain management and orthopaedic surgery.18 Operationally, the US military uses an ‘echelon of care’ system to evacuate trauma casualties from the point of wounding back to the US hospital system. Telemedicine is used as a key enabler at every stage of this pathway, seamlessly transmitting medical data, including radiographic imagery, from one echelon to the next or directly to the final receiving hospital.18 The US Department of Veterans' Health Affairs (VHA) has also significantly expanded its use of telemedicine. Drawing on 44 clinical specialties to enhance the quality of healthcare delivery to over 23 million US military Veterans while concurrently reducing costs, VHA is now the largest global provider of telemedicine.19
The scope of telemedicine in the UK armed forces has evolved in an ad hoc way to satisfy obligated supervision requirements20 rather than forming part of an innovative, coordinated information exploitation system that enhances clinicians' performance and improves patient care. In 1998, the DMS' first telemedicine capability linked the military hospital in Sipovo, Bosnia with the Royal Hospital Haslar, Portsmouth. Over an 11-month period, 60 referrals were made using a digital camera, computer, email and telephone line. Patient care significantly improved in one third of cases.21 Similar links were then established with the Royal Naval Hospital in Gibraltar, Princess Mary's Hospital in Cyprus, Port Stanley Hospital in the Falkland Islands, South Georgia, Belize, Kosovo, Macedonia and Sierra Leone. Forward teleradiology, including CT scanning, was enabled in Iraq and Afghanistan but there has been little UK military telemedicine enhancement at the strategic level since the early 2000s. Development of a more sophisticated DMS telemedicine capability has been constrained by a lack of defined standards for deployed medical communications and limited access to robust, secure global health informatics platforms. Indeed, UK expeditionary telemedicine has often had to rely upon host nations' communication infrastructure.
The next steps?
The DMS is yet to fully exploit telemedicine. As we reset to contingency, more innovative military telemedicine may have utility within DMS primary and secondary care in the firm base, on exercise, on deployed operations and in contingent response to humanitarian crises and natural catastrophes. Ensuring adequate communications and the early deployment of suitable technologies enhance the speed and quality of deployed medical care.22 Such a capability would allow the provision of more relevant, timely advice to isolated patients, medical assistants afloat, ‘patrol medics’, clinicians and commanders. It could also support military medical staffs' supervision, educational and developmental activities while away from the firm base.
As demonstrated by US forces in Iraq and Afghanistan, satellite systems with low bandwidth requirements (9.6–464 kbit/s) can facilitate voice transmission, data and video teleconferencing even in austere environments with limited host nation infrastructure. The UK Skynet satellite system, an Astrium-Ministry of Defence Private Finance Initiative, already carries this capability. Unlike commercial platforms (including Skype, Cisco Jabber and Google Hangout), the current DMS health informatics platform cannot reliably support the VoIP modalities necessary for voice and video interactions. To address this capability gap, Programme CORTISONE23 articulates the need for the next DMS health informatics platform to include a synchronous telemedicine capability supporting videoconferencing. Strategic allocation of UK military bandwidth and satellite technologies could also enable seamless clinical data transmission and receipt. Military clinical information, including patient records, could be made available in real time, aiding informed clinical decision-taking in the maritime, land and air environments. As ‘the internet of everything’ and ‘cloud computing’ are already established within the psyche of the UK military and civilian communities, global coverage could be achieved through confidential, yet patient-friendly cloud-based solutions.
Future DMS health informatics platforms could also usefully exploit biosensors, wearable patient monitoring and near-patient testing. Organisationally, clinical interpretation of the recorded data could be assisted by subject matter experts at remote ‘safe’ locations. Such advice may enhance clinical effect, force enable and force multiply. Following the US military's proof of principle, telemedicine could enable the DMS to adopt: remote consulting by primary and secondary care doctors, nurses and allied health professionals informed by sensor-collected biometric data and decision-support software; enhanced medicines management in response to automated prescribing trend analysis; dermatological image sharing; teleradiology; cardiological telemetry; imagery-assisted surgery and real-time monitoring and tracking of casualties on the battlefield and throughout their onward care pathways.18 At the tactical level, smart stethoscopes, ophthalmoscopes, otoscopes and dermatoscopes could be used to seamlessly and securely transmit audio–visual outputs directly to a patient's medical records, or transmit data to a specialist for near real-time interpretation and expert management advice.
Like the NHS and the US military, as it takes the next step forward in enhancing its health informatics capability, the DMS could embrace telemedicine as a necessary technological advancement in support of contemporary healthcare delivery afloat, in the firm base and overseas and in the air. Telemedicine is reliable, non-detrimental and key to the move towards home-based care. It supports enhanced diagnosis-making and enables more informed clinical decision-taking especially in remote locations. Personal and organisational health data can be appropriately protected. The US Army's MDTN is the world's most developed telemedicine capability and the VHA is the largest global provider of telemedicine. Through innovative approaches within Programme CORTISONE, further research and robust evaluation, UK military patients, staff and commanders could all benefit from a DMS telemedicine upgrade.
Contributors All parties were involved in producing this editorial. RDJW has overall responsibility for content.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.