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Basic Training

Basic Training

First, be very clear of one thing: This is not just another story about information technology. This is a about Lucyana Hayes. Lucyana Hayes is a petite 30-year-old Malaysian woman with a 2-year-old daughter and a husband in the US military. She has big brown eyes, a brilliant white smile, closely cropped sable hair. And breast cancer. It was discovered just after her daughter, Paula, was born, while Lucyana and her husband, Tim, were stationed on the tiny Pacific island of Guam, thousands of miles from nowhere.

It was a devastating diagnosis, but Lucyana's rough road was eased at least a little because her illness was discovered at a time when her local Army doctor was able to confer, via the internet, with cancer experts at Tripler Army Medical Center in Honolulu, some 3,500 miles away. Working together as they never had before, these physicians were able to agree quickly on a treatment for her that would maximize her quality of life with her family.

Had Lucyana been diagnosed just a year earlier, her treatment would have been very different. She would have been placed in the hands of a local, young military doctor fresh out of a residency program. Likely a surgeon or internist by training, he would not yet have developed any expertise in cancer specialties such as radiology or oncology. And unaware of any other options, he probably would have performed a radical mastectomy and then "mailed" his patient via a seven-hour air evacuation flight to Tripler or a larger stateside hospital to receive more specialized care.

Once there, Lucyana-uprooted from family and friends, scared and confused-would have had to start from scratch, be retested, rediagnosed and reevaluated by new doctors who would create a new treatment plan. The good news, of course, is that the arduous trip would have given Lucyana access to more advanced care. The bad news is that her treatment would have meant traveling far away from her home and family, spending many months puzzling through complicated cancer care with new doctors. It wasn't that the system was designed to be deliberately cruel; it's just that no one had thought of a better way to treat such patients.

No one, that is, until Dr. Brian Goldsmith arrived at Tripler in 1993. A radiation oncologist on active duty in the US Army, Goldsmith is the mastermind behind the Internet Tumor Board-a web-based telemedicine system that allows medical specialists to coordinate cancer care by sharing diagnoses, lab reports and X-rays via the internet. Simply put, the system is a lifeline for doctors and cancer patients stationed at remote military outposts in Guam, Seoul or Okinawa.

Funded initially as a research project, the Internet Tumor Board has now become standard operating procedure, according to Commanding General Nancy R. Adams, Tripler's CEO. Effective this fiscal year, she has agreed to continue the funding needed to keep the Internet Tumor Board operational.

Probably not surprising, the return on investment for the project wasn't positive in terms of dollars. In three years, $1.8 million was invested in simple technologies, resulting in what Lt. Col. Rosemary Nelson, program manager and CIO of the Pacific Regional Program Office, estimates as about $800,000 in reduced costs for unnecessary medevacs, surgeries and patient visits. Yet the Internet Tumor Board's value goes beyond simple ROI, earning the support of such prominent proponents as Hawaii Sen. Daniel Inouye. "I've supported this program because it successfully utilises low-cost, high-tech resources to improve health-care services," Inouye says. "Although we have no foolproof way of quantifying the program's returns and benefits, I am certain that it has saved lives."

One sure sign of the project's lasting value is its endurance despite the turnover of military doctors who are reassigned to new locations every one to three years. "The concept of the Internet Tumor Board has survived even after its champions have moved on," says Patricia M. Wallington, retired CIO of Xerox and one of the judges of this year's Enterprise Value Awards. "Newcomers continue to be willing to participate, and that's what makes this such a great public-health service."

For Goldsmith, the Internet Tumor Board seemed the least Tripler could do for patients. For Lucyana Hayes, it meant the difference between simply treating her cancer and treating her.

A System Comes to Life

Located just eight miles from Waikiki Beach, Tripler Army Medical Center is the largest military medical treatment center in all the Pacific-serving the Army, Navy, Air Force, Marines and Coast Guard-and it is the only Army medical center not located on the US mainland. The Pink Lady, as Tripler is affectionately called by Hawaiian locals, sits high atop the Moanalua Ridge, a part of the Koolau Range overlooking Pearl Harbor. Its sprawling stucco facade was painted a rosy hue to blend with the red dirt from its surrounding hillside, but, nonetheless, it still stands out in a Pepto-Bismol sort of way.

The role of the 338-bed hospital is as unique as its geographic location: Military readiness is job one. Strategically located in the Pacific to provide care to forward-deployed forces in times of war, Tripler played a pivotal role in the life-saving care given to hundreds of military and civilian casualties from hostile fire by Japanese war planes on Dec. 7, 1941. Today, Tripler supports a referral population that includes Guam, Kwajalein, Eniwetok, Johnston Atoll, various US Associated Pacific Islands, Japan and Korea-an area that encompasses 3 million square miles of ocean and 700,000 square miles of land mass. In all, more than 850,000 individuals-active-duty personnel, retirees, veterans and their families-are eligible for care at the Honolulu hospital, which also serves as a major medical teaching facility.

When Goldsmith arrived at Tripler, he was just one of a team of doctors who would meet weekly with a traditional tumor board-a practice known to most large hospitals as a means of coordinating the many facets of treating cancer, which, unlike other medical problems, usually requires the input from various specialists. On a tumor board, medical oncologists, radiation and surgical oncologists, pathologists, radiologists and social workers each contribute expertise to coordinate the multidisciplinary care necessary for integrated cancer treatment.

At Tripler, traditional tumor boards made sense for local cancer patients who came directly to the hospital. But treating patients from the outlying islands in the Western Pacific-patients like Lucyana Hayes-was more of a challenge to Tripler's doctors. "Too often patients would be referred to Tripler after their initial diagnosis and surgery, and arrive at Tripler unclear about their treatment and their duration of stay," says Goldsmith. "That confusion would intensify their anxiety and often translated into a delay in getting their treatment started."

In addition, Tripler's physicians had little connection with the remote doctors, and, as a result, communication between the two factions was greatly impaired. "They didn't know how to get a hold of us to tell us a patient was on the way," says Goldsmith, "and we didn't know how to get much follow-up from them once the patient returned home."

But what if Goldsmith could find a way to include the remote doctors in Tripler's tumor board sessions each week? What if all these specialists could use the Internet to bridge their geographic and communications gaps? Wouldn't the patients' treatment be more effective and better coordinated? These are the questions that led to the rise of the Internet Tumor Board. The goal was not to save the lives of patients, necessarily-no one could guarantee that-but to help them get to Tripler in record time with a treatment plan in place. The patients would know their new doctors, and their doctors would know them.

Remote doctors in Guam or Seoul or Okinawa suddenly would have access to cancer experts at the large teaching hospital in Hawaii.

"Brian's idea was beautiful in its simplicity," says Nelson, who is also the head of the department that facilitated the technical expertise the doctors needed to realise Goldsmith's vision. "And to make it work, the technology would have to be simple as well."

Tripler's reputation for medical care was superb, but when it came to IT, its capabilities were hardly state of the art. Doctors had basic Internet connections. They knew how to use conference phones. And they dabbled in some digital photography. Still, Goldsmith says, "I figured we had enough with all that to support the notion of an intra-hospital tumor board."

So in 1995, with the help of Tripler's technology experts and then Col. Laurie Davis, Goldsmith applied for funding available through the US Army Breast Cancer Research Program. Goldsmith wrote a proposal asking for $900,000 for fiscal year '96 to fund the Internet Tumor Board project. It was to provide a basic telecommunications infrastructure and install teleradiology equipment at six different Pacific medical sites: Tripler, Guam, Seoul, Korea, Okinawa, Yokota and Yokosuka. "We didn't have to establish any connectivity because the Department of Defense had already done that," says Davis, but the funding was necessary to install minimal equipment and train physicians at each of the pilot sites.

"And then we did a little evangelism to get people excited about the idea," Goldsmith says. It was important that the technology staff not try to change the way the doctors already practiced medicine-physicians didn't want to fiddle with the Tumor Board concept; they simply wanted to find a way to make it work long distance.

Because of a lack of bandwidth, Project Manager Robert Whitton says it made sense to teleconference the audio portion of the weekly meeting via speaker phone. "By doing so, we also addressed the security issues," says Whitton. "We didn't use anything that would identify the patient on the web; instead sharing personal information only over the phone lines."

In October 1996, Tripler's doctors were ready to test the premise and reap the rewards. But they soon were surprised at how the project would affect business-as-usual. "Physicians began to prepare differently for the Internet Tumor Board than for their regular tumor boards," says Goldsmith. Veteran doctors now had a chance to emerge from the ivory tower and teach their less experienced colleagues in faraway lands. And because the specialists could get information about each case in advance and at their leisure, Goldsmith says, they could think more about their recommendations before they met. "When they showed up at the first Internet Tumor Board," he says, "they hit the ground running."

A System Changes Lives

If Goldsmith was the great communicator of the Internet Tumor Board, then Dr. Bruce Cairns was its loudest voice. "Hardly," he says, modestly. "I was simply a believer." Cairns had just finished his residency and was a general surgeon stationed in Guam in 1996 when he met Goldsmith, who was out preaching his vision of the Internet Tumor Board. "Others may have felt skeptical at first-they saw it as another project whose funding might dry up," says Cairns. "But when Brian told me about the project, I couldn't wait to get involved."

It seems medical resources on Guam were, well, less than Cairns had come to expect back in the States. "Because patients there didn't have high expectations about their medical care, you could get away with less," he says, "but you couldn't go to sleep at night thinking like that."

Without a tumor board of their own, remote doctors were hungry to communicate with Tripler's experts. "But we didn't know them, and we didn't know how to get a hold of them," says Cairns. "Phones there would just ring and ring." It meant a lot that the doctors at Tripler were willing to reach out to their colleagues in the Pacific. "It also meant a lot to the patients," Cairns says.

It was against that backdrop that the first Internet Tumor Board was conducted with Cairns in Guam and the team of experts, including Goldsmith, in Honolulu. Says Cairns, "I presented my patient's case, and they presented their recommendations for her care, including the coordination of her trip to Honolulu and the follow-up treatment when she returned."

The Internet Tumor Board provided a new kind of link between the referring physicians and the specialists. "Before, we had a funny disconnect," says Cairns. "The referring docs thought that once we sent a patient to Tripler, no one would talk to us, and we wouldn't find out what happened until our patients came back home. And for the specialists, once they sent that patient back home, often times they were left wondering how [the patients] were doing," he says.

Suddenly, everyone was talking on a regular basis, the way they might if they had all been under the same roof. "We agreed early on that we had to be colleagues," says Cairns. "We weren't going to spend a lot of time working on something like this to be treated like garbage," he says. "We needed to trust them, and they understood that."

They also understood that trust cuts both ways. "New doctors have a lot of confidence issues," says Cairns. "They needed to trust us to take care of the patients locally as much as possible. That alone made an impact when we were trying to make life-and-death decisions."

One of the project's greatest benefits was that remote doctors were able to gain enough expertise to treat some patients locally. In fact, eight out of 26 patients presented in the first year alone were able to receive all their treatment in their community hospital setting. "We were spending thousands of dollars sending patients back and forth to Hawaii," says Cairns. "Suddenly, we had the ability to treat some patients without the added expense and confusion of sending them thousands of miles away for care."

And then, if patients needed to go to Tripler, the new-found colleagues on the remote islands could send along the right kinds of information so that key tests would not have to be repeated. "It had an amazing effect on everyone," Cairns says.

Just as significant were some unexpected benefits that came from the newly created connection.

Continuity. Doctors learned to create better, seamless care for patients referred to Tripler. Thanks to the efforts of people such as Joan Foley, a registered nurse who served as a case manager to eliminate any potential for discontinuity, a treatment plan was in place before patients ever left their small islands. This continuity was particularly important since military doctors are frequently transferred.

Shared expertise. The Internet Tumor Board also gave birth to the Internet Grand Rounds, where every month, one of the hemisphere's experts would present a lecture on a particular medical subject, and the doctors involved could participate in a Q&A session afterward using the internet for multimedia presentations.

Continuing education. Participating physicians earn one hour of Continuing Medical Education (CME) credit for every hour they participate in the Internet Tumor Board's weekly lectures and discussions. Because physicians need CMEs to maintain their credentials, the Internet Tumor Board became a great alternative to the burden of traveling stateside for educational conferences.

New rules. Participants also learned some simple rules about telemedicine that have been transferred to Tripler's expanding telehealth efforts in military installations in Alaska and with the University of Hawaii Medical School.

Still, Cairns and others didn't need outcome data or statistics or a positive return to understand the Internet Tumor Board's value. "It was obvious," he says. "I'll never forget the first day I met Lucyana," Cairns remembers. "When you're 28 years old and pregnant, and you have a cancer diagnosis, you're terrified. I decided there was no way we weren't going to find out immediately how to help her.

"You can't put a price tag on what a project of this sort means to people like Lucyana," Cairns says. "We sometimes overlook the impact. Until it's you. Or someone in your family. Then a project like the Internet Tumor Board becomes priceless."

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