NASA's Johnson Space Center, Houston, TX
NASA Tech Briefs: What is telemedicine?
Jeff Jones: Telemedicine is the delivery of healthcare via electronic means from a remote location. So it makes use of tele-electronics, whether it be audio, video, or a combination of media, to virtually put the physician in a remote location that does not have the medical expertise and provide care in that location using that technology. So it is way of broadcasting the presence of medical expertise to a remote location with telemedical equipment.
NTB: What sort of technology is used?
Jones: A variety of things now are coming into play for telemedicine. It began initially with audio. I mean, early in the space program, we were doing telemedicine from places like spacecraft using electronic signal from, for instance, electrocardiographic monitors and sensors like oxygen and CO2 sensors, and then using audio transmissions from individual, from the spacecraft, back to the mission control center. So that was one of the big drivers in telemedicine early on in the space program.
Now, telemedicine has since been generalized to the clinical practice, terrestrial clinical practice, to take, for instance, medical expertise at a medical center and send it out to rural environments in order to provide medical assistance and expertise to those locations. And it has expanded from just equipment like ECG and other sensors—blood pressure, etc.—to include video as well as audio to get an optical look at the patient for the physician in another location.
And now, imaging is coming online, and we’re beginning to see imaging technology being broadcast in the telemedicine route, imaging such as ultrasound, X-rays, etc., so that images are either taken ahead of time and then transmitted through a still image link, or the can even be real-time broadcast. We’ve done that from space and places like Devon Island in northern Canada, rural communities, out on ships in the middle of the ocean, back to medical centers in the continental United States, mission control center, etc.
And then it has gone even beyond that. We are now able to direct surgical procedures, even robotic control, from a remote station. Such operations have been conducted from several hundred miles away at a center of excellence for a particular surgical discipline and delivered to a patient in a remote hospital because of the telemedical presence of a trained individual using technology built into the robotics and on-track transmission. So things are evolving from where they began in the early 60s, from the space program standpoint, and have a number of terrestrial applications.
NTB: What NASA projects use telemedicine, or would use it?
Jones: Well, we’re conducting telemedicine in a number of our analog projects. And so Haughton, the Mars project, is a NASA project where we’re doing analog work at a very both lunar- and Mars-like location up at the Haughton meteor crater, so it’s a meteor crater very much preserved and like what we’d find on the lunar surface or Mars surface. And it’s very rocky, rugged terrain, absent of typical flora and fauna, and kinda harsh elements there. So that’s why it was chosen as a good analog location.
But there are other NASA analog activities that are also employing telemedicine. As an example, NEEMO, where you have underwater extreme environment crews being sent down to that location, and we had the ability to transmit images, audio, etc., back and forth from an undersurface research station and we’ve been able to take care of cuts and other medical conditions that have developed in the crews there back at the NASA Johnson mission control center. So there is another location were telemedicine has come into play.
We’re also participating some of our flight surgeons. As an example, I, myself, participated in the Operation Deep Freeze in Antarctica. Operation Deep Freeze is the US DOD (US Air National Guard, Navy, etc) support of the NSF- National Science Foundation research mission on Antarctica. Myself (as a Naval Reservist and NASA FS) and others, like Smith Johnston of NASA FS and Christian Otto, former medical student clerk, now ER MD, have done rotations as either flight surgeons, expeditionary or base physicians on Antarctica and have participated in telemedicine demonstrations and actual telemedical health care delivery from Antarctica to mainland locations, most recently to Cleveland Clinic. We’ve had some of our residents train with them, to combine the new team and the NASA space medicine program, and go down to Antarctica. They participate in telemedicine either from the South Pole Research Station or McMurdo or one of the other Antarctic stations, providing telemedicine information from the site back to the continental US or other telemedicine stations in New Zealand and getting expertise then brought back out to the Antarctic location via the telemedicine experience. So those are all examples of terrestrial applications of NASA telemedicine.
But we continue to have space flight application in telemedicine where we conduct private medical conferences. We send back audio and video transmissions from the station to mission control center on a routine basis, and we’re now doing imaging from the International Space Station and transmitting the information back and forth in a project led by Dr. Ashot Sargasyan and a research project led by Scott Dulchavsky in Detroit. We’ve been using image technology to better understand the anatomy and physiology of space flight as well as to provide a means to diagnosing clinical conditions and sending those images back to the mission control center. So those are some examples of NASA application of telemedicine for our analog environments: near the North Pole, near the South Pole, underwater, as well as space flight direct-application of telemedicine.
NTB: These are both synchronous [real-time] and asynchronous [store-and-forward]?
Jones: Well, we’ve done real-time a lot of real-time work. “Real-time” I believe I think you were calling synchronous, and the real-time telemedicine experience provides a level of clarity and fidelity of information that is unparalleled, and we tend to prefer that one if possible.
However, there are occasions when the real-time transmission is not practical. We may have limitations in the bandwidth for telemedicine application. We may have problems with communications that make real-time transmission not possible. So, in those conditions, we employed a store-and-forward approach where the individuals at the remote site, whether it be a terrestrial remote site (or in the space station, or in the space shuttle), have acquired information—electronic information, audio or video information, or image information—stored it electronically, put it into a queue, and then when communication was possible, then bring that information down or over to the mission control center or to one of our other NASA locations for later interpretation and analysis and return recommendations based on that analysis. So we’ve used both the real-time and the store-and-forward methodology.
Now, when it comes to the imaging, if you do not have an expert in imaging at the site, something we have to direct that from the site of expertise—and usually that’s the mission control center—and for that activity to work well, you really do need some real-time feedback. If there is much delay in that feedback, then it doesn’t work particularly well. But I think we have proven that with real-time direction and real-time mentoring, the individuals on the station can be directed to acquire very high-quality diagnostic images even if they were not experts in operating that equipment. Dr. Sargasyan, I think, has been a pioneer in that, and he and I have worked hand-in-hand for the very first time we did this, during Expedition 5 on the International Space station with Dr. Peggy Whitson, who is not a physician, but a Ph.D., a physiologist, and was not trained in imaging or acquiring the images. Subsequent to that a number of other International Space Station crews have participated in that project.
NTB: How much of telemedicine is preventative?
Jones: Well, I would say quite a bit of current practice of space medicine, of telemedicine, is preventative. Our chief philosophy in the space medicine arena is to prevent problems and nip them in the bud, so to speak, before they become something we have to treat in orbit. And so, if we can get an understanding of something beginning to go awry via a laboratory analysis or routine evaluations, examinations and evaluations, then we can diagnose them very early or we can determine they exist prior to developing a clinical condition, and thereby we prevent the sequelae.
And we do routine monitoring. Every week we have a private medical conference with the crews on the space station. It’s all prophylactic. None of those are in response to a clinical event. That’s a scheduled, preventative-type activity. Now, either the crew or the crew surgeon involved with the space station can call a medical conference at any time if there is a contingency that develops. That happens periodically for situations that happen despite our preventative medicine program. But the majority of our private medical conferences are done in a prophylactic setting, where we are not responding to a medical contingency, but instead trying to make sure that crewmembers are well-kept. And we’re evaluating and prophylaxing prior to developing any clinical condition. So I’d say that a routine part of our program is to have prophylaxis and preventative medicine in our telemedicine program on the space station.
Now the shuttle, when we’re flying crews in the shuttle, we had daily private medical conferences with the crew, but those are very short missions, usually 10 to 14 days, and that because it is a very high-operational tempo. Crews are doing a lot of EVA activity, we need to have a lot of pre-EVA medical conferences, post-EVA medical conferences, and so we need to have daily communication with the crews in keeping up with the pace of the mission and to make sure those crews stay healthy. Therefore, I would say we’re very much in the philosophy of preventative medicine in those telemedicine sessions as well. However, a number of times we have to respond to medical contingencies that develop in orbit, and about 97% of our crew has some medical issue in the course of their mission that we address. If you look at the statistics, it may be mild, maybe just a minor thing, but something that has some kind of symptometology that we addressed in those private telemedical sessions.
NTB: And the same protocols would be applied terrestrially?
Jones: Yeah, I would say. I think we are probably more aggressive on the preventative side of things in space medicine than in most terrestrial medicine. I think that there are not enough resources in terrestrial medicine to be that aggressive about preventative medicine, especially in the telemedicine sense, around the world. A lot of telemedicine that goes on terrestrially is really focused on what we call “tertiary prevention” or treatment of existing medical conditions as opposed to trying to prevent them. Terrestrial telemedicine practice typically is directed at addressing existing medical conditions or disease versus prevention, whereas the majority of space medicine practice is directed at prevention, with a small amount directed at treating medical conditions that develop or that we’re trying to mitigate. That’s the difference between the applications of telemedicine currently, but that’s just a resource limitation. Obviously, if we could be as aggressive in terrestrial practice at preventing disease, everybody would like to see that. But it’s just not practical.
Nor is there funding. Insurance companies and major health programs don’t typically pay for preventative medicine and services. So, it would be very hard to get that introduced into practice of telemedicine on the planet, going out to rural setting to address healthy people and try to keep them healthy. It’s unfortunate, but it is a constraint of the system.