Dermatology Online Journal

A review of the practices and results of the UTMB to South Pole teledermatology program over the past six years
Angel Sun MD, Russell Lanier, Dayna Diven MD
Dermatology Online Journal 16 (1): 16

Texas Tech University Health Sciences Center, University of Texas Medical Branch at Galveston, Lubbock, Texas. angel.sun@ttuhsc.edu

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Abstract

There is no place on earth more remote and inaccessible than Antarctica. In 2002, Raytheon Polar Services Co. (RPS) awarded The University of Texas Medical Branch (UTMB) at Galveston the contract to provide specialty medical services via telemedicine to the approximately 3,500 National Science Foundation (NSF) researchers and support personnel who rotate through Antarctica in a given year. We present the practices and results of the UTMB to the South Pole teledermatology program over the past six years, from 2003 to 2008. Issues encountered include logistics of sending out biopsies for pathologic diagnosis, limited bandwidth, and satellite availability for data transmission. The UTMB to the South Pole teledermatology program demonstrates the clinical practicality of telemedicine in providing dermatologic care to remote populations in extreme climate conditions.

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Introduction

Telemedicine has been defined as the use of telecommunications and information technology to provide health services to persons at some distance from the provider. In 1995 Perednia and Brown coined the term "teledermatology" when they described a telemedicine application designed to bridge the health care gap and improve the delivery of dermatologic care to rural Oregon [1]. Being a highly visual field, dermatology is well-suited to take advantage of the many possibilities of telemedicine applications. There are two methods of teledermatology: asynchronous, or store-and-forward, and synchronous, or real-time. In store-and-forward teledermatology, a dermatologist reviews still images of skin disorders along with patient history to make a diagnosis or treatment plan. The consulting physician and the dermatologist do not interact directly with each other as consults and can be reviewed several hours to several days after they are generated. In synchronous teledermatology, the dermatologist, patient, and referring physician all interact with one another in a real-time video-conferencing event. By this method, the dermatologist can directly question the patient such as in traditional face-to-face consults. The usefulness of teledermatology in remote and medically underserved populations has been shown through experiences with sub-Saharan Africans, Pacific Islanders, migrant farmworkers, and prison inmates [2, 3].

There is no place on earth more remote and inaccessible than Antarctica. The potential for telemedicine is obvious in this environment; indeed telemedicine has emphatically improved health care to Antarctic populations by providing a crucial link to specialists [4, 5]. In 2002, Raytheon Polar Services Co. (RPS) awarded The University of Texas Medical Branch (UTMB) at Galveston the contract to provide specialty medical services via telemedicine to the approximately 3,500 National Science Foundation (NSF) researchers and support personnel who rotate through Antarctica in a given year. Through the U.S. Antarctic Program, established in 1956, the NSF maintains three year-round scientific stations in Antarctica: Palmer, McMurdo, and Amundsen-Scott South Pole stations. Although the stations are staffed by a physician with emergency medicine experience, on-site specialty care is limited. In this letter we present the practices and results of the UTMB to South Pole teledermatology program over the past six years, from 2003 to 2008.

Methods

The vast majority of our teleconsultations are performed asynchronously. At the NSF stations in Antarctica, patients are seen by NSF physicians or physician assistants in dedicated telemedicine exam rooms. The exam rooms are equipped with an Oracle-based Electronic Medical Record (EMR) workstation, digital diagnostic and examination capabilities, medical peripherals, and a videoconferencing system. A fiber-optic illuminated, high-resolution medical camera that can be linked to a dermatoscope captures images of skin lesions. The images captured at the remote patient sites are stored in "jpg" format and combined with a clinical history and physical exam (H&P) into an e-mail that comprises the consult. The polar physician requesting the consult notifies the UTMB 24/7 access center by e-mail that a consult is pending. The access center then notifies the UTMB dermatologist to take the consultation. After receiving and reviewing the images and H&P, the dermatologist provides an assessment and plan that is sent to the NSF physician also via e-mail. This network is part of the normal communications between Antarctica and UTMB. All patient information is secured and processed either over private lines, which are inherently HIPAA-compliant, or over a virtual private network (VPN) connection.

Discussion

The personnel of the three NSF stations inhabit extreme climate conditions where resources are limited. During the austral winter, which lasts from February through late August, there is no opportunity for evacuation from the continent because extreme cold and darkness prevents aircraft landings. During the summer months of October through February, the first stop for all evacuated personnel is Christchurch Hospital in New Zealand, a large tertiary, teaching and research hospital. All pathologic specimens and laboratory studies from the NSF stations are sent to Christchurch Hospital during the summer months when weather permits the pick-up and drop-off of medical supplies. The NSF stations are equipped with very basic and limited staining capabilities so that any biopsies performed during the winter months can be initially interpreted by the physician on-site if desired or held until a send-out is possible.

The physician on-site at the NSF stations usually changes every six months. In February, the last plane of the summer season picks up the physician completing his/her stay in Antarctica and brings in the physician who will be wintering over on the continent. On-site physicians most often have completed post-graduate training in emergency medicine. Raytheon Company's Global Health Services has implemented a survey tool to assess satisfaction of all participants utilizing the Antarctic telemedicine program. Dr. Bud Ferguson, Raytheon director, reports that in general, on-site physicians have been satisfied with the telemedicine program between UTMB and the NSF stations.

One of the main technical issues of the Antarctic telemedicine program is bandwidth and satellite availability. Because the Antarctic is below the horizon, it has limited access for geo-synchronous satellites. Data can only be sent at certain times of the day based on satellite availability, which varies during the year. Additionally, sending digital images, for example dermoscopic pictures or histopathologic slides, takes up large amounts of bandwidth and can cause Internet connections for researchers at the stations to slow down or be lost. Possible solutions for expanding bandwidth capability are being investigated, such as launching long duration balloons over the Antarctic to allow satellite images to be bounced over the horizon and obtaining bandwidth allocated solely for medical and educational purposes. An early problem that arose involved the proper setup of cameras and room lighting at the remote location and was resolved by collaborative efforts between technicians at the NSF stations and UTMB's Electronic Health Network. Because video is sensitive to light, it is important that the telemedicine equipment be optimally setup to produce good image quality, which can be a key contributing factor in making dermatologic diagnoses.

References

1. Perednia DA, Brown NA. Teledermatology: one application of telemedicine. Bull Med Libr Assoc. 1995;83(1):42-7. [PubMed]

2. Schmid-Grendelmeier P, Masenga E, Haeffner A, Burg G. Teledermatology as a new tool in sub-Saharan Africa: An experience from Tanzania. J Am Acad Dermatol. 2000;42:833-5. [PubMed]

3. Norton S, Burdick A, Phillips C, Berman B. Teledermatology and underserved populations. Arch Dermatol. 1997;133:197-200. [PubMed]

4. Hyer RN. Telemedical experiences at an Antarctic station. J Telemed Telecare. 1999;5 Suppl 1:S87-9. [PubMed]

5. Lugg DJ. Telemedicine: have technological advances improved health care to remote Antarctic populations? Int J Circumpolar Health. 1998;57 Suppl 1:682-5. [PubMed]

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