David M. Lam, MD Secretary, TMED Panel Geneva 23 May 2003

1. Report to ITU-T Telemedicine Workshop from the Telemedicine Panel of COMEDS/NATO David M. Lam, MD Secretary, TMED Panel Geneva 23 May 2003

2. NATO Telemedicine Panel Purpose To Develop Telemedicine Interoperability Standards For Use Among Deployed NATO Forces

3. Medical Lay-Down in Bosnia 2+ Tuzla 3 SIPOVO SARAJEVO 3 2 ROLE 3 ROLE 2 MIMU 2+ Mostar Note: the + signifies a role facility, augmented to cover additional peace time requirements

4. Kosovo Medical Facilities l Lesak ROLE 2 (MO) Leposavic ROLE 2+ (FR) l ROLE 2 (UAE) HEN MITROVICA l ROLE 2 (SP) z o s l l Zubin Potok Zvecan MNB(N) ROLE 3 (UK) MNB(C) l t Rudrik Vucitrn G Klina ISTOK l S i t n ROLE 3 (RS) i c Kacikol PRISTINA l a N . S e l o l n l i l K PEC B D e l i r m i l Obilic KOSOVO POLJE ROLE 3 (IT) l G r a i c k o l l Klina l l MNB(W) l Dacane l Rznic GNJILANE ROLE 2 (GR) MNB(E) ROLE 2+ (ARG) DAKOVICA Prozaranje MNB(S) ROLE 3 (US) l UROSEVAC Sasare l PRIZREN l Brod l FOX l ROLE 2+ (GE) LION Musrjikov l D - Ljubinje COMMZ (W) DURRES/ALB FYROM COMMZ (S) THESSALONIKI/GR Dragas ROLE 2+ (GE) ROLE 2 (FR) ROLE 1 (IT) Brod ROLE 3 HNS l MED HNS Restelica

5. NATO Telemedicine Panel Background • Jun 00 (Brussels) - General Medical Working Group Telemedicine Panel established - Tasked to develop a Telemedicine Policy paper & achieve NATO endorsement • Nov 00 (Washington) – Policy paper developed • Apr 01 (Brussels) - Policy panel finalized • Jun 01 (Brussels) - Telemedicine Panel formed - Decision Made to Integrate TMED Panel into COMEDS MIMS WG • Sep 01 (Cologne) - Developed Terms of Reference - Decided to concentrate on Teleconsultation - Established 8 subcommittees to develop topical issues • Apr 02 (Luxembourg) - Discuss the way ahead, in light of upcoming transfer to the MIMS WG - Evaluate subcommittee work

6. Background-2 • Oct 02 (Victoria, BC)- Joint meeting with MIMS WG. Identification of new tasks, beginning of submission of TMED requirements for insertion into overall Technical Architecture. Identification of standards required, and incorporation into new draft document. • Mar 03 (Gosport, UK)- Continued work on draft standardisation document. Identification of additional requirements to provide to MIMS. Discussion of legal issues and quality assurance issues. • Sep 03 (Oslo, Norway)

7. NATO Telemedicine Panel Approach 1. Collect and analyze prior Telemedicine concepts developed from other organizations 2. Identify individual NATO member nations’ concepts for deployable telemedicine systems 3. Establish & promote a NATO Telemedicine “Vision” for future care across the spectrum of military conflict

8. NATO Telemedicine PanelLeverage We plan to leverage the Telemedicine Interoperability issues already being pursued by the: - NATO nations - G-8 nations - Government Telemedicine Organizations - National Telemedicine Associations (Technology Special Interest Groups) - Industry - International Standards Organization

9. Telemedicine Interoperability: An International Organizational Approach International Standards Organization (ISO) • Currently 5 medical working groups: • Medical Records - Australia • Messaging - USA • Terminology - United Kingdom • Medical Smart Cards - Germany • Patient Confidentiality - Sweden • Emerging international standards… • e.g. X.12

10. Telemedicine Panel Objectives • Develop a standardization strategy for the use of Teleconsultation as a tool to support NATO military operations • Identify the clinical processes which would be supported by teleconsultation and the benefits to NATO across the spectrum of NATO operations (Roles/Echelons 1-4). • Identify the baseline and target NATO communications and security architectures that would support teleconsultation (in association with the MIMS WG) • Identify the “Gap Analysis” of communications across the Roles or Echelons of Care.

11. Telemedicine Panel Objectives - continued • Identify existing NATO Standardization Documents that may be relevant to the production of a future Telemedicine Standardization Document. • Identify associated regulatory & legal issues that may impact on multi-national teleconsultation. • Identify options, and associated costs, to provide a teleconsultation capability in an operational environment • Assess the clinical need for teleconsultation in Operations & consider a “Proof of Concept” project evaluating the use of telecommunication devices among Theater Medical Facilities and Medical Staffs.

12. Telemedicine Panel Accomplishments • 8 meetings of the Telemedicine Panel have taken place. • Input from BG Leo Klein, ACE Medical Advisor, has been received • Teleconsultation – a subcategory of Telemedicine – was accepted as the focus of the Telemedicine Panel • Teleconsultation Policy paper has been submitted for comment from various groups and NATO nations as AJP • STANAG on TMED drafted • Teleconsultation modality requirements within a given Role/Echelon of Care have been identified • Subgroups have been formed to address specific topics of concern • We are now an integral part of the COMEDS Medical Information Management System (MIMS) WG

13. NATO Telemedicine PanelFuture Directions • Identify current NATO Standardization Documents which will affect a TMED Standardization Document • Insert the Telemedicine Policy Paper into NATO Policy & Doctrine as an AMedP or STANAG after full review from the MIMS WG and MMSOP WG, taking into account national comments • Develop a NATO technical STANAG on Telemedicine (in coordination with the MIMS WG) • Ensure TMED requirements are provided to NATO for inclusion in the NATO IT architecture

14. Future Issues • The need for identification of common clinical process architectures (high level business architectures) between TMED Panel and MIMS WG; • Development and submission of requirements for a common Technical/communications architecture, to include security/patient privacy considerations; • Examination of various legal issues in the multinational environment; • Our demonstration project which is planned to look at reproducibility of results in a multinational teleconsultation environment.

15. Final Comments • This is a long-term project. We estimate completion in many years, and are not going to finish in the next year. An incremental, phased in approach is the only practical way to go about it.

17. BACKUP SLIDES

18. Spectrum of Tele-consultation capabilities 1. Two way voice – telephone or radio. 2. Store-and-forward – the ability to exchange medical knowledge asynchronously using: a. Facsimile (FAX) b. E-mail text only c. Email with small size still image attachments d.Email with data & large size image attachments in compressed form, such as motion picture (MPEG), digital pathology (JPEG) or digital radiography (DICOM) 3.Real-time Video-teleconferencing (VTC) 4. Web-based education & teaching systems utilizing advanced distributed learning concepts & technologies (streaming video & multimedia education formats)

19. User Interface Medical Devices Protocols Backplane Patient Records ... Processing Communi- cations A Strategic Direction Informatics, Robotics, Autonomous systems Store & Forward, RealtimeTeleconsultation Virtual systems & Telementoring Practice Guidelines, Knowledge bases & Reference Materials Security

20. FORCE SURGEON LEVEL 1 -VOICE -VOICE -E-MAIL -FAX -INTERNET -VTC WAN -VOICE -E-MAIL -DIGITAL IMAGES -INTERNET LEVEL 2 -VOICE -E-MAIL -FAX -INTERNET LEVEL 3 -ALL MODALITIES LEVEL 4