Hawaii: Testbed for Telemedicine

(This reportage was published by the Metro newspaper syndicate in 2001.)

“We are geographically challenged,” says Dr. Greigh Hirata.
 
A remote ultrasound examination of a pregnant woman.

Dr. Hirata at his telemedicine station. Photo: Hans Sandberg

The last thing a woman who is going through a difficult pregnancy wants to do, is fly to another city to have her ultrasound taken - but until recently, those Hawaiians living far from Honolulu had little choice. “We are geographically challenged,” says Dr. Greigh Hirata, an expert on high-risk pregnancies. Over the last few years, Hawaii has invested in telemedicine, allowing specialists to “see” their patients via videoconferences and the Internet. The goal is to make Hawaii a center of “tele-health” in the Pacific Ocean.

Hawaii is proud of its health care system, and the fact that 85 percent of its citizens have health insurance. Oahu -- the home of Honolulu, as well as 75 percent of the state’s 1.2 million inhabitants -- has several large, modern hospitals - including the huge army veteran’s hospital, Tripler Medical Center. But while most medical specialists are concentrated in Honolulu, a quarter of the state’s population is spread out over seven other major islands.

Each year, some 3,000 Hawaiian women experience complicated pregnancies, and many of them consult the Kapiolani Medical Center for Women and Children in Honolulu. The center’s Fetal Diagnostic Clinic is lead by Dr. Hirata, a firm believer in telemedicine. Dr. Hirata travels regularly to visit with his patients on Maui, Kauai and the Big Island (Hawaii,) but if there is an emergency, the patient would usually do the traveling – something that telemedicine could change.

“We want to spare our patients the expense,” says Dr. Hirata. “The patient and her husband usually have to take a whole day off from work, fly out here, rent a car, and so forth,” he says. Patients come to Kapiolani from as far away as Guam - an eight-hour flight that costs $1,500. “When these people get here, everything could look perfectly normal, or maybe we have to tell them that there is nothing we can do, because it is a lethal birth defect. It would be better if we could do this all via tele-ultrasound,” Hirata adds.

This and other Hawaiian telemedicine programs are paid for by a combination of federal money and private donations. Kapiolani only needed to raise half of the $1.2 million it needed for its tele-ultrasound network - that today reaches seven remote clinics: two on Oahu, one on Maui, one on Kauai, and three on the Big Island.

On a Wednesday morning in August, Dr. Hirata has an appointment with a 33-year old patient at a clinic in Hilo, the capital city of Hawaii’s Big Island. He consults with the attending physician via videoconference, while the nurse prepares the patient. Sitting in front of two high-resolution monitors, he can see the remote office and the ultrasound images. Because of the high-speed connection, the picture and sound are of good quality.

It takes a while getting used to working with video conferencing equipment, but he feels that the live connection makes it easy to tell the local doctor exactly how he wants to position the instruments. He can study the chambers of the baby’s heart in detail, and listen to its heartbeat as clear as if he was in Hilo. In this case, both the mother and her baby were fine, which means that a trip to Honolulu would have been an unnecessary expense.

Dr. Hirata dreams of expanding the program to even more remote locations, like American Samoa, 3,700 km to the southwest, and Guam, 6,000 km to the south. “Over time we hope to expand the service to the entire South Pacific. The need is definitively there, since Guam, for example, has only a few obstetricians but a very high pregnancy rate,” he says. He is not quite sure if tele-ultrasound would work in all places, but believes in genetic counseling through videoconferences, and wants to get more pediatric cardiologists involved - a rarity on many smaller islands.

Col. Donald Person is medical director of the U.S. Army’s Pacific Island Health Care Project, which is headquartered at Tripler Medical Center in Honolulu – not far from Pearl Harbor. He has been involved in providing medical services to the half million people who live on U.S. islands in the Pacific.


Donald Person medical director of the U.S. Army’s Pacific Island Health Care Project. Photo: Hans Sandberg

To get the hospital’s telemedicine project -- named Akamai -- started, Tripler provided four remote hospitals with computers and communications links, costing about $14,000 each. Funding came from a grant from the National Science Foundation in1998, and soon after they began providing free medical care to Pacific islanders, as long as their cases could be used to further research and education. “We are now working over five time zones, from the island of Yap in the east, to the Republic of Palau in the west,” says Person, and to date, the hospital has about 1,850 telemedicine patients in their database.

Tripler is also involved in futuristic high-tech projects -- like long-distance radiation treatments using satellites that connect distant hospitals with Maui’s military supercomputer center -- but most of Col. Persons work is done via the Internet. Local medical officers and doctors send e-mail and pictures, or upload their cases into a database, which Col. Person and his colleagues regularly visit. “This lady from the Marshall Islands thought she was pregnant, but it turned out that she had a 90 lb. benign ovarian tumor,” he says, pulling a patient from his database.

Many of the islands of Polynesia are very poor and sparsely populated, and their hospitals lack medical experts, supplies and medicines. For example, the island of Yap got electricity for the first time in 2001, thanks to a $100,000 gift from France. They put in solar panels to give power to 50 homes, which can now have a radio and two lights each.

For the local medical staff, the connection to the specialists in Honolulu provides not only critical medical advice, but also a means of education. “It is a wonderful exchange,” says Person. “Being able to talk to specialists, and other colleagues makes them feel not nearly as isolated.” And it’s not just one doctor that they can talk to, but hospitals full of specialists. “A little girl fell out of a second story window in Yap - probably the only such building in town. She fractured her femur, and I forwarded her information to an orthopedic surgeon, who didn’t like the position of the traction,” says Person. Thanks to his advice, she was treated at home, and Tripler saved between $24,000 and $40,000 in evacuation costs. Overall, he estimates that the Akamai project has saved his hospital up to $8 million over the three and a half year since it started.


Daniel Davies and Rodney Moriyama from Queens Medical Center in Honolulu.
Photo: Hans Sandberg

Drs. Daniel Davies and Rodney Moriyama from Queens Medical Center in Honolulu are developing a business model to make telemedicine profitable for medical centers. Dr. Davies, who is the head of the hospital’s Department of Medicine, also runs a small company that developed “eCare” – an Internet-based “home nursing” service which helps patients manage their health in-between visits to the doctor. “What they do at home is probably more important than what happens during their visit with the doctor,” he says. Patients can register their preferences online, and take Internet “classes” in self-care.

“This self-monitoring includes sending reminders to patient’s cell-phones and pagers,” he says. The system can also use wireless local area networks to connect to the patient’s home or office. By having fewer face-to-face visits, nurses can handle more cases, and the software is designed so that she can pull up information in an interactive session with the patient and drop it right onto their desktop.

Thanks to a state telemedicine initiative, some Hawaiians are now able to taking tele-home nursing to an even higher level. Using in-home, or clinic-based blood pressure/pulse meters, stethoscopes connected to the Internet, and small Web cameras, patients can send their blood pressure, pulse rate, and heart and lung sounds -- as well as high-resolution digital images of their wounds -- directly to the specialist they need in Honolulu. If the results are alarming, a software agent will immediately alert a physician.

Advances in telemedicine are good news for this natural paradise, which depends mainly on its tourists, and needs alternative industries. Frank Fukunaga, a telemedicine consultant, is betting on a high-tech future for Hawaii: “The market is too small here, which is why we need to find ways to export our expertise.” Telemedicine could turn Hawaii into a regional (medical) center, eventually serving the entire South Pacific, Japan - and even Asia’s emerging economic giant, China.

Hans Sandberg

Cables Connect the Tropics

It was Governor Benjamin Caetano of Hawaii who launched the state’s telemedicine program back in 1997. “We realized that we were just a dot in the Pacific region. We were isolated, and needed a high-quality telecommunications infrastructure, so that we could communicate with the rest of the world,” says Frank Fukunaga, a consultant at Tripler Medical Center in Honolulu. “As it turned out, Hawaii had an abundance of trans-Pacific fiber optic cables running through the state,” says Fukunaga, who played a key role in the telemedicine program as the state’s leading information technology-official during the 1990’s.

Fiber optics and satellite links helped bolster Hawaii’s information technology industry, and subsequent distance learning and telemedicine projects. In 1994, a telecommunications network called STAN (State of Hawaii tele-health Access Network,) was established, and now connects 16 hospitals and 7 clinics on 22 Pacific islands. “The over 125,000 veterans in the Pacific Region are the largest beneficiaries - we have veterans in places like Guam and Samoa, and they had to fly to get service,” says Fukunaga. “Why not use technology to increase their access to health care, improve quality, and in the long run even reduce costs?” he adds.


Frank Fukunaga, a hawaiian expert at telemedicine.
Photo: Hans Sandberg


Long distance videoconferencing between doctors and patients was initially used, but it was found by many to be expensive and cumbersome to use: “We tried interactive videoconferencing in the early 1990’s between Hawaii and the Marshall Islands -- where the missile command has a very fancy system -- but it wasn’t helping those people out much, and it was exceedingly expensive,” says Col. Donald A Person of Honolulu-based Tripler Medical Center. “We realized that we didn’t need any of the bells and whistles – we could do almost everything using still photos (of the patients,)” he adds.

Sharing Col. Person’s skeptical view of videoconferencing are Drs. Daniel Davies and Rodney Moriyama of Queens Medical Center in Honolulu, who are instead trying to develop easy-to-use Internet-based applications. “We had an emergency videoconferencing system between Molokai General Hospital and our emergency room here. The technology worked fine, but nobody used it,” says Dr. Davies. “Nobody knew where the equipment was, and when I went looking for it, I found it in a closet covered in cobwebs, and a mop leaning on it,” says Dr. Davis, noting that the last thing doctor’s want is to work with a technical person beside them.

But even before the Internet -- which can now be accessed locally on remote islands for under $30 a month -- there was a “tele”-medicine of sorts: the telephone. “Part of the problem working by phone is that long distance phone calls are very expensive in this region - $5 to $10 dollars per minute. And islands who don’t have money for medicine certainly don’t have the money for long distance phone bills,” says Person. “Besides, the telephone would also sometimes disconnect, and we were sometimes unable to get back to them the same day. The Internet has cut through all of that,” he adds.

Hans Sandberg

Mauna Kea’s Amazing Gazing

(Syndicated article for the Metro newspaper group).

The building that hosts the Gemini North telescope.
It's twin sibling sits on top of a mountain in Chile.
                                                        Photo: Hans Sandberg


At 13,796 feet, not much grows and the air is mostly clear. 
                                                                  Photo: Hans Sandberg

There is probably no better place on Earth for stargazing than on the summit of Hawaii’s Mauna Kea (Hawaiian for “white mountain.”) The long dormant volcano climbs 4,205 meters (13,796 feet) over the Pacific Ocean on the Big Island of Hawaii, and its clear and stable atmosphere has attracted the largest collection of telescopes in the world. Giants such as the Keck twin observatories, Gemini, and Subaru, are there to help us understand the birth of planets, stars and galaxies, and to search for celestial objects so far away that their faint light may reveal secrets about the beginning of time.

The island of Hawaii is the biggest and most southern of the state’s eight islands. It’s twice as large as all of the others combined, hence the nickname - “The Big Island.” It is also the youngest -- and still growing -- as nearby Kilauea pours huge amounts of molten lava into the sea on the island’s southern shore. Mauna Kea has not erupted in 3,000 years however, which explains why eleven countries dared over the last four decades to spend more than a billion dollars building thirteen telescopes on it’s summit.

Way up there, astronomers and their expensive telescopes may be safe from eruptions, but not necessarily from Mother Nature. It is not uncommon for winter storms to deliver winds reaching over 160 km (100 miles) per hour, sometimes dumping a thick layer of snow on the volcano’s peak. Most of the time however, it is not heavy winds, but the height of Mauna Kea itself -- with its cold and thin air -- that threatens human life, as well as most other life forms.

“If you drop anything when you are exiting the car, don’t pick it up,” says Peter Michaud, a press and community relations manager for the Gemini Observatory, which runs two of the most sophisticated telescopes in the world – one on Mauna Kea, the other in Chile. With 40 percent less oxygen to breathe, bending down can lead to fainting.

The trip from Hilo to Mauna Kea starts on Saddle Road – a roller coaster-like ride that becomes a bit nauseating after driving on it for an hour. Halfway to the other side of the island, another small road continues upward to the Onizuka Center for International Astronomy. At 2,800 meters (9,300 feet) above sea level, this quaint visitor’s center is named after the Hawaiian astronaut who perished when the space shuttle “Challenger” exploded in 1986, but is also known to the Hawaiians as Hale Pohaku (“stone house”). The view is stunning during the day, and evening stargazers are in for a treat – seeing the Milky Way as never before. Most tourists shy away from driving the extra 1400 meters up to Observatory Hill, which is at the end of a steep, narrow, eight-mile dirt road, and can be treacherous at night.

Since both the visitor’s center and the summit are open to the public, some experienced off-road drivers do take their four-by-fours up to the top (most car rental companies explicitly prohibit taking their vehicles anywhere near Mauna Kea,) but not before pausing for at least one hour at the Onizuka Center to allow the body to adjust to the high altitude. A dedicated weather and road condition telephone hotline is updated each day for potential visitors. Hale Pohaku also has a lodge that sleeps 72, and is used for astronomers and staffers who work on the summit during the night – so that they’ll have a place to rest during the day without having to repeat the altitude adjustment over and over again.

To prevent altitude sickness, it’s suggested that visitors don’t smoke, drink alcohol or coffee -- or go scuba diving -- the day before, and eat no heavy meals right before the ascent. Drinking a lot of water is also necessary to prevent severe headaches. Warm clothing (including hats and gloves) is a must, and like airline pilots who are exposed to strong sunlight in the upper atmosphere, extra strong sunglasses (preferably with UV-filters,) and sunscreen with a factor of at least 15, is needed.

It’s a lot to remember, especially for an oxygen-starved brain. Michaud warns that people become forgetful sometimes, and wander off aimlessly. That is, until they lose their breath, and their heart starts pounding like that of an 85-year old. A photographer visiting the summit admits to opening his camera without rewinding the film while on the summit, thereby ruining his entire photo shoot.

The landscape at the summit is completely barren, except maybe for black, gray, and rust colored stones. There are no trees, no bushes, no visible vegetation or animals - but for a stray mountain goat. The area is often compared to the planet Mars, and in fact, NASA used the area to train its Mars Lander equipment. Looking down, one can see several copper red cinder cones shooting up from the steep lava slopes. And peeking out from the clouds in the distance is the active volcano Mauna Loa (of macadamia nut fame,) and Haleakala (“House of Sun,”) a 3,049 meter (10,000 ft.) high volcano on the neighbor island of Maui.

Once the sun sets, the temperature quickly approaches the freezing level -- even during the summer months -- as there are few clouds to lock in the heat. This is good news for astronomers however, who would if possible, prefer do all of their observing from the crisp clarity of outer space.

Sitting above 40 percent of the Earth’s atmosphere, Observation Hill has few clouds, and benefits from strict local laws against light pollution on the sparsely populated island. Its location in the middle of the Pacific Ocean also creates an unusually stable and clean atmosphere (something that may not be obvious as you drive through the Kona district on the island’s west coast, where coffee growers complain that ashes from ongoing eruptions cloud the sky and block the sun.)

“There is no getting around the fact that the Earth’s atmosphere is a pain to have to work through,” says Matt Mountain, director of the Gemini Observatory. But if space observation has to be earthbound, Mauna Kea is the place to be.


Hans Sandberg (at Mauna Kea)

Stairway to the Stars

(Syndicated article for the Metro newspaper group).


Some of the telescopes at Mauna Kea's peak.

Interest in building an astronomical center on Hawaii caught on in the 1950’s, but the location of choice was Maui’s Haleakala, which had one thing the Big Island’s Mauna Kea did not have -- a road to the top. A solar observatory was built, but it soon became clear that Haleakala was not ideal, as clouds reached its summit, and its crater sometimes filled with fog that spilled over. Surrounded by fog, the scientists looked outward, and across the Pacific waters saw Mauna Kea rising tall above the clouds.

It took a lot more than clear air and a tall mountain to make a home for telescopes however, all of which is detailed in Barry Parker’s 1994 book Stairway to the Stars. Building on the mighty White Mountain took money and politics, as well as daring individuals willing to take risks. And in the case of Mauna Kea, tragedy also played a role, as the nearby city of Hilo was almost totally destroyed by a huge tidal wave on May 22, 1960.

With its capital city’s downtown in ruins, the mayor of Hilo began to look for new ways to generate income and jobs. Astronomy was one solution, and the governor of Hawaii was soon convinced to fund the building of a road up to Mauna Kea’s summit. (This decision would later translate into hundreds of new jobs and $80 million annually to Hawaii’s economy.)

The first big telescope to open on Observatory Hill was the 2.23-meter (88-inch) telescope built by the University of Hawaii, which opened in 1970, but wasn’t fully operational until 1976. In 1979, a 3.6 meter Canada-France-Hawaii telescope went into operation, followed by several more - including both infrared and radio telescopes.


The Keck Twins at Mauna Kea.  Photo: Hans Sandberg.

But the project that put Mauna Kea on the world map was the Keck observatory. This revolutionary giant telescope had a “honeycomb” mirror with a diameter of 10 meters (33 feet). Such a large disk would have been almost impossible to build and operate using the technology of the time: a single mirror. Keck designer Jerry Nelson instead opted for 36 smaller mirrors, which would all work together as one. To do this, it was necessary to develop a highly innovative system that could change the shape of every single mirror segment continuously, and then align them with extreme precision. This technology is called active optics (adjusting the shape of the mirrors.) By combining active optics with another new technology: adaptive optics (where computers calculate disturbances in the Earth’s atmosphere and “correct” them by continuously adjusting the telescope’s mirrors and lenses,) Keck began a new era for astronomers everywhere.

Behind the $76 million Keck project was the University of California and Caltech (California Institute of Technology,) and the Keck Foundation. Later on, the fund paid for a second Keck-telescope -- which today sits next to the first. The idea is to get them to function as a single telescope, thereby doubling the power. This technique -- which is common in radio astronomy -- is called interferometer. Since it is however much, much harder to perfectly match up optical images than it is radio signals, this goal has yet to be completed.

One problem that the new telescopes did not solve was the shortage of telescope time. Two-thirds of the observation requests made by astronomers were routinely turned down, which is why some of the world’s leading associations for astronomy proposed building two new large telescopes – one in the northern hemisphere and one in the south. The National Science Foundation (NSF), which funds most of the industry’s basic research in the US, financed half of the $176 million needed to build twin telescopes in Hawaii and Chile. Six other countries also funded the Gemini plan: Argentina, Australia, Brazil, Canada, Chile, and the UK.

Like Keck, Gemini broke new ground in many ways. They decided to use a single piece of glass, but a much thinner disk than those of previous generations. The 8.1 meter mirror is flexible, and is coated with a super-reflective silver solution, instead of aluminum. “Our thin mirror, which is basically a twenty-ton contact lens, no longer relies only on glass and steel to keep it aligned. Behind it, there are 120 computers, which constantly monitor the shape of the mirror, and adjust it as it moves across the sky,” says Matt Mountain, director of the Gemini Observatory on Mauna Kea. The result is a telescope that in some respects can match both the Hubble Space Telescope, and the Keck twins – a “fly-by-wire airplane” as Mountain calls it.

When completed in late 2001, Chile’s Gemini South will work with Hawaii’s Gemini North to give researchers a chance to study the entire hemisphere from remote locations - via super fast computer networks. “For example, the Magellan Cloud, our nearest galaxy, is not visible from the north. The center of that galaxy is very low down in north, and we have to look at a lot of atmosphere to see it, while in the south it goes straight overhead,” says Mountain. So theoretically, a team of observers -- one sitting in Brazil, one in Washington, and one in Hawaii -- can collaborate over a network using both telescopes. “It will be a long night if we get the right overlap, because you can get one twelve hour night, and then another seven hour (night) for certain parts of the sky,” he adds.

Gemini is designed to look far into the universe, and is especially good at capturing infrared light. Though infrared heat radiation is invisible to the human eye, it is tremendously important for modern astronomy. Infrared telescopes for example, can see right through the vast, dark clouds that obscure our view, and allow astronomers see the universe at its very early beginnings. “You can see into the heart of stellar nurseries, and can catch information about planets and planetary disks that you couldn’t catch (before.) You can also see into the heart of our own galaxy - to the galactic center where there is probably a black hole hidden,” says Mountain.

As telescopes get bigger and optics more precise, demands on the rest of the system increase as well. The machinery that moves the telescope and the dome, must do so without causing any vibrations. In an almost surreal act, Gemini’s 673-metric ton shiny silver dome rotates almost without a sound. Vertical “doors” open to expose the sky, while the rest of the dome splits horizontally in half and rises up in order to circulate the air. Another impressive sight is the cable room below the telescope, which holds its “spinal cord” in the form of hundreds of wires nested into dozens of thick bundles.

For an astronomer, it is essential to have good resolution as you focus on smaller and smaller objects. To give an idea of how sensitive the Gemini telescope is, Gemini’s Peter Michaud explains that it would be like seeing a pair of headlights on a car driving on the Golden Gate Bridge in San Francisco from the top of Mauna Kea 2,000 miles away. “That is assuming however, that the Earth had no atmosphere, and was completely flat,” adds Michaud.

As for the future, Matt Mountain foresees a new generation of 30 to 100-meter telescopes, one of which is actually slated to be built on Mauna Kea. This enormous telescope will however, be Mauna Kea’s last, he adds.

Hans Sandberg

“Garage Attendant” Astronomy

(Syndicated by Metro World News in 2001)

Three of the more than dozen telescopes at Mauna Kea.
                                                             Photo: Hans Sandberg

New technology for observing the sky is rapidly changing the way astronomers work. The lonely genius standing by his telescope and smoking a pipe is harder and harder to find these days, as satellite links and fiber optic data networks make it possible to use telescopes from afar. For example, most of the astronomers using the Keck twin observatories do their viewing from the city of Waimea, on the north shore of the Big Island. And Gemini North’s telescope is operated from its base camp in nearby Hilo, as well as from the top of Mauna Kea.

“It is changing the way we do science. Not only can we access these big telescopes over the net, but we also have access to huge databases from other areas,” says Matt Mountain, director of the Gemini observatory. “Sociologically it’s a radically different way of doing astronomy, which makes some of the traditional astronomers uncomfortable – they even call remote observing ‘garage attendant astronomy,’” says Mountain. He compares Gemini to the Hubble Space Telescope, where an astronomer submits an application, and someone on Gemini’s staff does the observing (when the conditions are just right.) Besides, it is easier and cheaper for Mountain’s staff and visiting astronomers to remain on sea level in the city of Hilo, rather than 13,796 feet up.

In the future, even amateur astronomers and school children may get to peek over the shoulders of astronomers. Mountain dreams of the day when school classes visiting New York’s Rose Center for Earth & Space will hook-up with Mauna Kea’s telescopes via the internet. “Astronomy has got to get more accessible - people are fascinated by it,” he says.

Hans Sandberg