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