In 1995 I left the British Army and joined the Casualty Care Research Center (CCRC) in Washington DC as Technical Director of the US DOD Telemedicine Training Team.

CCRC was, at that time, part of the Uniformed Services University of the Health Sciences (USUHS). Since the peace implementation force had been deployed into the former Yugoslavia, the US Army Surgeon General looked to technology to ensure that his deployed troops could expect and receive first class health support. The prime objective was to utilise technology to move information, rather than sick people, wherever possible. This was achieved by training Medics, Physicians Assistants and Doctors in the use of Telemedicine. The unit deployed consisted of an Inmarsat Satellite Earth Station capable of receiving and transmitting at 64 KBPS, a ruggedised PC and a selection of digital cameras or scopes. The system worked well for troops that were in a fixed facility with their medical support team but for the more mobile element of the Armed Forces something more lightweight was required.

I found what I was looking for in the VitalLink. Small footprint and light weight. It requires only 2.4KBPS to transmit an ECG , SpO2, NiBP and Temp. I first deployed it with the Secret Service in Africa and it has since clocked up an impressive list of patients and airmiles. One interesting trial I conducted was an air-to-air telemedicine link. At the time I was working in Ethiopia with Sheik Mohammed Hussein Ali Al-Amoudi. We had proven the VitalLink in a number of difficult environments using portable satellite telephones so, while transiting the Red Sea in the Sheik's private jet, we established a real-time link to his other aircraft that was also in the air. While the scenario was perhaps a little extreme, the trial demonstrated the resilience and versatility of the system for use in any conceivable environment.

After leaving CCRC I returned to the UK as head of medical engineering with the NHS at a trust in the East Midlands, where I was responsible for the procurement care and maintenance of medical equipment across three hospitals. I maintained my interest in Telemedicine by putting together three initiatives during my time there.

1. A GP with special interest in Ophthalmology was trained in the hospital outpatients department for one session a week by a consultant ophthalmologist. After 12 months he went back to the community. In the meantime I had purchased three portable fundus cameras and three slit lamps which were deployed into Opticians in the local community. There was, of course, a PC with each and software and security to ensure there would be no breach of patient confidentiality.

The system worked as follows:

If one of the Opticians detected a condition that required investigation or treatment in a customer they would electronically refer them to the special interest GP. After studying the images the GP would then either come up with a diagnosis and treatment plan for the patient's own GP to administer or if the condition needed treatment from a sub-specialist, he would treat them himself. In a few cases the special interest GP would forward the images to the hospital-based consultant who would diagnose and recommend a treatment plan for delivery in the community. If this was not possible the patient would be booked into the hospital for treatment without the need for an initial consultation, this having already been completed 'virtually'!

2. There is anecdotal evidence to suggest that more Caesarean sections are carried out when a Consultant is not present due to the concerns of the attending SPR or SHO. We decided to attempt to reduce the number of C-sections that were carried out in the out of hours period. To do this we designed a trolley that could be wheeled around the delivery suites that had the following:

- A video phone linked to the consultant's house
- A Cardiotocograph linked to a PC which had remote share and security software installed

At home the Consultant had a video phone and a PC with the same software as the trolley.

Prior to establishing this pilot, when a labour was becoming difficult the consultant would first be contacted by phone and the paper trace from the Cardiotocograph would then be sent through by fax. This did not allow for any real-time interaction between the attending physicians, the consultant or the mother.

Using this system, for the first time, the consultant was able to watch the effect of his instructions in real-time and the result was a reduction of C-Sections by 22%.

3. I installed systems in the Consultant Radiologists' homes so they could respond immediately when on call instead of having to travel in to the hospital. They could also report from home routinely when on call or at the weekends to reduce the backlog of reports, whilst maintaining a better quality of life. I negotiated and established a link between our District General Hospital and a well-known London Hospital to facilitate remote Radiology reporting to help cover our shortages such as sickness and holidays.

It was clear that medicine would have to move more and more into the community. What was also clear was that for this to work, clinicians had to be at the centre of the process. Furthermore, the 'technical bit' needed to be practical and effective. Hospital-based systems, usually from large vendors, lacked the flexibility to address the issues involved. To that end, I maintained my link with TeleMedic Systems.

I was most interested in the VitalLink 1200, which was designed with a clear objective based around mass casualty incidents in remote environments. I believed there was potential here for out of hospital monitoring. As well as the same level of medical support offered by its predecessor, it utilised wireless technology and was years ahead of any competitor. This too is deployed in austere environments worldwide providing first class medical support to deployed personnel who are quite literally out on a limb. As far as use within an NHS environment was concerned, however, there appeared to be too many obstacles in terms of funding and the health service had not, at that stage, woken up to the benefits of such systems. This led to a great deal of frustration on my part and from the clinicians with whom I had worked. It contributed to my decision to move to the private sector.

I was offered the position of Medication Safety Clinical Scientist at Alaris Medical. One of the projects I was involved in was Guardrails, which looked at the errors relating to the use of infusion pumps in hospitals. It was clear that there are significant benefits in connecting medical devices to IT systems and patient records. In this way a block could be put on an incorrect dosage entry on an infusion pump preventing a potentially serious incident. The computer isn't doing the job of the clinician; just acting as a safety net. This is Telemedicine or e-health within a conventional healthcare environment.

In light of this I again approached TeleMedic Systems to see what developments they may have made in this area. What was needed was an interface between the medical devices and IT systems. Through our combined practical experience it seemed that TeleMedic Systems had come to the same conclusion. Their new unit, the VitalLink3, is smaller, lighter and much more powerful and versatile.

The VitalLink3 acts as an interface between medical devices and IT/communications systems at a very low level. This information can be seen on local IT devices such as PCs or PDAs and is also sent to a central server. The VitalNet server is part of a secure, real-time data distribution network that will allow any number of appropriate and authorised clinicians to log in from anywhere to view the same real-time information as those local to the patient. This data can be saved in or accessed from patient record systems, decision support systems and other applications like data analysis programmes.

What became clear was that the VitalLink3 and VitalNet system offers exactly the versatility and interfaces that clinicians are calling out for. VitalLink3 is just that, the Vital Link between clinician and patient information, in real-time, irrespective of where in the world either one might be.

In light of all this it should not seem strange that I was delighted to accept the appointment of Sales Director for TeleMedic Systems, where I now help others, across the whole spectrum of healthcare, overcome the frustrations of the limitations of current systems.

Alan Fisher