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Can you tell me how you became involved with Telemedicine and how you became involved with East Carolina University?

I have been working in media development for education and entertainment since getting out of graduate school in Kentucky. I started working at ECU in 1974 and built one of the first video synthesizers called the Sandin Image Processor. Later I worked with the Datamax UV-1, a first generation video animation system developed by Tom Defanti. I produced music videos for network television from 1978-80 (before MTV). I have always been attracted to the edge of technology and applications. I started the Telemedicine project at ECU in 1991 as a way to apply edge technology to extend health care into a very needy region of the country.

Can you tell me the history of Telemedicine at ECU and how it has evolved?

I started working for the Medical School at ECU in 1974. We started a distance-learning program using a statewide microwave network in 1989.Having some background in broadcast and network television, I have always been interested in real-time video and looking for ways to do real-time at a lower cost than broadcasters pay. In 1991 first generation H.320 compressed video became widely available and our region had installed a T1 infrastructure.Finally we had a way to do decent real-time video at affordable costs.With the vast geographic challenges of this region, telemedicine fit like a glove to the mission of this Medical School. We started out with a correctional care contract, and quickly expanded into rural hospitals throughout the region. We have since expanded into homecare links, school and mental health centers, and recently into global disaster medicine.

The Telemedicine Center has an international reputation for training. How many trainees have been through the program and what do they learn and take with them?

We have trained around 500 healthcare professionals from 25 different countries. Advanced Telemedicine Training offers 5 core "tracks": administrative, technical, clinical, telehomecare, and international and many more options for individual customization. Trainees enjoy small class sizes; we typically limit it to 8 people per session. They also enjoy access to our state of the art facility and to our experienced staff. Trainees take home reimbursement forms, and clinical and technical knowledge and protocols for building their own programs.

Tell me what is going on with your program these days besides training and providing daily consultations to the areas you serve?

We are currently funded by NIH to develop Biomedical applications for the Next Generation Internet (NGI). The NGI will use high-speed IP networks to provide ubiquitous Internet access everywhere. The challenges are: 1) guaranteeing quality of service over the Internet, 2) protecting patient confidentiality, and 3) making it affordable and easy to use. We have already stumbled onto some very interesting discoveries along the way. I suspect that wearable "wellness" monitors will be part of healthcare's future because of the potential for prevention, intervention, and huge cost savings.

In the past couple of years The Telemedicine Center has had the opportunity to gain hands-on experience in disaster relief efforts and international connectivity. During the aftermath of Hurricanes Dennis and Floyd, that devastated eastern North Carolina in 1999, we were able to deploy portable systems to the shelters and victims stranded by the damage. These telemedicine systems facilitated telecommunications links to support healthcare delivery from surrounding offices and clinics.

This past June, we had the unique opportunity to participate in a disaster exercise called Strong Angel. Strong Angel was the first-ever humanitarian component to the Rim of the Pacific (RIMPAC) exercise. This exercise occurs every two years in the Asia-Pacific region and involves seven nations militaries. Strong Angel provided us with the opportunity to test telemedicine applications of technology in an austere environment while trying every communications media from smoke signals (ham radio) to satellite.

Due to interests sparked by work in Hurricane Floyd and Strong Angel, we are now developing the Global Telemedicine Resource Center. The GTRC is a way for our center to apply its resources towards the connection of healthcare professionals to communities that otherwise lack access due to underdevelopment or environmental trauma.

Other research areas are focused on wirelessly wearable biosensors and small deployable telemedicine toolkits for a variety of environments.

ECU has a lot going on in R&D (i.e., Strong Angel, NLM Biomedical Applications of NGI, Telemedicine Practice Suite (TMPS), Docking Station, Web Casting, Interventional Informatics, Pulsar, and Telemedicine Lab) Can you tell me a little about these?

The ECU Bridge is a diverse communications hub that is used to link just about any point of need, such as a rural home, a clinic, and an isolated village, to any point of medial care. We are making plans to build disease-tracking capability into the Bridge, headed toward a sort of automated epidemiological knowledge system.

The Rapid Prototyping Lab is an in-house facility where our engineers design, develop and test new telemedicine technologies. You can take a virtual tour of our lab on the web at http://www.telemed.med.ecu.edu/2001/pan/frame2.htm

The Telemedicine Practice Suite (TMPS) is a customized telemedicine space for healthcare professionals. The space is designed to support the ergonomic and multimedia needs of the healthcare professional.

Interventional Informatics is a new term for me. Can you elaborate on it?

Interventional informatics is the application of information to alter an outcome. For instance, we have access to knowledge and information that, when applied properly or shared with the people that lack that information, can act as a catalyst for a desired outcome. For example, if you were doing real time monitoring of a heart patient at home, and automatically charting their EKG in real time (which is very doable, but not yet reimbursable), you could have preset thresholds in the software, which call 911 and sends a page the physician when the patient was getting ready to have a heart attack. I think this is the holy grail of interventional informatics.

What excites you the most about these projects? Do you have a favorite?

Telemedicine development is an accelerated evolutionary process. There is always a "next generation" of technology to discover, learn about, acquire, develop, and apply. The applications are all so exciting. My favorite project right now is the development of the Global Telemedicine Resource Center. It goes back to interventional informatics and couples knowledge systems to humanitarian medical needs.

What about some of the demonstration projects?

Demonstration projects differ from our ongoing daily, weekly, and monthly services. Demos are temporary projects that are designed to demonstrate our capabilities. They bring awareness to healthcare professionals, educators, and the people we serve regarding a new tool and application. They also give us a chance for feedback from potential end users. We then incorporate some of this feedback in further development efforts.We have done lots of different kinds of demos, most recently the Strong Angel exercise. But we always come away from these events with modifications to our technology or new development projects.

What is ECU doing in the areas of Teleschool and Telehome?

In partnership with the Eastern Area Health Education Center, our telemedicine network supports school based health clinics with distance education and clinical evaluations. As part of the University Health Systems we support telehome applications. There are currently 25 homes linked through regular phone lines supporting chronically ill patients through links to a nursing call center. The rapid prototyping lab makes it possible for us to develop tools that allow healthcare professionals to monitor and assess a patient from a distance. We've created widgits that transmit information related to balance, dexterity, strength, flexion, and extension from a rural home to a clinic. See www.pulsar.org for more information on this.

After the earthquakes in India someone emailed an item about a Japanese medical team using a portable satellite dish and digital camera to take and send a picture of an injury from the site. This is along the lines of KISS. I am convinced that one of the most exciting areas in telemedicine is the potential role it may have in international health care and disaster responses. Tell me about what you and ECU are doing in this area?

There are both high- and low-tech solutions out there that facilitate healthcare to isolated, underserved, and disaster-stricken communities. This is a very exciting area for me, figuring out "appropriate" technology. There are still a lot of barriers that have to be worked out: language, time zone, regulations, confidentiality, and cultural differences. this is all very exciting. We hope to build disaster response solutions through the Global Telehealth Resource Center.

Looking ahead 1, 5, and 10 years from now, where and what do you see in telemedicine?

If telemedicine is successful it will disappear. By that I mean it will become a natural part of clinical delivery services, and will not be a separate entity, except for maybe the R&D.As technology becomes more organic, ergonomic, and a part of everyday appliances, it's marriage to medicine will become more natural.

For the future of home care, I see set-top networked boxes with disposable sensors which you buy at the pharmacy.. the emergence of home wellness monitors. These systems will encourage patients to take responsibility for their health, reduce overall costs of healthcare, and reduce the cost of insurance premiums. This is way over-due, because the technology is here. In fact, the technology has gotten way out in front of the practice of medicine. Instead of slowing down the evolution of technology, we need to speed up the adaptation of technology by the culture of medicine.

The ATA annual conference is one way to keep up with world of telemedicine, yet I am convinced we need to use the medium of email and the internet more to keep our peers up to date such as what Hutchinson does in Georgia. What do you want to say or add to your colleagues out there? And what word of advice can you offer?

The telemedicine community is still pretty small. We have a unique opportunity to make a difference. We need to recognize ourselves as being part of the same family, collectively trying to build better medical delivery systems, promote compatibility, and distribute medical intelligence to the points of need on this spaceship, Earth.

David Balch is currently the Director of the Telemedicine Center and Director of the Center for Health Sciences Communication at the East Carolina University School of Medicine in Greenville, North Carolina. David is part of an external review team for NASA Telemedicine and Commercial Space Centers. He is currently working with a multidisciplinary team developing biosensors and collaborative Web tools for next generation telemedicine systems. He is the founder of DMI Conference, which promotes global Distributed Medical Intelligence models for humanitarian applications. He is Co-Principle Investigator on a $4.6 million contract with NIH to develop Biomedical applications for Next Generation Internet. He has 25 years experience in communications and media development and has produced interactive educational programs and network television shows for Nickelodeon, Showtime, and PBS. David is past chair of the Technology Task Force for the American Telemedicine Association and a U.S. representative on the international G7/G8 working group on telehealth. http://www.telemed.med.ecu.edu

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