An Internet-Based Referral/Consultation System for the U.S.-Associated Pacific Islands: Its Contribution to Orthopedic Graduate Medical Education at Tripler Army Medical Center

Military Medicine, Mar 2005 by Hensel, Kurt S, Person, Donald A, Schaefer, Richard A, Burkhalter, William E

To evaluate the benefit of the Pacific Island Health Care Project (PIHCP) to our orthopedic graduate medical education program, we performed a retrospective review of our 8-year operative experience with patients referred through this program. Between July 1994 and June 2002, 69 patients underwent 79 orthopedic operative procedures. Patients were categorized by primary diagnosis, anatomic site involved, and surgical treatment rendered. Because many of the patients referred from the PIHCP with tumors were noted to have either unusually large lesions or advanced-stage disease, further analyses of tumor stage and pathologic grade were made. Seven of the 14 oncologic cases surgically treated in our department in the past 8 years were referrals from the PIHCP. Unique operative procedures performed for these tumor patients included one forequarter amputation, one hip disarticulation, one hemipelvectomy, two partial scapulectomies, and one distal ulna excision. We conclude that the PIHCP referrals provide an important and relatively unique contribution to the clinical and operative experience of our orthopedic residents. These patients from the Pacific basin also enhance our orthopedic graduate medical education program by exposing our residents to the special socioeconomic and cultural issues related to caring for people from developing insular countries.

Introduction

The primary goal of graduate medical education (GME) programs is to train physicians to be clinically competent in their respective areas of practice. As established by the Academic Orthopaedic Society of the American Academy of Orthopaedic Surgeons, an "ideal" orthopedic program would contain an ". . . adequate volume and diversity of case material . . . ," including ". . . appropriate (neither too few nor too excessive) numbers of cases of trauma, adult reconstructive, pediatric, hand, foot, sports, spine, metabolic, tumors, and microvascular orthopaedic disorders (p 271)."1 Because of increasing requirements for GME cases at Tripler Army Medical Center (TAMC) in the late 1980s, as well as its proximity to the South Pacific region, the Pacific Island Health Care Project (PIHCP) was initiated. This review was performed to quantify the success of the PIHCP in improving orthopedic GME at TAMC.

The PIHCP is a congressionally mandated program whereby patients from the United States-Associated Pacific Islands (USAPI) (formerly the Pacific Trust Territories of the United States), are referred to TAMC for definitive medical care. The PIHCP was initiated in 1989 at the behest of a number of senior "teaching chiefs," for the purpose of enhancing their trainees' experiences in dealing with patients with advanced diseases from the developing world.2,3 Such patients are rarely available in mainland training centers. Under the aegis of Hawaii's senior U.S. senator, the Honorable Daniel K. Inouye, funds were appropriated to provide solely for transportation of the patients from their homeland jurisdictions to TAMC and their return. Initially, however, the cost of medical care for this program was borne by TAMC.

Six island jurisdictions, with a population of more than 500,000 people, spread over an immense area of ocean larger than the continental United States, make up the USAPI (Fig. 1). Three of these are U.S. flag territories, i.e., Guam, Commonwealth of the Northern Mariana Islands, and American Samoa. The other three are independent but freely associated with the United States, i.e., the Republic of the Marshall Islands, Federated States of Micronesia (which includes the states of Chuuk, Kosrae, Pohnpei, and Yap), and the Republic of Palau. In an effort to ". . . contain costs, increase access, and provide consultative and referral services to physicians in the Pacific Basin,"3 in 1998 this project evolved into its current state as an Internet-based referral and consultation system.

More detail on the logistical and operational aspects of how the Internet referral system was established and how it is currently managed is provided in several publications by Person et al.2,3 In brief, a remote medical provider initiates the process by entering an Internet referral at one of the Pacific Island sites previously established by the PIHCP. Four referral sites throughout the South Pacific region were provided with the required equipment for generating Internet referrals, including computers, scanners, and digital cameras. Medical providers were trained in the use of the equipment, as well as how to input and send consultation requests. This requires providers to enter patient information such as the medical history, physical examination results, laboratory data, and sometimes digital photographs of the patient and radiographs. This information is sent via the PIHCP World Wide Web page in a "store and forward" fashion. The project director located at TAMC reviews new consultation requests and either approves, disapproves, comments on, or forwards the case to a specialist at TAMC for consultation. These consultants access the case via the PIHCP World Wide Web page by case number, review the consultation request (including all previous correspondence and data), and provide their opinion of appropriateness for GME and recommended evaluation and treatment. Patients requiring surgical treatment are then sent to TAMC via commercial airline. Once the patient's treatment is completed, Instructions for follow-up care are given and the patient is returned to his or her homeland. Such instructions, as well as follow-up data, can be entered into the patient's file on the World Wide Web page for continuity of care. To date, more than 4,000 USAPI patients have been treated (either medically or surgically) through the PIHCP at TAMC. In addition, the PIHCP has provided countless online medical consultations for patients who ultimately did not require transportation to TAMC but did benefit from expert medical advice as a result of the referral.