Background: In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rear-based specialists in a timely and consistent manner.

Methods: Consults are generated using the AKO e-mail system routed through a contact group composed of volunteer, on-call consults. The project manager receives and monitors all teleconsultations to ensure Health Insurance Portability and Accountability Act compliance and consultant's recommendations are transmitted within a 24-hour mandated time period. A subspecialty “clinical champion” is responsible for recruiting consultants to answer teleconsultations and developing a call schedule for each specialty. Subspecialties may have individual consultants on call for specific days (e.g., dermatology and toxicology) or place entire groups on-call for a designated period of time (e.g., ophthalmology).

Results: As of May 2007, 2,337 consults were performed during 36 months, with an average reply time of five hours from receipt of the teleconsultation until a recommendation was sent to the referring physician. Most consultations have been for dermatology (66%), followed by infectious disease (10%). A total of 51 known evacuations were prevented from use of the program, while 63 known evacuations have resulted following receipt of the consultants' recommendation. A total of 313 teleconsultations also have been performed for non-US patients.

Conclusions: The teleconsultation program has proven to be a valuable resource for physicians deployed in austere and remote locations. Furthermore, use of such a system for physicians in austere environments may prevent unnecessary evacuations or result in appropriate evacuations for patients who initially may have been “underdiagnosed.”