Dr. Folen is employed by the U.S. federal government. He has worked at Tripler Army Medical Center in Hawaii since 1984 and serves as Chief of the Behavioral Medicine and Health Psychology Service. He became interested in psychophysiological monitoring during his junior year in college, when he was studying the "incubation of threat" effect. He did further study in biofeedback after finishing graduate school and has been engaged in a number of interesting projects, one with NASA entitled "Autogenic Training and Pilot Performance During Emergency Flying Conditions". The most notable experience about that project was his required presence in the airplane while the engines were being shut down in order to simulate emergency flying conditions.

What is Tripler?

The Tripler Army Medical Center is actually a 'TRI-SERVICE' medical facility that provides medical care to all active duty U. 5. Army, Navy and Air Force personnel located in the Pacific. We provide care to family members and military retirees, as well. We also have responsibility for providing care to Pacific Islanders in American Samoa and other Pacific Island governments. Our area of responsibility covers over 1/2 of the earth's surface.

We have soldiers and sailors deployed to many remote settings where highly specialized care is not available. Biofeedback, for example, is not available on our bases in Japan, Korea or Guam, where we have a large number of personnel. in order for them to receive biofeedback services, the patient must be flown to Hawaii and housed for the duration of the treatment. This may take up to 10 weeks or more, which leaves the remote duty station understaffed for that period of time. As a result, having the capability to provide health care and health information across great distances by utilizing the latest in telecommunications technology (the definition of telehealth) is of great interest to us, since it provides the patient with significantly improved access to care. Several years ago, Dr. Larry James wrote the first grant proposal for us, to utilize telehealth technology and we've been at it ever since. We are now providing treatment services to patients located thousands of miles away. The patient is able to remain with his or her family and can continue to engage in regular work duties.

There are two primary components to the system. The first establishes the video and audio communication between patient and provider. The second component allows the provider to control the biofeedback system at the remote site and 'see' the remote site biofeedback computer display. All this must happen in 'real time', which can present a challenge, given that many remote sites do not have a well-developed communication infrastructure. Often, the only telecommunications available remotely are the "plain old telephone service" (POTS) lines. This is certainly true for most of our sites in the Pacific. Fortunately, realtime simultaneous visual and audio communications have recently undergone major technological advancement, to the point that excellent audio and acceptable video signals can be sent over POTS. To establish the video/audio connection, we utilize H.324-compatible videophones, of which many are available commercially for as low as $450 per unit. (A web search under 'H.324' will easily locate the vendors). All are designed to work over a single phone line. To establish a videophone call, the sender and receiver must have their videophone units turned on at their respective site. One party then dials the other using a standard phone attached to the videophone. Once a connection is established, one party presses a key on the phone and the two videophones link up. While picture quality is not up to broadcast standards, we have found it to be very adequate for the job. The biofeedback system is set up at the remote site. The clinician controls the remote computer using commercially available 'remote control' software. This allows for all computer-intensive activities (signal acquisition, signal processing, data collection and visual display) to occur at the remote site. The clinician is able to control the remote computer (keyboard and mouse) as well as view an exact image of the remote computer display. To property maintain remote control of the biofeedback equipment, we found it necessary to use 100% Windows based biofeedback software. For a number of technical reasons, biofeedback systems that were DOS-based were found to be completely incompatible with the remote control software. This was also true for DOS-based biofeedback programs running in a Windows environment. The system we used that met our project's requirements was the ProComp+/BioGraph system.

We have utilized the above system with a number of patients and have now established remote stations at the U. S. Army 121 General Hospital in Seoul, Korea, the U.S. Navy General Hospital in Yokosuka, Japan, and the U. S. Navy General Hospital in Guam. In each location, connectivity has proved to be very reliable and patients are currently receiving biofeedback services for a variety of conditions, including migraine headache, irritable bowel syndrome, temporomandibular joint disorders and chronic pain.

There is a tendency for clinicians, when considering telehealth, to think that 'more is better'. This is often not the best choice, as highend telehealth systems can cost from $20-100 thousand and have high infrastructure requirements (technician support, ISDN phone lines, etc.). The system we developed, including all biofeedback and telecommunications equipment, cost approximately $9000. The equipment was designed to have minimum installation requirements two phone tines and an electrical outlet. The video/audio connection is established with a videophone ($450), good speakerphone ($200), and 20" TV ($300) on each end. The biofeedback connection consists of remote control software ($100) and a Pentium computer ($1000) on each end and biofeedback equipment and software ($5000) at the remote site.

Telehealth is growing at an incredibly fast rate. From radiographic imaging to remote robot-controlled surgeries, to psychotherapy, hypnotherapy and biofeedback, the limits of the technology are yet to be reached. Telehealth incorporates high end, high-bandwidth technologies as well as low-bandwidth mediums such as 11.324 videoconferencing, remote control software, web sites, e-mail, pagers, cell phones, telephone and, yes, even the postal service!

Absolutely. What we are doing with biofeedback, for example, can be utilized today In the civilian sector. All of the equipment is commercially available, off-the-shelf technology. If we can see a 1 PM patient in Guam, a 2PM patient in Korea and a 3PM patient in Japan, any clinician can take the same equipment and establish biofeedback systems at several satellite locations. The only other technical requirement at the remote site is the minimal training of a technician, sufficient for them to competently attach the sensors to the patient, turn the equipment on and answer the phone. Of course, the provider should have clinical backup in place at the remote site. For example, if a patient comes in and reports imminent suicidal tendencies, someone at the remote site should be available to intervene.

Good question, and the answer is no. One can talk on the phone to someone at the remote site and explain how to set up the videophone. Once the videophone is hooked up, it can be used to explain how to set up the biofeedback system. It's all pretty straightforward. We've done it easily with some rather "technology-com promised" folks.

Tripler is an incredibly active research site cutting-edge of a number of emerging technologies and treatment methodologies. In the Telehealth arena, for example, Congress has funded a Pacific e-health Innovation Center that is based at Tripler. Our success with the biofeedback project has generated a number of other projects that utilize low-bandwidth technology as well.

Yes. Our particular interest is in lowbandwidth telehealth (LBT), where the technology requirements are no more than a POTS line. Just about every presentation we have given on the subject generates a great deal of enthusiasm. We've had participants come up to us and say, "Not only do I want to set up the biofeedback system, I would like to use LBT in another clinical application as well." So yes, the interest is quite strong and one of our goals for the next year is to 'export' what we have learned throughout the armed forces as well as in the civilian sector.

Dr. Larry James started the Tripler behavioral telehealth project in 1997. The current team consists of Drs. Ray Folen, Larry lames, Jay Earies, Michael Ketlar, Mark Verschell, and Ms. Rosa Castra, Mr. Angelo Alvarez and Mr. Steve Blotzky. The project is funded by the Pacific c-health Innovation Center, located at Tripler. The opinions and assertions contained in this manuscript are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army, Department of Defense or the U.S. Government.

Return to Article Index