AAMI planned its first-ever videoconference as a keynote presentation that would link two sites in Boston and introduce attendees to medical simulation technology and telemedicine. And then things got interesting.

Standing at the podium in a ballroom in Boston's John B. Hynes Veterans Memorial Convention Center in June, Jeffrey B. Cooper, PhD, director of the Center for Medical Simulation (CMS) at Harvard Medical School, welcomes the audience to the keynote presentation of the 34th Annual Meeting and Expo of the Association for the Advancement of Medical Instrumentation (AAMI). He then introduces Yadin David, PhD, director of biomedical engineering at Texas Children's Hospital, visible on a rear projection screen but actually sitting in a broadcast studio in Petah Tikva, just outside Jerusalem, Israel. Later in the session, Cooper welcomes medical personnel at CMS, in Boston, and at Texas Children's Hospital in Houston, who in turn appear on screen. Over the course of two hours, people at the four locations participate in an interactive videoconference that dramatically demonstrates the power and potential of both medical simulation and telemedicine.

After the videoconference, the planners are thrilled, but they also are enormously relieved. When they began planning this videoconference--their first--they had no idea how complex it would become.

Planning an Experience It all started last September, when Ellen P. Bonanno, director, marketing and expositions for Arlington, Va.-based AAMI, was searching for a stimulating keynote for the meeting. Most of her attendees are biomedical engineers and equipment technicians (BMETs), who service and support medical equipment, and clinical engineers, who manage those departments. Both groups are facing intense pressure professionally.

"A lot of those departments have been downsized and the functions outsourced," Bonanno explains. "So people aren't sure what kind of future they have. Our objective was to give them a vision of the opportunities and challenges."

But AAMI is under pressure as well. It's facing increasing competition from other meetings targeting this market, says Kathy Warye (pronounced wear-eye), senior vice president, education and government programs. That competition is keeping meeting attendance flat; this year's event drew 2,345. To strengthen its position, AAMI "needed to create an experience, to generate energy and excitement," Warye says.

A suggestion came from Cooper, who, in addition to his Harvard post, is also director of biomedical engineering for Partners HealthCare System, Inc., as well as an AAMI member. Since 1993, CMS has conducted medical education programs using a computer-controlled patient simulator. The simulator has a heartbeat, pulse, and measurable blood pressure; its eyelids open and close, it exhales real carbon dioxide, it speaks, it bleeds. Cooper's idea: Combine two technologies, medical simulation and telemedicine, to bring CMS to the meeting.

"Simulation is a tool to educate," says Cooper. "For example, if we want to educate people about how to manage a crisis, we simulate the crisis and have them debrief afterward." Telemedicine, which links health care professionals with patients anywhere in the world, is already being demonstrated. "It's not novel," says Cooper. "It's only novel to this engineering group. I wanted to give these people lots of ideas, psych them up, energize them."

The suggestion appealed to AAMI. Says Warye, "We'd been attempting to bring more technology into the meeting. We were looking for a high energy, high-tech concept." Adds Bonanno, "The original idea was to have the videoconference show the simulator at CMS in a critical care event. We would involve the audience in Boston in solving the crisis."

More Complex, More Valuable This would be a new experience not only for the attendees, but for AAMI as well. "I didn't know anything about videoconferencing," Bonanno acknowledges. "I read up on it so I'd at least understand what was involved. But I didn't see my role as extensive."

In fact, at the beginning, everyone thought that setting up the videoconference between CMS and the Hynes would be simple and inexpensive. It could be handled completely by Partners HealthCare, which has done a number of such conferences. The cost would be between $3,000 and $5,000, and Partners would even help AAMI secure sponsorship. "We just had to coordinate the AV equipment," says Bonanno.

"Then it got more complicated," says Cooper. "I wanted Yadin on the panel. He's the pioneer in telemedicine, and he's a biomedical engineer." But David couldn't attend the AAMI meeting in Boston because he was scheduled to be in Israel at the 4th International Conference on the Medical Aspects of Telemedicine. No problem. This was going to be a videoconference, after all.

David agreed to appear long distance, but had his own suggestion. He wanted to tie in his colleagues from Texas Children's Hospital to discuss the applications of telemedicine.

Each new idea was making the videoconference more valuable for the attendees. But for AAMI, it was becoming not only more complex, but also riskier. "There's the risk to your reputation and your credibility," says Warye. "What if your primary event falls flat?" The event was also becoming--surprise!--more expensive.

Then, just three months before the meeting, Bonanno recalls, "Jeff said, 'By the way, Partners isn't going to be able to do the videoconference.'" It had grown into an event whose scope simply was beyond Partners' abilities to handle. Bonanno's calm tone belies the panic she must have felt. If Partners couldn't do it, who would?

Point to Point to Point to Point Fortunately, Partners didn't leave AAMI in the lurch. They recommended TVR Communications, a technology contractor in Woodside, N.Y., which handles videocon-ferences and telemedicine in six states in the Northeast. TVR has the capability to integrate all the major videoconferencing systems, and that was critical because each participant had a different system: At the Hynes, TVR used Polycom; CMS used PictureTel; Houston used CLI, and the site in Israel used VTEL.

Partners had to step back because the videoconference had expanded from point-to-point--that is, only two sites participating--to multipoint. Howard Brown, TVR's vice president, sales and operations, explains why multipoint is so much more complicated: "Whenever a videoconference has three or more sites, they must go through a bridge, a piece of hardware that allows multiple sites to dial in." The bridging hardware is known as a multipoint control unit (MCU). During the actual videoconference, David showed attendees a schematic of the four sites linking into the MCU.

Each site that calls into a bridging service must be certified before the videoconference. "Certification is an independent test between the site and the bridging company to ensure that the site can dial in and can do audio and video," says Brown. "The systems all talk to each other, but depending on the vintage, there could be connectivity problems. The certification test usually clears up any problems."

It was not necessary to reserve costly satellite time for the event. All the sites--Jerusalem included--called in over regular telephone lines. Still, the Jeru-salem call raised an issue: Who would place the call? "The dialing direction is up to us," says Brown, who learned that if the call originated in the United States, the charge would be $708 per hour, or a total of about $4,500 for the videoconference plus setup and testing time. If the call originated in Israel, the rate would be closer to $500 per hour. "The rates already exist, so we try to call the less expensive way," Brown explains.

The video came into the Hynes over ISDN lines that were already in place and just needed to be connected. Three ISDN lines, a total of 384 Kb, were used. "That's the minimal acceptable bandwidth," says Brown.

Finding a Money Tree Meanwhile, costs were rising. The tab for the videoconference was now close to $10,000. Where would the money come from?

Cooper stepped in to help secure funding. "I saw it as my role because it was my keynote," he says. But there was more to it than that. He had a good prospect for sponsorship: GE Medical Systems, which was exhibiting at AAMI for the first time. Last year, GE Medical, maker of diagnostic imaging systems, bought Marquette, maker of patient monitoring, diagnostic cardiology, and clinical information systems, and an established AAMI exhibitor. There had been some tensions between GE Medical and the biomedical community; this was an opportunity to smooth relations. Don Trombatore, biomedical program manager for the acquired company, now known as GE Marquette Medical Systems, negotiated the sponsorships. GE Medical picked up the lion's share of the cost because GE Marquette's AAMI budget was already largely accounted for with a grant and an award. Says Trombatore, "AAMI is my vehicle to the biomedical industry. I want to give them absolute support. The keynote was my effort to show solidarity between GE Medical and GE Marquette in support of the biomedical profession."

That negotiation took time, however. It was less than two weeks before the meeting when Brown at TVR found out that the bridging agreement would be paid for and it was OK for him to proceed.

Testing 1, 2, 3 The videoconference was scheduled for 8 a.m. on Monday, June 7. At 3:30 on the preceding afternoon, the test run began. The Hynes, CMS, and Houston were connected to the bridge. Jerusalem was not included because it was seven hours ahead--late evening. Just one day before the event, people still didn't know if that site was going to work. There was, however, a back-up audiotape of David, just in case, plus a backup video from CMS.

A lot of fine-tuning was needed at the sites that were connected. At first, people at CMS couldn't hear Cooper clearly. Once they could hear him, they started getting feedback. Repositioning the CMS mike solved that problem; then the tech contact in Houston found that he got feedback when CMS was on the line. The solution: When no one at CMS was speaking, that site should mute its speaker. The tweaking continued for several hours. Another test--this time with Jerusalem included--was planned for early Monday.

The schedule was routine for the tech types, but was a major stress-inducer for the planners. "A lot of the technology didn't fall into place till just before the event," says Warye. "The ISDN lines weren't in; the sites hadn't been certified." In fact, the sites weren't certified until the Friday before the event. "We're people who are used to planning things months ahead," she says. "It was the do-it-in-advance culture vs. the just-in-time culture."

On with the Show It's 8:05 Monday morning. Cooper has introduced David; audio is coming through from Israel, but no video. Behind the scenes, a tech from TVR walks an Israeli contact through the connection process until the source of the problem is located: a loose cable. It's tightened, David appears, and the videoconference is under way.

After a summary of the session objectives, the conference connects to "the intensive care unit at Harvard Hospital"--in reality, a hospital room mock-up at CMS. On the right-hand screen, a real nurse, Ellen Kinnealey, RN, attends a "patient"--the simulator--suffering from pulmonary hypertension. On the left screen, you see a monitor tracking the patient's vital signs.

Kinnealey says that she needs to realign the monitor. Cooper calls for an audience volunteer who is familiar with Marquette systems. One walks to the mike and explains what needs doing.

Suddenly the right screen goes black. This time, however, it's in the script: It's a power failure at the hospital. When the power comes back up, Kinnealey needs to "re-zero" the transducers. Can anyone in the audience help?

And so it continues as the BMETs at the conference assist the nurse at the CMS. At the end of this sequence, "Harvard Hospital" signs off, and Cooper explains the use of simulation in medical education and training, and the types of simulators that are available today. "This will change the culture of medicine," he tells the audience. "People will believe you have to train on simulators before you train on patients."

The remainder of the videoconference focuses on telemedicine. Doctors at Texas Children's Hospital discuss the applications and impact of the technology. "Some of our operating rooms can transmit images so a consultant can observe and give an opinion," says one. As a film of a surgical procedure is shown, he provides a running commentary for the attendees. David explains the technology involved in telemedicine, and there is a dialogue between Texas, on the left screen, and Israel, on the right. Says David, "This looks easy, but you need experts behind the scene."

The videoconference worked--for the attendees and for AAMI. "On the general evaluation sheets, people said it was one of the highlights," says Bonanno. "Because the videoconference worked so well and was so different from anything we'd done before, it helped change our image. We'd been doing the same thing for too long. This was a giant step forward for us."

*The Center for Medical Simulation (CMS) at Harvard Medical School gives hands-on simulation training to five people at a time, at a cost of $600 to $700 for a day that earns them eight CME credits, says Jeffrey B. Cooper, PhD, director of CMS. With telemedicine, he says, people can get realistic crisis management training at a cost closer to $100 for the day. For information on medical simulation, contact Cooper at (617) 726-1636, fax (617) 726-6973, jcooper@partners.org or go to www.harvardmedsim.org or web.anes.rochester.edu/simulate/webpages.htm.

*For information on telemedicine, contact Yadin David, PhD, director of biomedical engineering at Texas Children's Hospital in Houston at ydavid@msmail.his.tch.tmc.edu

*For information on videoconferencing, contact Howard Brown, vice president, sales and operations, for TVR Communications, Woodside, NY at (718) 335-3031, fax (718) 779-5293, h.brown@tvrc.com or go to www.tvrc.com.