Military Telehealth: A Model For Delivering Expertise To The Point Of Need In Austere And Operational Environments.

Austere clinical environments are those in which limited resources hamper the achievement of optimal patient outcomes. Operational environments are those in which caregivers and resources are at risk for harm. Military and civilian caregivers experience these environments in the context of war, natural disasters, humanitarian assistance missions, and mass casualty events. The military has a particular interest in enhancing local caregiver capabilities within austere and operational environments to improve casualty outcomes when evacuation is delayed or impossible, reduce the cost and the risk of unnecessary evacuations, enhance the medical response during aid missions, and increase combat effectiveness by keeping service members in the fight as long as possible. This article describes military telehealth as it relates to care in austere and operational environments, and it suggests implications for policy, particularly with respect to the current emphasis on telehealth solutions that might not be feasible in those settings.

Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments.

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."

Clinical presentations for influenza and influenza-like illness in young, immunized soldiers.

Concern about respiratory diseases in soldiers increased in the late 1990s as production of the successful adenovirus vaccines stopped and the possibilities of an emergent pandemic influenza strain and use of bioweapons by terrorists were seriously considered. Current information on the causes and severity of influenza-like illness (ILI) was lacking. Viral agents and clinical presentations were described in a population of soldiers highly immunized for influenza. Using standard virus isolation techniques, 10 agents were identified in 164 (48.2%) of 340 soldiers hospitalized for ILI. Influenza isolates (29) and adenoviruses (98) occurred most frequently. Most influenza cases were caused by influenza A and probably resulted from a mismatch between circulating and vaccine viruses. Most (58.5%) patients with an adenovirus had a chest radiograph; 31.3% of these had an infiltrate. Clinical findings did not differentiate ILI caused by the various agents. Only 29 cases of influenza occurred in approximately 7,200 person-years of observation, supporting the use of influenza vaccine.

Physician-to-physician consultation via electronic mail: the Walter Reed Army Medical Center Ask a Doc system.

INTRODUCTION: Physician-to-physician consultation and discussion have traditionally been conducted by telephone, paper, and "curbside" (face to face meetings). The implementation and use of physician-to-physician consultation via electronic mail in a military health care system has not been reported previously. METHODS: The group mail function of the Composite Health Care System, the main outpatient medical automation system for the Department of Defense, was modified to create mailgroups for every specialty of the Walter Reed Army Medical Center to facilitate ease of physician-to-physician consultation. This modification was called the "Ask a Doc" system. The system was deployed to a 21-state health care network among triservice participants. RESULTS: There were 3,121 consultations logged from April 22, 1998, to December 31, 2000. Growth in use expanded initially and was sustained during a 3-year period. Average response time to consultations was less than 1 day (11.93 hours). Additional training and maintenance requirements were minimal. In general, the use of electronic consultation mirrored that of clinical practice. Most specialty consultations involved the disciplines of internal medicine. CONCLUSIONS: Use of the Ask a Doc system was representative of total clinical workload and increased access to specialty medical care over a wide geographic area. The distribution of use indicated that user statistics were legitimate, and quality improvement programs could easily troubleshoot the system. Ask a Doc was inserted into a regional health care network with minimal cost to support and implement and was sustained with very little effort for 3 years. Barriers to even wider use currently include lack of secure communications and the difficulty in assigning workload credit for electronic consultations.

Telepresence and telemedicine in trauma and emergency care management.

The use of telemedicine is long-standing, but only recently has been applied to the specialties of trauma, emergency care, and surgery. Subsequently the concepts of teletrauma, telepresence, and telesurgery have evolved and are being integrated into modern care of trauma and surgical patients. This chapter will review the current applications and future endeavors of telemedicine and telepresence to trauma and emergency care as the new frontiers of telemedicine application.