Teleophthalmology in the United States Army: A Review From 2004 Through 2018.

INTRODUCTION: We describe results of the U.S. Army Ocular Teleconsultation program from 2004 through 2018 as well as the current condition, benefits, barriers, and future opportunities for teleophthalmology in the clinical settings and disease areas specific to the U.S. Military. MATERIALS AND METHODS: This was a retrospective, noncomparative, consecutive case series. A total of 653 ocular teleconsultations were reviewed; 76 concerned general policy questions and underwent initial screening to determine the year each request was received, the average and median initial consultant response time, the number of participating consultants, the country from which the request originated, the military status and branch of each U.S. patient for which a request was submitted, and the nationality, age, and military status of foreign patients for whom consults were requested. The remaining 577 requests were further analyzed to determine the diagnostic category of the request, whether or not an evacuation recommendation was provided by a consultant, the relationship of the request to trauma, if and what type of nonocular specialty consultant(s) participated in the consultation request, and if and what type of ancillary imaging accompanied the request. RESULTS: The number of requests was 13 in 2004, compared to 80 in 2011 and 11 in 2018. The average response time in 2018 was 2.27 hours compared to 9. 73 hours in 2004. The number of participating ocular specialists was 5 in 2004, compared to 39 in 2013 and 13 in 2018. Requests originating from Iraq and Afghanistan comprised 61.1% (399/653) of requests. The U.S. Army personnel comprised the largest percentage of consults at 38.6% (252/653). Nonmilitary patients from the USA accounted for 18.5% (121/653) of consults. Non-U.S. patients including coalition forces, contractors, detainees, and noncombatants accounted for 14.4% (94/653) of consults, of which 22% (21/94) were children. Anterior segment consults accounted for 45.1% (260/577) of consults, with corneal surface disease being the largest subset within this diagnostic category. Evacuation was recommended in 22.7% (131/577) of overall cases and 41.1% (39/95) of trauma cases. Requests were associated with either combat-related or accidental trauma in 16.5% (95/577) of cases. Dermatology and neurology were the most commonly co-consulted specialties, representing 40.0% (32/80) and 33.75% (27/80) of consults, respectively. Photographs of suspected ocular pathology accompanied 37.4% of consults, with the likelihood requesters included photographs being greatest in cases involving pediatric ophthalmology (7/9, 77.8%) and oculoplastics (86/120, 71.7%). CONCLUSIONS: Army teleophthalmology has been an indispensable resource in supporting and advancing military medicine, helping to optimize the quality, efficiency, and accessibility of ophthalmic care for U.S. Military personnel, beneficiaries, allied forces, and local nationals worldwide. A dedicated ophthalmic care and coordination system which utilizes new advances in teleconsultation technology could further enhance our current capability to care for the ophthalmic needs of patients abroad, with opportunity for improving domestic care as well.

The US Army Medical Department Email Teleconsultation Program.

The US Army Surgeon General authorized the formation of an email based teleconsultation program in 2004 to support deployed healthcare providers in Iraq and Afghanistan. The program, which began its 12th year of operation in April 2015, was originally viewed as a temporary solution until a robust system was fielded. Although future of the program as a going concern has not been determined, there is the possibility it could be incorprated into the critical care consultation program managed at an Army Medical Center.

Utilization of telemedicine in the U.S. military in a deployed setting.

BACKGROUND: A retrospective evaluation of the Department of Defense teledermatology consultation program from 2004 to 2012 was performed, focusing on clinical application and outcome measures such as consult volume, response time, and medical evacuation status. METHODS: A retrospective review of the teledermatology program between 2004 and 2012 was evaluated based on defined outcome measures. In addition, 658 teledermatology cases were reviewed to assess how the program was utilized by health care providers from 2011 to 2012. RESULTS: As high as 98% of the teledermatology consults were answered within 24 hours, and 23% of consults within 1 hour. The most common final diagnoses included eczematous dermatitis, contact dermatitis, and evaluation for nonmelanoma skin cancer. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. Biopsy was most commonly recommended for further evaluation. Following teleconsultation, 46 dermatologic evacuations were "avoided" as the patient was not evacuated based on the consultants' recommendation. Consultants' recommendations to the referring provider "facilitated" 41 evacuations. CONCLUSION: Telemedicine in the U.S. military has provided valuable dermatology support to providers in remote locations by delivering appropriate and timely consultation for military service members and coalition partners. In addition to avoiding unnecessary medical evacuations, the program facilitated appropriate evacuations that may otherwise have been delayed.

Outcomes from a US military neurology and traumatic brain injury telemedicine program.

OBJECTIVE: This study evaluated usage of the Army Knowledge Online (AKO) Telemedicine Consultation Program for neurology and traumatic brain injury (TBI) cases in remote overseas areas with limited access to subspecialists. We performed a descriptive analysis of quantity of consults, response times, sites where consults originated, military branches that benefitted, anatomic locations of problems, and diagnoses. METHODS: This was a retrospective analysis that searched electronic databases for neurology consults from October 2006 to December 2010 and TBI consults from March 2008 to December 2010. RESULTS: A total of 508 consults were received for neurology, and 131 consults involved TBI. For the most part, quantity of consults increased over the years. Meanwhile, response times decreased, with a mean response time of 8 hours, 14 minutes for neurology consults and 2 hours, 44 minutes for TBI consults. Most neurology consults originated in Iraq (67.59%) followed by Afghanistan (16.84%), whereas TBI consults mainly originated from Afghanistan (40.87%) followed by Iraq (33.91%). The most common consultant diagnoses were headaches, including migraines (52.1%), for neurology cases and mild TBI/concussion (52.3%) for TBI cases. In the majority of cases, consultants recommended in-theater management. After receipt of consultant's recommendation, 84 known neurology evacuations were facilitated, and 3 known neurology evacuations were prevented. CONCLUSIONS: E-mail-based neurology and TBI subspecialty teleconsultation is a viable method for overseas providers in remote locations to receive expert recommendations for a range of neurologic conditions. These recommendations can facilitate medically necessary patient evacuations or prevent evacuations for which on-site care is preferable.

The United States Army Ocular Teleconsultation program 2004 through 2009.

PURPOSE: To describe the United States Army Ocular Teleconsultation program and all consultations received from its inception in July 2004 through December 2009. DESIGN: Retrospective, noncomparative, consecutive case series. METHODS: All 301 consecutive ocular teleconsultations received were reviewed. The main outcome measures were differential diagnosis, evacuation recommendations, and origination of consultation. Secondary measures included patient demographics, reason for consultation, and inclusion of clinical images. RESULTS: The average response time was 5 hours and 41 minutes. Most consultations originated from Iraq (58.8%) and Afghanistan (18.6%). Patient care-related requests accounted for 94.7% of consultations; nonphysicians submitted 26.3% of consultations. Most patients (220/285; 77.2%) were United States military personnel; the remainder included local nationals and coalition forces. Children accounted for 23 consultations (8.1%). Anterior segment disease represented the largest grouping of cases (129/285; 45.3%); oculoplastic problems represented nearly one quarter (68/285; 23.9%). Evacuation was recommended in 123 (43.2%) of 285 cases and in 21 (58.3%) of 36 cases associated with trauma. Photographs were included in 38.2%, and use was highest for pediatric and strabismus (83.3%) and oculoplastic (67.6%) consultations. Consultants facilitated evacuation in 87 (70.7%) of 123 consultations where evacuation was recommended and avoided unnecessary evacuations in 28 (17.3%) of 162 consultations. CONCLUSIONS: This teleconsultation program has brought valuable tertiary level support to deployed providers, thereby helping to facilitate appropriate and timely referrals, and in some cases avoiding unnecessary evacuation. Advances in remote diagnostic and imaging technology could further enhance consultant support to distant providers and their patients.

Deployed provider satisfaction with infectious disease teleconsulation.

The Army Knowledge Online provides an e-mail service to assist deployed health care providers with specialty consultation. This performance improvement project evaluated the impact and utility of the infectious disease Army Knowledge Online teleconsultation service. Health care providers using the service from January 2010 through December 2010 were emailed a 9-question survey. The survey sought to determine if teleconsultation changed care or evacuation plan, and if responses were timely and clear. 123 consults were received, primarily from Afghanistan (58) and Iraq (26), and primarily regarding U.S. service members: (Army-36, Navy-18, Air Force-10, and Marines-3). Consults were answered on average in 3.3 hours. Completed surveys were obtained from 87 of the total 123 consultations. Responses to survey questions were as follows [scored on a 5-point scale from 1 (no, not at all) to 5 (yes, absolutely)]: Response Helpful (4.6), Response Changed Care (3.3), Response Changed Evacuation Plan (1.8), If Evacuation Plan Changed; was Evacuation Prevented (2.4), Response Timely (4.8), Response Verbose (1.1), Recommendations Clear (4.6), Too Many Recommendations (1.2), and Response Answered Your Question (4.8). The infectious disease teleconsultation service provides timely, helpful, and relevant feedback and plays an important role in influencing patient evacuation plan.

Paging the worldwide cardiology consultant: the Army Knowledge Online Telemedicine Consultation Program in cardiology.

BACKGROUND: Global operations place large numbers of military and nonmilitary personnel in austere environments. Aeromedical evacuation for cardiovascular issues is periodically required. The Army Knowledge Online (AKO) Telemedicine Consultation Program was initiated by the Office of the Surgeon General to electronically link deployed medical providers with subspecialty consultants to assist and guide triage and disposition. METHODS: Electronic consultation triggered a text page to an on-call staff cardiologist at Brooke Army Medical Center. Cardiology teleconsultations for the first 3.5 years were analyzed. RESULTS: Two hundred seven cardiology teleconsults were managed, with an average response time of 4 hours 54 minutes. The three most prevalent reasons for teleconsultation were electrocardiographic abnormalities, chest pain syndromes, and syncope. Six evacuations were avoided; 29 evacuations were facilitated. An estimated $144,000 was saved, plus intangible benefits. CONCLUSIONS: Cardiology teleconsultation provides a valuable service to deployed providers, decreases medical evacuation costs, and facilitates transfer of patients to appropriate facilities.

Infectious disease teleconsultative support of deployed healthcare providers.

Specialty teleconsultation is being provided to deployed healthcare providers in the current wars in Iraq and Afghanistan through the use of the Army Knowledge Online (AKO) e-mail service. We reviewed 374 teleconsults received by the infectious disease (ID) service between January 2005 and June 2008. The patients were 65% male, 12% female, 33% the gender was not stated or the consult did not involve an individual, and 41% were U.S. Army. The average response time was under 5 hours. Ninety-one percent of consults originated from the U.S. Central Command area of responsibility. Consults included questions pertaining to therapy (42%), diagnosis (21%), prevention (13%), or mixed categories (24%). Bacterial infections were the most common (32%), followed by parasitic infections (16%). Tuberculosis and methicillin-resistant Staphylococcus aureus accounted for 13% and 8% of consults, respectively. Data from this program should be useful in focusing predeployment provider training. It also provides the military ID community situational awareness of problems encountered in theater.