Telemedical Support for Military Medicine.

Introduction: U.S. military forces have engaged in combat in mature areas of operations (AOs) in Iraq and Afghanistan that allow for casualty evacuation to definitive surgical care within "The Golden Hour." Future combat casualty care will be complex and challenging. Facing the medical demand of the Multi-Domain Battlefield remains an uncertain problem set. What can be anticipated is that a near peer adversary will not allow freedom of movement, air superiority, or uninterrupted communications. Telemedicine is one solution that can aid in this environment because it can reduce the medical footprint in a theater of operation by bringing the remote expert's knowledge and experience to the point of need. Materials and methods: Telemedicine can augment the capabilities of caregivers in austere, operational settings using synchronous or asynchronous technology to optimize the care of casualties who are delayed in evacuation to higher levels of care. These technologies have been implemented and tested over the past 30 yr. We reviewed the historical literature about military telemedicine and assembled current leaders in military telemedicine to write this review. Results: This manuscript reviews the history of and current capabilities of military telemedicine. Conclusions: Broad implementation of telemedicine in the operational setting is challenged by network limitations and cyber security concerns. Reliable, high bandwidth, low latency, secure communications that is necessary for advanced telemedicine capabilities (i.e., procedural telementoring) will not likely be available at all times during future engagements. The military must develop and train a full spectrum of telemedical support options that include low-to-high bandwidth solutions. Telemedicine is not a substitute for deploying anticipated medical resources or optimizing training: telemedicine is plan B where plan A is training, deployment, and casualty evacuation. Nevertheless, when network and communications resources are sufficient, telemedicine brings advanced expertise to austere, resource-limited contexts when timely evacuation is not possible.

Assessment of patient engagement with a mobile application among service members in transition.

OBJECTIVE: This article examines engagement with a mobile application ("mCare") for wounded Service Members rehabilitating in their communities. Many had behavioral health problems, Traumatic Brain Injury (TBI), and/or post-traumatic stress disorder (PTS). The article also examines associations between Service Members' background characteristics and their engagement with mCare. MATERIALS AND METHODS: This analysis included participants who received mCare (n = 95) in a randomized controlled trial. mCare participants received status questionnaires daily for up to 36 weeks. Participant engagement encompasses exposure to mCare, percentage of questionnaires responded to, and response time. Participants were grouped by health status-that is, presence/absence of behavioral health problems, PTS, and/or TBI. Histograms and regression analyses examined engagement by participants' health status and background characteristics. RESULTS: Exposure to mCare did not differ by health status. Participants usually responded to ≥60% of the questionnaires weekly, generally in ≤10 h; however, participants with behavioral health problems had several weeks with <50% response and the longest response times. Total questionnaires responded to and response time did not differ statistically by health status. Older age and higher General Well-Being Schedule scores were associated with greater and faster response. DISCUSSION: The sustained response to the questionnaires suggests engagement. Overall level of response surpassed trends reported for American's usage of mobile applications. With a few exceptions, Service Members engaged with mCare irrespective of health status. CONCLUSION: Mobile health has the potential to increase the quantity and quality of patient-provider communications in a community-based, rehabilitation care setting, above that of standard care.

Review of mobile health technology for military mental health.

Mental health problems pose challenges for military veterans, returning service members, and military family members including spouses and children. Challenges to meeting mental health needs include improving access to care and improving quality of care. Mobile Health, or "mHealth," can help meet these needs in the garrison and civilian environments. mHealth brings unique capabilities to health care provision through the use of mobile device technologies. This report identifies high-priority mHealth technology development considerations in two categories. First, priority considerations specific to mental health care provision include safety, privacy, evidence-based practice, efficacy studies, and temperament. Second, priority considerations broadly applicable to mHealth include security, outcomes, ease of use, carrier compliance, hardware, provider perspectives, data volume, population, regulation, command policy, and reimbursement. Strategic planning for the advancement of these priority considerations should be coordinated with stated Department of Defense capability needs to maximize likelihood of adoption. This report also summarizes three leading, military programs focused on mHealth projects in mental health, The Telemedicine and Advanced Technology Research Center, The Military Operational Medicine Research Program, United States Army Medical Research and Materiel Command, and The National Center for Telehealth and Technology.

mCare: using secure mobile technology to support soldier reintegration and rehabilitation.

BACKGROUND: The U.S. Army Medical Department conducted a pilot mobile health project to determine the requirements for coordination of care for "Wounded Warriors" using mobile messaging. The primary objective was to determine if a secure mobile health (mhealth) intervention provided to geographically dispersed patients would improve contact rates and positively impact the military healthcare system. METHODS AND MATERIALS: Over 21 months, volunteers enrolled in a Health Insurance Portability and Accountability Act-compliant, secure mobile messaging initiative called mCare. The study included males and females, 18-61 years old, with a minimum of 60 days of outpatient recovery. Volunteers were required to have a compatible phone. The mhealth intervention included appointment reminders, health and wellness tips, announcements, and other relevant information to this population exchanged between care teams and patients. RESULTS: Provider respondents reported that 85% would refer patients to mCare, and 56% noted improvement in appointment attendance (n=90). Patient responses also revealed high acceptability of mCare and refined the frequency and delivery times (n=114). The pilot project resulted in over 84,000 outbound messages and improved contact rates by 176%. CONCLUSIONS: The mCare pilot project demonstrated the feasibility and administrative effectiveness of a scalable mhealth application using secure mobile messaging and information exchanges, including personalized patient education.

A lexicon of assessment and outcome measures for telemental health.

BACKGROUND: The purpose of this document is to provide initial recommendations to telemental health (TMH) professionals for the selection of assessment and outcome measures that best reflect the impacts of mental health treatments delivered via live interactive videoconferencing. MATERIALS AND METHODS: The guidance provided here was created through an expert consensus process and is in the form of a lexicon focused on identified key TMH outcomes. RESULTS: Each lexical item is elucidated by a definition, recommendations for assessment/measurement, and additional commentary on important considerations. The lexicon is not intended as a current literature review of the field, but rather as a resource to foster increased dialogue, critical analysis, and the development of the science of TMH assessment and evaluation. The intent of this lexicon is to better unify the TMH field by providing a resource to researchers, program managers, funders, regulators and others for assessing outcomes. CONCLUSIONS: This document provides overall context for the key aspects of the lexicon.

The U.S. Army Telemedicine and m-Health Program: making a difference at home and abroad.

This article highlights the deployment of telemedicine by the U.S. Army through the various echelons of care and in overseas locations, including range and scope of health services provided by telemedicine in a challenging environment. This is followed by a discussion of technological developments advances in mobile communications likely to change the practice of telemedicine in the military from limited fixed-point access to a highly mobile individual with handheld communication devices.

Innovative new technologies to identify and treat traumatic brain injuries: crossover technologies and approaches between military and civilian applications.

Traumatic brain injury (TBI) has become the signature injury of Operation Iraqi Freedom and Operation Enduring Freedom. The use of improvised explosive devices has seen an exponential increase in both Iraq and Afghanistan. In previous conflicts prior to Iraq, survivability of such an injury was far less. Today, technological improvements in trauma care have increased an injured warfighter's chance of survival. A reduction in severe TBI has been achieved but an increase in mild or moderate TBI has been observed. The consequences of this kind of injury can be both physical and mental and can often be hidden or even misdiagnosed. The U.S. Army is interested in pursuing technological solutions for early detection and treatment of TBI to reduce its lasting impact on the warfighter. Such technological breakthroughs have benefit beyond the military, as TBI is a high probable event in nonmilitary settings as well. To gauge what technologies or methods are currently available, the U.S. Army's Telemedicine and Advanced Technology Research Center partnered with the American Telemedicine Association to organize and conduct a discipline-specific symposium entitled "Innovative New Technologies to Identify and Treat Traumatic Brain Injuries: Crossover Technologies and Approaches Between Military and Civilian Applications." This symposium was held in Palm Springs, CA, in September 2009. The purpose of the meeting was to provide a unique opportunity for leaders from disparate organizations involved in telemedicine and related other activities to meet and explore opportunities to collaborate in new partnership models. The meeting was designed to help Telemedicine and Advanced Technology Research Center identify opportunities to expand strategic operations and form new alliances. This report summarizes this symposium while raising awareness for collaboration into better ways of adapting and adopting technologies to address this growing health issue.

E-prescribing in the optometric practice.

E-prescribing offers optometrists and other health care providers important opportunities to prevent medical errors and adverse reactions, facilitate smooth claims filing, and encourage proper patient compliance with care regimens. However, as with any new technology, practitioners first need to implement it, learn how to use it, and become accustomed to it. The AOA-HITTC is continuing to develop materials on e-prescribing in optometric practices. AOA members should watch the electronic and print versions of the AOA News as well as the AOA Web site for details. The eHealth Initiative's list of the top tips for successful e-prescribing (see Box 5) can provide some valuable hints. Health care providers should also be aware that the federal Drug Enforcement Administration presently prohibits the e-prescribing of controlled substances (see Box 6). For those who wish an even more detailed discussion, the eHealth Initiative offers The Guide to E-Prescribing for Physician Practices. However, it will ultimately be up to each practice to make sure practitioners, staff, and patients realized the full range of benefits e-prescribing can offer. "For the practice to have the optimum experience with e-prescribing, it is important that leadership is committed to realizing its benefits and working through issues rather than giving up when they hit a bump in the road; the entire practice is involved in planning and selection and chooses software and hardware solutions that have robust functionality and support the practice workflow; the practice communicates with pharmacies, patients, and the vendor about e-prescribing; an individual is assigned to manage prescription renewal and provide assistance to all users of the system to help them get comfortable; and training and support is adequate," the eHealth Initiative reports emphasizes.

Efficiency of automation and electronic health records in optometric practice.

BACKGROUND: Health information technology (HIT) consists of technological advancements in health care instrumentation, integration, and documentation. It is now beginning to reach a level of consistency, and its benefits are being realized in clinical practice. Comparisons between paper and digital documentation have been conducted in various specialties. There have also been studies comparing manual and automated documentation. Our study was designed to compare the overall benefit of an electronic health record (EHR) and clinical automation accompanied with HIT advancements to traditional modes of practice within the Optometry Clinic at Walter Reed Army Medical Center. PATIENTS AND METHODS: All processes and procedures used in the study were equivalent to those used in patient visits common to most optometric practices. They included patient check-in, pretesting by an ophthalmic technician, and a comprehensive eye examination by an optometrist. In addition to the quantitative time measurements for these procedures, the frequency of certain events was recorded to ascertain the value of automation versus conventional methods of patient management, testing, treatment, and documentation. RESULTS: Although no process time showed any statistically significant difference, some trends were evident. There was a trend toward increased efficiency in the automated group during "Doctor Examination" and "Total Time" subsections. Also, there was a trend toward decreased efficiency with the automated group during the "Check-In" section. CONCLUSIONS: Automation and EHR technology will likely improve over time and surpass the medical efficiency of conventional modes of care. It is impressive that the early stage of HIT used in this study showed no detraction from clinical efficiency while potentially offering many patient, provider, and administrative benefits.

Attrition of military enlistees with a medical waiver for myopia, 1999-2001.

BACKGROUND: Military service requires physical fitness, including vision within set standards. Premature attrition inflicts a considerable manpower and fiscal burden upon the military. METHODS: We conducted a retrospective cohort survival analysis of newly enlisted military personnel who entered active duty with a medical waiver for myopia between January 1, 1999, and December 31, 2001. Premature attrition rates, both medical and overall, were compared with those for a matched, fully qualified, comparison group. RESULTS: New enlistees with a waiver for myopia had the same probability of remaining on active duty through the first 2 years of service as did fully qualified peers. Enlistees with a waiver for myopia also had a low probability of an early medical discharge for myopia. CONCLUSION: The results of this study tend to validate the current branch-specific myopia waiver processes. They also provide evidence that current myopia accession criteria may be too restrictive and in need of policy review.

Telehealth practice recommendations for diabetic retinopathy.

Telehealth holds the promise of increased adherence to evidenced-based medicine and improved consistency of care. Goals for an ocular telehealth program include preserving vision, reducing vision loss, and providing better access to medicine. Establishing recommendations for an ocular telehealth program may improve clinical outcomes and promote informed and reasonable patient expectations. This document addresses current diabetic retinopathy telehealth clinical and administrative issues and provides recommendations for designing and implementing a diabetic retinopathy ocular telehealth care program. The recommendations also form the basis for evaluating diabetic retinopathy telehealth techniques and technologies. Recommendations in this document are based on careful reviews of current evidence, medical literature and clinical practice. They do not, however, replace sound medical judgment or traditional clinical decision-making. "Telehealth Practice Recommendations for Diabetic Retinopathy" will be annually reviewed and updated to reflect evolving technologies and clinical guidelines.