By Edward Neeley, MD; Roger Hesselbrock, MD, FAAN; Charles Lappan, MBA, MPA; Philip Girard, MS; and Jack Tsao, MD, DPhil, FAAN
US military members deploy to remote, austere, and dangerous locations. While these overseas locations all have some medical care capability, it is largely limited to basic primary care services. Aid stations and clinics have minimal diagnostic and therapeutic capacity. They are often staffed by more junior medical personnel, including non-physician providers and in some cases by enlisted independent-duty medical technicians. Until recently, there were rarely neurologists, even at hospital-level medical facilities in the combat environment. Thus, access to specialty services is both difficult and cumbersome due to limited telecommunication access, time zone differences, and specialist availability. With advances in communication technology, deployed US military providers now have timely access to military specialists in a variety of disciplines, including neurology.
The United States Army Medical Command (AMEDD) has led the way in military telemedicine, beginning in 1992 with deployed reach-back teleconsultation from Somalia to AMEDD sites using satellite dishes, laptop computers, and digital cameras. Currently within AMEDD there are more than 100 deployed teleradiology systems, 22 telepathology systems, and consolidated teleophthalmology and teledermatology capability. Regional telemedicine hubs were established at Landstuhl (Germany) Regional Medical Center, Walter Reed (Washington, DC), Brooke (San Antonio, TX) and Tripler (Honolulu, HI) Army Medical Centers.
The Army Knowledge Online (AKO) telemedicine program was established in 2004 to provide a user-friendly system available to deployed providers of all branches (Army, Navy, Air Force, and Marine Corps) and echelons of care in the military. Dermatology was the inaugural specialty offered, and presently there are 19 specialty areas. The focus of the program ranges from patient management questions to guidance on potential medical evacuations to second opinion consultation requests. Consultation requests are sent to a single military email address grouped by specialty and automatically forwarded to on-call consultants. Deployed providers often use their personal digital cameras to transmit images through the non-secure Internet Service Provider at their deployed location. No patient identifying information is transmitted, allowing easier compliance with HIPAA and the Privacy Act. However, because patient-identifying information is not transmitted, consultants do not receive formal workload credit for their input. As noted above, referrals come from primary care physicians, general medical officers and non-physician providers. Consultants are located worldwide and are from Army, Navy (which also provides physicians to the Marine Corps), and Air Force.
More than 6,300 teleconsultations were received from April 2004 to December 2009. Despite time zone challenges, the majority were answered within five hours. The top specialties requested in the past fiscal year were dermatology, orthopedics and neurology. The teleconsultation system is utilized by all services and has been very well received. While originally intended to support Operations Iraqi Freedom/Enduring Freedom, its use has expanded to deployed providers stationed in Africa, Asia, Central and South America, and has been accessed by Navy providers at sea. Current program limitations include email file size restrictions, difficulty sending medical images due to Department of Defense (DoD) prohibitions on uploading images directly from digital cameras, and occasional unpredictable email problems between AKO and AMEDD domain accounts.
In addition to providing invaluable assistance to deployed providers, teleconsultation services offer interesting educational opportunities. Formatted into case studies illustrating the types of medical problems encountered during deployment, teleconsultations are a powerful teaching tool for health care providers preparing to deploy. Teleconsultation case studies also educate specialty consultants about deployed medical unit/provider capabilities and common conditions seen in their disciplines.
Since the establishment of neurology as a stand-alone specialty group within the program, it has been one of the most requested specialties. The neurology teleconsultation group has answered more than 390 teleconsultations, with an average response time from receipt of 7½ hours. Of the 390 requests, 62 consultations involved collaboration with 20 other specialties. The majority of collaborations involved traumatic brain injury, ophthalmology, cardiology, infectious diseases, internal medicine, and otolaryngology specialists. A total of 121 consultants, responded to neurology teleconsultations. neuro-ophthalmology, child neurology, clinical neurophysiology, and movement disorder specialists were included.
The majority of neurology teleconsultations came from Afghanistan and Iraq. A lesser number came from deployed health care providers at sea, in Bahrain, Djibouti, Ecuador, Germany, Kuwait, Kyrgyzstan, Qatar, Senegal, and the United Arab Emirates. Most requests involved patients from the Army, Marine Corps, Air Force, and Navy, but requests have also been received for assisting DoD civilians, detainees, foreign nationals employed by DoD contractors, and host-nation civilians and service members. The average patient age is 30 years old with the youngest being a one-year-old child, while the oldest was 55. The clinical conditions addressed in these consultations have largely been: headache disorders, traumatic brain injury, peripheral nerve conditions (largely entrapment neuropathies), spells of various types, and movement disorders.
In 2008, the AKO Teleconsultation system added Traumatic Brain Injury (TBI) specialty group to specifically address the increasing numbers of traumatic brain injuries sustained by deployed military service members. This specialty group, comprised of neurologists and other TBI specialists, is coordinated by the Defense and Veterans Brain Injury Center (DVBIC), headquartered in Washington, DC, and assists with TBI identification and patient care in remote areas. Consultation requests submitted to this service are often intended to help determine level of TBI severity following a blast event or motor vehicle accident. The group also assists with questions regarding medical evacuation, in-theater clinical practice guidelines, and provides medical consultation to support headache management, medication management, vision, hearing, vestibular, neurologic or other clinical concerns following TBI/concussion. Similar to general neurology consultation requests, referral to and from other specialty groups is common.
Regarding program impact, 22 percent of medical evacuations recommended by teleconsultation specialists were from neurology. While only three teleneurology consultations are known for certain to have prevented an evacuation from theater, this most likely is an underestimate, as deployed providers often do not inform the teleconsultants if their recommendations prevented medical evacuation. However, the teleneurology consultations markedly facilitated the decision process for providers in the field with respect to medical evacuation.
One major accomplishment of the teleneurology program has been the widespread release of a stratified headache protocol to the primary care level. Another significant contribution: in addition to facilitating dissemination of the DVBIC mild TBI clinical management protocol, it has aided the further development of an early management protocol for mild TBI and post-traumatic headache with a practical treatment regimen.
Direct neurologic care is also taking place between specialists at DoD trauma centers and remote military treatment facilities within the United States via interactive video-conferencing. Interactive video-conferencing allows a neurologist, neurosurgeon, or other specialist to evaluate and treat patients with the aid of a local provider. The DVBIC has developed a remote headache management clinic to treat patients with continuing or worsening symptoms following their deployment. Presently, this program is being expanded within the continental United States and European medical commands, but, in the combat environment, bandwidth variability and frequent troop movements make it difficult to direct specialty care via interactive video-conferencing. The AKO system, though limited to store-and-forward technology, remains the most reliable means to support neurologic care in theater.
The military teleneurology program has been a resounding success, offering deployed providers easy access to timely, cutting-edge management information to aid a wide variety of patients. Teleneurology service has improved care of deployed military personnel and facilitated the spread of neurologic treatment protocols for common neurologic ailments to primary care providers. It has even resulted in piquing the interest of several junior physicians into seeking neurology residencies. Continued advances in communications technology should further enhance the impact of teleneurology services for the benefit of patients and providers operating in austere environments.
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Edward Neeley, MD, has no disclosures to report.
Roger Hesselbrock, MD, FAAN, has served as one of the Air Force Surgeon General medical malpractice expert reviewers.
Charles Lappan, MBA, MPA, has no disclosures to report.
Philip Girard, MS, has no disclosures to report.
Jack Tsao, MD, DPhil, FAAN, has received support from US Army and Dana Foundation for research on phantom limb pain. He has also received support from Comprehensive Neuroscience Program (Congressional funding) for research on axonal and synaptic degeneration.