Dr. Maria Crane says telehealth connects soldiers in Europe with care providers such as Capt. Janet Payne, a clinical social worker.

May 04 2011

Taking Care of Our Soldiers (from a Distance)

Telehealth initiatives let military doctors truly go where their patients are — to a battlefield clinic, a base halfway around the globe or maybe soon even their barracks or living room.

For years, the Army has brought high tech to the battlefield. Now it's using some of those tools to enhance the mental health of our fighting forces.

Last fall, the Army began using telehealth technology to remotely screen soldiers returning from Iraq and Afghanistan, looking for signs of post-traumatic stress disorder and other brain injuries. But instead of flying a soldier or a caregiver halfway across the world, they connected via IP-based teleconferencing equipment for a 10-minute behavioral health screening.

Dr. Maria Crane, behavioral health specialist and director of the Traumatic Brain Injury Program for the Army's European Regional Medical Command (ERMC), took part in her first massive telehealth screening last December.

"It was impressive," she says. "The beauty of it was that we were able to connect our soldiers with care providers in Heidelberg and Landstuhl, and our people did not have to leave their offices at all."

What the Doctor Ordered

Telehealth is about delivering more and better healthcare by making it easier for both patients and providers to take part, Crane says. In Europe, it's not unusual for Army personnel to drive four hours or more to reach a base that has the type of specialist they need. And because some units do not allow junior troops to travel alone over long distances, two soldiers might need to be away from their unit for an entire day just so one of them could have a 30-minute appointment.

"If you have to drive four hours in each direction for a follow-up appointment, you're less likely to do it," she says. "But if you can go to your local clinic, walk into a video booth and connect directly with your provider, you're much more likely. A lot of people won't seek medical care because of the duress involved. They might wait until the problem is much worse and suffer more complications than if they had sought medical care earlier."

Crane says the biggest challenge isn't convincing the soldiers, about a third of whom willingly opted for the telehealth screening. The hard part is persuading healthcare providers that the technology is a viable alternative to in-person care for many patients.

Capt. Janet Payne, a clinical social worker at ERMC in Heidelberg, Germany, says she was skeptical of telehealth at first.

"As a behavioral health provider, I rely a lot on nonverbal communications as part of my assessment," Payne says. "I felt that nothing short of meeting face to face would provide me with enough information. But when I was brought in to use the technology I was blown away by the quality of the interaction and how comfortable I was doing it. It really is like being there — face to face."

Telehealth is also helping Army doctors deliver better care stateside, says Dr. Michael Lynch, chief of the telehealth service at Walter Reed Army Medical Center, where the first telehealth programs were launched in 1996. When hundreds of troops deploy overseas, doctors often have to be pulled away from their own bases to screen them, he says. Using video teleconferencing reduces time and money spent on travel, while keeping medical professionals available to see their regular patients.

Lynch says Walter Reed conducts 2,500 patient contacts each month using video teleconferencing (VTC).

"On a typical Monday, I might have an 8 a.m. appointment in Pennsylvania, see another patient in New York at midmorning, go down to Fort Eustis, Va., after lunch and then see someone at Fort Hood, Texas, at 3 p.m. — all with no jet lag," he says. "And if a patient drops out and we have an opening, we can take a walk-in appointment from virtually anywhere. VTC allows us to be so flexible; we can help whoever needs us."

Photo: Joshua L. Wick/WRAMC
"Video teleconferencing allows us to be so flexible, we can help whoever needs us," says Dr. Michael Lynch of Walter Reed Army Medical Center.

Making the Connection

These days, creating a point-to-point video connection is relatively straightforward, says Mark Abernathy, a technical adviser to ERMC. All you need is a hardware or software codec that employs the H.323 standard to compress, decompress and encrypt the video; a camera; a display and a reasonably fast and reliable Internet connection.

Though standards set by the American Telemedicine Association call for bandwidth of at least 384 kilobits per second in both directions, Abernathy says it's often sufficient to use less, thanks to codecs that only transmit data for the pixels that change in each frame. Making a call is often as easy as connecting the equipment and entering the IP address of the VTC client you need to reach.

ERMC uses high-definition cameras and hardware codecs that run just under $8,000 per station, Abernathy says, but a PC-based solution with a webcam and a software codec can cost as little as $2,000.

A good high-resolution image is key, Lynch says.

"I don't trust a typical webcam; it's not good patient care," he says. "You need to be able to closely observe the patient, and for them to be comfortable they need to be able to see you. It's why you can't do a proper screening via a phone call. They may be saying the right things, but visually you won't be able to pick up on the other stuff."

Still, even low-res video may be good enough in some cases, counters Dr. Matt Mishkind, acting chief for the Clinical Telehealth Division at the National Center for Telehealth and Technology (T2), which researches telemedical issues for all branches of the U.S. military.

"If you're diagnosing a traumatic brain injury and need to see if someone is tremoring, high definition may be of clinical value," he says. "But research shows low-end video connections can work, though they do take a bit more getting used to."

T2 has been experimenting with delivering telehealth care via dual-cam smartphones, where patients can dial into their doctors and engage in video chat sessions from virtually anywhere.

"At this point, smartphones would not be considered a standard of care from a technology point of view," he says. "We're looking at them from a usability perspective: Would this be an acceptable way to receive care? How do patients feel about the screen size? We see smartphones as the future.


Service members returning from combat in Iraq or Afghanistan who show signs of traumatic brain injury

SOURCE: Invisible Wounds of War, Rand

But first we need to show that the technology works and is acceptable, and then address a lot of policy issues before it gets implemented anywhere."

'The Teledoctor Will See You Now'

In some ways, telehealth may prove to be more effective than in-person care, Lynch says. Today's soldiers, who often use Skype to stay in touch with family and friends stateside, are extremely comfortable with technology and may actually be more at ease in front of a camera than in a room with a doctor.

"People actually tend to disclose more — and do it more quickly — using video teleconferencing," he says. "When you're in a room with someone, a degree of guardedness comes up, but that goes away when you're sitting and talking to a TV screen. Many times when I see someone on VTC, I find out things their therapist hasn't heard yet."

<p>Photo: Bert Bostelmann/Getty Images</p>