“There are always opportunities for improvement as technology continues to develop and those will have to be explored. The hard part now is typing a prescription into the system, so it is much faster if it is sent to the pharmacy electronically. I also hope they are looking at further enhancements to the CAC [Common Access Card], the ID card we use,” he added.

“You never know what new technology will come along next, so we always have folks attending conferences and looking into what is being developed – and industry is never shy about showing us what they are doing. If someone finds something, that information is shared across the system so we can determine if and how to employ it. And if there is a good system now being employed, the manufacturer is always looking at how to improve it – not specifically for the government, but for the overall healthcare market.”

For Dr. Matt Mishkind, acting chief of the Clinical Telehealth Division of the National Center for Telehealth & Technology (T2), the goal is extending as many forms of health care as possible to patients who cannot – or, in some cases, will not – travel to a clinic or hospital. DoD is looking at two approaches: Take the doctor directly to the patient electronically or using mobile units to, essentially, meet the patient halfway.

“Our definition of telehealth is the use of telecommunications technologies to deliver health care, primarily at a distance, by connecting a patient to a provider,” he said. “Our Transportable Telehealth Units [TTUs] primarily evolved from us noticing there are some access-to-care barriers, mainly mobility, geography and, to some extent, stigma. TTU is a possible solution now being implemented on a limited basis.

“The concept is to take a modified RV, commercial bus, or even shipping container, outfit it with telehealth technology – video teleconferencing, computers for Web-based communications, fax, and so on – and place them in areas where there are beneficiaries but not a lot of providers. The Guard and Reserve, for example, come home from deployment and they may have to drive hours to get the military care for which they are eligible. By placing TTUs at armories or Reserve centers, we can reduce that travel distance.”

The “stigma” barrier primarily relates to situations where a military patient may be concerned about his or her career if some problems become part of the permanent record. But the new generation of young service members and veterans – who are considered at the greatest risk for PTSD, suicide, substance abuse, etc. – tend to be more comfortable with technology, including as a way to talk with doctors remotely when they might balk at doing so face-to-face.

TTUs also enable DoD – and, under a different program, the VA – to locate clinical outreach capability in a remote area more quickly and inexpensively than would be the case with a permanent facility, meet temporary demands (such as dealing with a short-term increase in warfighters returning from the withdrawal from Iraq and the surge in Afghanistan), and extend the ability of all military doctors, especially specialists, to see patients they otherwise could not.

“The TTUs can be an extension of an existing military hospital or connect with TRICARE providers, depending on the need,” Mishkind said. “But this is a new platform and we are still in the initial phases of getting them into the field, with only a few operational now, rotating on an as-needed basis to start. We’re still trying to figure out what the long-term demands would be, but we expect the number of TTUs to increase as time goes on.

“Our focus is on TBI [traumatic brain injury] and psychological care. We definitely want to use as much advanced technology as we can, but do so according to the need. We have two configurations – one is an 8×20 foot container, the other 8×40. We obviously can put more into the larger unit, especially for TBI, perhaps including MRI and other high-tech machines to better care for that specific need.”

The VA currently has 50 mobile veterans centers, which have some similarities to the TTUs, although they focus more on preclinical care, outreach, and health care, while the TTUs are primarily set up for telehealth clinical encounters.

But Mishkind and his fellow researchers at T2 and five other Defense Centers of Excellence created in 2007 believe those efforts are merely the beginning of an ongoing transformation of military healthcare – in some ways, a return to the past, electronically.

“We see telehealth going back to what we had when doctors did house calls. We’re utilizing higher end and rapidly developing and refining technologies to put the doctor in the patient’s home – not physically, but providing the same level of care,” he said. “TTUs put care closer than before, but the ability to use a webcam to talk to a provider from the patient’s home is a long-term goal for beneficiaries anywhere.”

Another goal also harkens back to an era when doctors set up permanent practices, seeing the same patients on a lifetime basis, often through multiple generations. Now technology offers the prospect of recreating that type of relationship, but among beneficiaries and providers who routinely move, throughout the country and around the world, every two or three years for decades.

“Telehealth allows you to maintain contact with the same primary care manager, no matter where either of you may be – a continuum of care that lasts throughout your service time,” Mishkind explained. “We aren’t quite there yet, but there is a lot of senior level interest in making this concept a reality. A lot of funds and initiatives have been put into further development of the DoD network and processes, as well as a push on pilot projects to take care to the patient’s home.

“There are certain policies that currently do not allow us to provide care to the home the way we ultimately would like to, so we are working on research studies and pilot projects to establish protocols to ensure that kind of care can be done in a safe and effective manner. Network availability also is part of the issue, especially in certain theaters, where communications links are not as robust. But within a couple of years, I would like to see the ability to get certain levels of ongoing health care from your home.”

A decade of war in Southwest Asia also has dramatically changed the demand for both DoD and VA healthcare for the spouses and children of National Guard and Reserve members who have been activated and deployed. Unlike the families of active-duty soldiers, sailors, airmen, and Marines, many of those families are not tightly woven into military life and practices.

“While those service members are deployed, the family becomes DoD and TRICARE beneficiaries, but that can be confusing to them. Some of that can be addressed through the TTUs, which can help provide health care to Guard and Reserve families while the service member is away,” Mishkind added.

Another area in which technology is providing new approaches to both patient treatment and provider training is virtual reality (VR), with which many warfighters are familiar from its use in training. On the medical side, it is being investigated as a tool for treating PTSD, among other conditions.

But Greg Reger, acting chief of T2’s Innovative Technology Application Division, which looks into how VR, shared virtual environments and other emerging technologies can be leveraged, from disseminating resources to treatment to evaluating assessment tools, also sees a possible telehealth application.

“Could I connect with a patient at a remote location, where they can access VR and I control it from another location to reduce the travel burden? That question remains open, but if a patient in the same room using VR proves effective, it’s worth researching,” he said. “We also need more research in the area of remote delivery of care by telehealth models. And using VR-based or even traditional prolonged exposure treatment, delivered via telehealth, is probably the first study that should be done.”

VR also may improve training providers in new treatments or procedures and give warfighters a better understanding of healthcare issues and treatments. And perhaps much more, such as helping warfighters returning from combat readjust to family and, where applicable, civilian life in general, including work.

“We are building, in a virtual world called Second Life, assets we hope will improve PTSD education for our service members, veterans and their families. It is a 3-D virtual environment that can be accessed from any computer with an Internet connection,” Reger explained. “We also have thought about a model for provider training.

“One thing we are mandated by Congress to do is ensure our providers are using the best treatments available to care for our warriors. The traditional model is to bring 30 or so providers together in a room with an instructor for three or four days, requiring a lot of travel; now we are looking at whether this virtual world can be used to do that instead. I have a feeling we may pilot this within a year, but there is a lot of hard work yet to do.”

That virtual world originally was designed by the University of Southern California’s Institute for Creative Technologies to provide post-deployment support, offering returning warfighters, no matter where they may be, a sense of camaraderie and resources to help them reintegrate into civilian life. Incorporating immersive games, virtual world expertise and virtual human intelligence, it will be populated by both human beings and artificial intelligence-driven virtual characters.

“You can think of it as the VFW hall of the 21st century. Most veterans, when they come back, are not co-located into neighborhoods the way people were in World War II, so this gives people a chance to be together, even if they’re widely dispersed,” ICT’s Jacquelyn Morie explained on a Pentagon webcast.

“There probably isn’t a technology out there we are not looking at for application to a number of problems,” according to T2 Director Gregory A. Gahm. “VR, for example, is a relatively novel approach, bringing together several different technical modalities to give a person a more real-life experience, then using that as a tool within our treatments and research.

“We are the first group to really conduct an analyzed control trial to determine its value in the treatment of PTSD. But our ultimate goal is to explore whether VR can effectively be extended, via the Internet, to treatments involving care outside the office setting, such as our work on virtual worlds, and enable much more self-directed care – 24/7 – to the populations we serve.”

DoD and the VA have focused considerable effort and funding in recent years to adopt and adapt a host of new technologies to modernize all elements of health care delivery, for both the active duty and veteran communities.

Perhaps surprisingly, those involved believe technology – including working with patients online or in virtual worlds – not only is expanding provider reach, but also has increased the “human touch.” Military doctors may not drive blue Buicks to make house calls, as their civilian counterparts did more than half a century ago, but telehealth and VR may be the next best thing.

“I think this is an area that will continue to grow in importance. Clearly the problems we are addressing will not go away soon, during or following service,” Gahm concluded. “And there are a growing number of opportunities to apply technology in ways we have not thought of yet.

“Our mission is to be out there, looking and thinking about how to take what already may be standard technologies in some ways and apply them to new problems. And to find new technologies we may be able to use.”

This article was first published in The Year in Veterans Affairs and Military Medicine: 2010-2011 Edition.