Rapid advances in technology during the past two decades have combined with Defense Department and Veterans Affairs efforts to modernize health care delivery to a point where both are now leading civilian health care in many areas.

Electronic health records (EHRs) are now the standard for active duty, National Guard, and Reserve service members, as well as the nation’s rapidly expanding veterans community. Telehealth and telemedicine programs are expanding beyond increasing convenience for veterans and active duty dependants in remote locales to offering new – and sometimes more accepted – treatments. Pharmacy automation is increasing efficiencies and patient safety while reducing costs.

In short, virtually every aspect of health care for the nation’s warfighters – past and present – is being affected by new and evolving technologies. As with any such change, of course, there are glitches, incompatibilities, cultural resistance and a continuing need for new training. But unlike many other areas, where military technology development, adaptation and acquisition often lag one or more generations behind the commercial world, military health care has become a global leader in innovation.

“Where the DoD is unique is that we take care of patients in some very austere and rugged locales, unlike any other health provider organizations. We have 9.6 million beneficiaries and capture 148,000 outpatients a day, many of those in no- or low-communications areas, so our product line must support all of those different situations,” according to Capt. Michael Weiner (USN), deputy program manager and chief medical officer for the Defense Health Information Management System (DHIMS).

“Military health underwent a small transformation in 2008 when TMIP-J [Theater Medical Information Program-Joint] merged with CITPO [Clinical Information Technology Program Office] to baseline those code sets and capabilities so they were wholly aligned, ensuring the theater product and garrison product spoke to one another. I think everyone will agree that has been a successful merger with a positive outcome, with all work anyone now does related to everything from the point of injury in the battlespace to care as a veteran.”

The overall goal is to deliver better health care by utilizing modern technologies, he added.

“This is a uniquely transformational time in health care history. For the future, it is aligned with the nation’s vision of full interoperability of EHRs across the country. Health and Human Services recently issued a ‘meaningful use’ criteria for civilian doctors and hospitals. DoD and VA have been practicing meaningful use for two decades or more, not only in hospitals but on the battlefield,” Weiner explained.

“The nation has a 17 percent adoption EHR rate now, while DoD and VA have been 100 percent for decades. The nation will catch up and, as it goes from paper to digital – which is a truly radical change – the vision is to make sure data are standardized, fully interoperable and shared, not just as now done between DoD and VA, which share more non-billable health care data than any other two organizations in the nation, but with our civilian partners.”

A similar transformation is occurring within the DoD and VA pharmacy systems, although each has instituted its own system and the two are not compatible. In both cases, however, they have gone from handwritten prescriptions and manual pill-counting to a fully electronic system linking doctors, health care facilities, and pharmacies – including computerized systems to verify, count, and fill orders.

“In the last two decades, we moved from typewriters to TMPS [Tri-Service Microcomputer Pharmacy System] to CHCS [Composite Health Care Systems], the data entry system that ties in all military pharmacies,” noted Col. Everett McAllister, deputy chief of the DoD Pharmaceutical Operations Directorate. “So instead of having a system specific to pharmacies, every clinic, lab and physician now has access to the patient’s profile, which is a leap forward in patient safety.

14th CSH Providers Use MC4Medical providers with the 14th Combat Support Hospital at Bagram Air Field, Afghanistan, enter medical into the MC4 system. Photo courtesy of MC4.

“The next step – PDTS [Pharmacy Data Transaction Service], introduced into all our systems in mid-2001 – gave us visibility on patients throughout the system. If I’m at Nellis AFB in Nevada, for example, and have a patient in Florida, we have access to what medications that patient is on and they can have a prescription filled anywhere and screen for drug interactions – at our pharmacies, at retail and even by mail. And for order fulfillment, we now have pharmacy automation using barcode technology – digital imagery that reduces the potential for filling the wrong drug, so the right drug goes into the machine and then to the correct patient. All of which really enhances patient safety.”

Efforts also are now under way to provide interoperability to the DoD and VA systems.

“We’re working with the VA, trying to bring their pharmacies into our network, so if we have patients being seen at a VA facility, their prescriptions can be sent electronically through PDTS. We’re just now working an MOU [memorandum of understanding], but are not far from making that happen,” he said. “The VA still has to finish some software applications at their end. But we already have CHDR [Clinical Data Repository/Health Data Repository], developed in 2006 to combine the VA [HDR] and DoD [CDR] systems and allow us to share information electronically.”

According to the VA, the exchange of computable data begins with a DoD or VA health care facility or provider “activating” or flagging the patient’s EHR. That enables the data from each repository to flow through the CHDR interface and become a permanent part of the patient’s medical record in both systems. Termed a significant departure from “viewable” data, CHDR is considered an important step forward in achieving cross-agency interoperability.

Another upgrade to the system is telepharmacy, which allows pharmacies to leverage staffing, especially in remote areas and overseas. Led by a Navy pilot program in Florida, the goal is to enable a patient to access a pharmacy even if there is no local pharmacist available.

“The patient still goes to a local pharmacy with a hard-copy prescription, where the order is placed into the system and checked remotely. If the patient does not have a physical prescription, one is generated through CHDR,” McAllister explained. “The patient simply gives the pharmacy his name, doctor’s name, and ID card so they can pull up his profile and activate the prescription. The pharmacist on the other end – such as a central hub – will have a physical image of the medication and the fulfillment record.”

Versions of these same technologies also will be applied to in-patient care in military hospitals and clinics.

“Using barcode technology bedside, we will be able to identify the patient and make sure they receive the correct medications while an in-patient,” he continued. “The automation system for filling may be a bit different, with a pharmacist placing the filled prescription into a Pyxis MedStation and that drawer will release the medication to the patient’s nurse. So instead of having all medications on the ward, the nurse will go into the system through CHDR to release the prescription.”

The Air Force, for which McAllister previously served as chief pharmacist, already has standardized prescription fulfillment equipment throughout its health care facilities and the Army and Navy are working to do the same, he said. All such hardware and software will be compatible with CHDR, which is deployed throughout the Military Health System (MHS).

The next step is to take the DoD and VA e-prescription capability and make it standard in civilian operations – from physician to pharmacy.

“That is something Congress is trying to incentivize the civilian medical profession to move toward, using Medicare as the primary driver,” McAllister said, “so we are not far from making that happen.”

As to what else may be in the future for pharmacy automation, he said one possibility is using radio frequency identification (RFID) chips to track large inventories – but the primary focus, at least in the near-term, is on expanding e-prescription capability throughout all levels of American healthcare.

“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.

Hospital Corpsman 3rd Class John McCallum prepares a prescription by using a telepharmacing system at the Naval Support Activity (NSA) Capodichino branch clinic in Naples, Italy. Barcode technology reduces the chances of filling the prescription with the wrong drug. U.S. Navy photo by Mass Communication Specialist 2nd Class Felicito Rustique.

“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.

Lt. Col. T. Sloane Guy IV (right), chief of surgery with the 47th Combat Support Hospital (CSH), Mosul, Iraq, reviews an image of a patient's chest with specialists located at Brooke Army Medical Center (BAMC), Fort Sam Houston, Texas, through a telesurgery system. Photo by Maj. Allan Long, 47th CSH.

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.

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