To provide better follow-up care for troops returning stateside with traumatic brain injury (TBI), the Department of Veterans Affairs (VA) is using telecommunications technology to link experts at major VA medical centers with doctors throughout the country.
ABC News anchor Bob Woodruff's personal story about suffering severe TBI in Iraq, and his prime-time television report in February on shortcomings in the military's system of care for TBI, helped draw attention to the need for improved monitoring of brain injuries that may not surface immediately, and to help injured veterans released from the centers receive optimal treatment as they recover. (See “Traumatic Brain Injury for Returning Vets Gets Prime-Time Treatment, Raises Questions About Injury Estimates,” Mar. 20, page 1.)
In testimony before the House Veterans' Affairs Subcommittee on Health shortly after the television report aired on Feb. 27, Barbara Sigford, MD, PhD, the VA's national program director for physical medicine and rehabilitation, described the telemedicine initiatives.
The VA's TBI program currently includes four Level I regional polytrauma centers for acute intensive medical treatment and rehabilitation for complex and more severe injuries; 21 Polytrauma Rehabilitation Network Sites, which manage post-acute complications; and 76 Polytrauma Support Clinic Teams located at medical centers throughout the 21 national VA Networks. These serve patients with stable polytrauma complications. All of the facilities are linked through the VA's Polytrauma Telehealth Network, which provides state-of-the-art multipoint videoconferencing and helps ensure that TBI expertise is available around the country, at locations and times accessible to each patient.
In addition to medical record review, clinician-to-clinician communication allows additional transfer of information and resolution of any outstanding questions, Dr. Sigford said. The centers have regularly scheduled video teleconferences to discuss the referral with the transferring team, and to meet the patient and family members “face to face” whenever feasible.
ARTICLE IN BRIEF
✓ The Department of Veterans Affairs is using telecommunications technology to improve care for troops returning with traumatic brain injury.
“The whole world has suddenly become much smaller,” said Steven G. Scott, DO, chief of physical medicine and rehabilitation services at the James A. Haley Department of Veterans Affairs Medical Center in Tampa, FL, a Level I polytrauma center.
Dr. Scott, who is leading the VA's telemedicine research initiative, told Neurology Today in a telephone interview that the next phase of this project will bring help even closer to TBI veterans.
Any time a patient with a head injury leaves one branch of the military's medical system for another, videoconferencing is a key part of the transition, he emphasized.
“The VA and the Department of Defense [DOD] today have a team-to-team hand-off for each patient. Their new doctors and therapists go over every medical aspect of their care plan with the original team. We're learning together and getting to know each other better.”
Families are invited to participate too, he said. “They come in and meet the new team at the opposite end, from Walter Reed Army Medical Center or Bethesda Naval Medical Center to Tampa, Manhattan, or the Bronx, or any of the other VA centers around the country.”
For the medical team in Tampa, this is followed by regular meetings with other centers throughout the Southern states where patients are being exchanged. “We have several different programs that we do collaboratively,” said Dr. Scott.
The VA is developing secondary polytrauma centers at VA medical centers in Dallas; Augusta, GA; Houston; and Nashville, and part of their operation will depend on telemedicine, Dr. Scott noted.
“Once we send a patient to a facility nearer home, we will continue to keep tabs on them. Often problems that weren't there initially surface later on.”
Complex neurological cases are much easier to treat with the exchange electronic images and other patient data, he added. “The resolution and degree of detail in the video systems we're using is really phenomenal. We can get close-up shots of injuries as they heal, as well as monitor how well skull implants are doing. The close-up imagery that the cameras provide is really amazing.”
If a patient has to come back in for more surgery, he added, there is a video “history” of close-up shots surgeons can use to better plan stages of surgery.
Another advantage of the system is that each patient has an ongoing medical record that is shared by DOD and VA doctors: medical history, exam records, X-rays, and pathology reports.
“In essence, all soldiers become their own personal medical databases, and as we evolve, this will allow us to use telemedicine resources more effectively. Patient privacy and confidentiality restrictions in the public sector and state licensing regulations are not a problem for us. If one of our physicians can practice in one state they can practice in any state.”
Because of this, he said, the VA-DOD telemedicine program could serve as a model for greater use of telemedicine in the general population as technology advances.
“We're developing practice procedures as we go along with regard to sharing patient information between teams of doctors around the country and the world. That's one of the positives of current operations in Iraq,” he said.
The VA hopes to eventually have a full tracking system for each patient. “Right now we have information from the field as well as early lab reports for open head wounds, for example, that tell us what bacteria are being cultured out, and because we have this information available, we are much less likely to miss anything that might appear later during their transition home.”
The VA is also providing recovering TBI patients at home with an “electronic nurse” — the Electronic Medical Management Assistant (EMMA) — a device that dispenses daily medications to ensure the correct dose is being taken.
“Many of these soldiers have cognitive, visual, and functional impairments, and they forget to take their medications or refill prescriptions,” Dr. Scott noted.
EMMA uses a unit dose card dispensed to the patient by the pharmacist; the patient inserts the card into the medication delivery unit to receive the correct medication. Telemonitoring allows for adjustments based on self-reported data sent electronically to a central facility. The system requires a land-line phone, but efforts are underway to offer the program to veterans who only have cell phones.
“The system is especially helpful for injured soldiers receiving care at multiple sites, and those in transition,” Dr. Scott said.
Earlier this year, the Defense and Veterans Brain Injury Center (DVBIC) held its first national videoconference with VA TBI experts, said Henry Lew, MD, PhD, clinical associate professor at Stanford University and medical director of the VA's Inpatient Rehabilitation Center in Palo Alto, CA, a Level I polytrauma center.
“It went really well and saved everyone a lot of travel time,” he told Neurology Today in a telephone interview. The centers presented progress reports on our brain injury and rehabilitation programs, medico-legal issues, shared new ideas, and discussed goals, he said.
The VA polytrauma centers are now able to consult with patients and their primary care physicians around the country, as needed. “This is proving very helpful for TBI veterans living in remote parts of the country where there are few medical resources available, and those who have to travel for hours to reach the nearest VA center.”
Patients and their families appreciate being able to participate in video consultations, he said, and military doctors at Walter Reed and Bethesda Naval, together with the VA are benefiting from being able to work together to help patients through videoconferencing and online forums.
“We're learning to share knowledge and provide consultations online,” he said. “But above all, the patients like it.”