Federal agencies have applied telehealth technology in innovative ways to expand health care beyond the walls of veterans' hospitals and other care facilities. Current efforts allow caregivers to reach patients in their daily lives while clinicians and specialists can share and archive medical information.

However, going forward a much more robust, integrated architecture and networking infrastructure will be needed so information can be captured and shared securely and in real time, according to industry and government experts.

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The Department of Veterans Affairs became a forerunner of telehealth with the June 2011 launch of Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), designed to increase access to specialty care services for veterans in rural and medically underserved areas through the use of videoconferencing equipment. Eleven Veterans Health Administration facilities serve as SCAN-ECHO centers, helping providers improve care for patients with chronic pain, hepatitis C and heart failure.

"What is needed is more expansive, open Internet access in rural areas. That is the major limiting factor for a lot of telehealth and telemedicine [initiatives] in rural locations," said Tim Hays, senior director for customer health solutions with Creative Computing Solutions, Inc.

"At least for rural health, that is going to be a big infrastructure problem that might not get resolved soon. But it is fundamental to increase telehealth work to those who need it in rural locations and that is a majority of our veterans." Both providers and patients need the ability to capture and send information from monitoring devices in real time, Hays noted.

"Telehealth is the use of electronic information and telecommunications technologies to support long-distance clinical health care, patient and professional health-related education, public health and health administration," according to the Health Resources and Services Administration, an agency within the Health and Human Services Department. Technologies include videoconferencing, the Internet, store-and-forward imaging, streaming media, and terrestrial and wireless communications.

Telehealth is viewed as a broader category than telemedicine by some organizations that say it includes training, administrative meetings, and continuing medical education, in addition to clinical services. Some agencies use the terms interchangeably.

The Defense Department has been a proponent of telehealth solutions for at least two decades, deploying the technology to assist soldiers on battlefields, most recently in Afghanistan and Iraq. For instance, telehealth/telemedicine was used to provide medical care to soldiers with traumatic brain injury in remote combat operating posts and forward operating bases in Afghanistan. The military was able to link care providers at the remote locations with subject matter experts in the U.S. to provide wounded soldiers the health care required to treat brain injuries, said Maj. Gen. Richard Thomas, director of health operations and chief medical officer with the Defense Health Agency, a joint medical support agency tasked with increasing collaboration and integration of services across the Military Health System.

Telehealth has been applied by the DoD to link care providers with specialists who help improve the quality of pain management physicians provide their patients. Plus, the DoD works with the VA on Project Echo programs and with others agencies such as HHS and the Agriculture Department — and even industry — on telehealth and mobile health solutions. For example, Kaiser Permanente has taken some of the DoD capabilities and modeled these tools for to reach out to its own customers virtually, Thomas said.

Air Force builds teleimaging program
The Air Force has been building a telehealth program for the past four years, focusing on the area of teleimaging, said Lt. Col. Antonio Eppolito, a physician and chief of Air Force telehealth within the Office of the Air Force Surgeon General. The Air Force is focused on the transmission, interpretation and archiving of images and documents in four specific areas within teleimaging: teleradiology, telecardiology, tele-endoscopy and telepathology.
The Army and the VA focus on telehealth encounters between provider and patient, Eppolito said. "Since they had that realm, we concentrated in a different area — with images."
Specialists such as radiologists and cardiologists currently share images through Web-based computer systems. In the future, image archives will be available to any and all physicians. This will require more commitment and funding, he noted.
According to Eppolito, there are four challenges related to the telehealth's architectural backbone infrastructure that have to be addressed to ensure compatibility with the forthcoming electronic health record system the Department of Defense plans to deploy around 2017. The DoD and military services need:

  • One, single medical network that all three services share. Currently each service has its own network. A single network will help eliminate security firewall issues associated with each service having its own separate network.
  • A single radiology information system (RIS) for storing, manipulating and distributing patient radiological data and imagery. A RIS also includes patient tracking and scheduling, result reporting and image-tracking capabilities. A single RIS will allow the services to perform order entry and interpretation of images from remote sites, Eppolito said.
  • Vastly greater network bandwidth. "In order to perform large volume image and document transfers and video-teleconferencing, you need larger pipes," he said.
  • Integration of Picture Archiving Communication Systems, which provide image archives across the military services. "As long as each service has its own network with its own PAC and archives, we can't cross-pollinate and query each other's systems."

"These are the architectural engineering [capabilities] that have to be in place [within] the same timeline as the forthcoming new EHR system to realize telehealth functionality at the scale we would like to get it," Eppolito said.

Expanding telehealth across the DoD enterprise has to be done in a coordinated way, said Thomas, a task that DHA will help facilitate. The agency — established a year ago under the leadership of Lt. Gen. Douglas Robb — operates under the assumption that there are a lot of medical capabilities that are similar across the services. As a result, DHA officials have identified 10 joint shared services that can be standardized across the DoD enterprise such as medical logistics, pharmacy, public health and health IT (under which telehealth/telemedicine falls).

"There's been a lot of good work done by the [military] services, but it's been done within their own silos. The big challenge is overcoming cultural differences within the services," Thomas explained. "We [DHA] have to be the tool to help them synchronize those efforts."

Security always critical

Enhanced security is also critical. For instance, a security flaw in the network of a home telehealth services vendor for the Veterans Affairs potentially exposed sensitive information on more than 7,000 veterans, agency officials reported in December. The exposed database included the name, address, birthdate, phone number and VA patient identification number of 7,054 veterans who have used the telehealth system. However, the vendor said no data was actually taken because of the flaw.

"The need to connect patient and physician, and the need for data to be transmitted in a clean, trusted fashion is critical — that exists for both civilian and defense agencies," said Dan Garrett, leader of PriceWaterCoopers' Healthcare IT Practice, which is proposing an open-source EHR system as part of its bid to help modernize the DoD health care management systems.

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