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Enhancing Access of Combat-Wounded Veterans to Specialist Rehabilitation Services: The VA Polytrauma Telehealth Network
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Enhancing Access of Combat-Wounded Veterans to Specialist Rehabilitation Services: The VA Polytrauma Telehealth Network Adam Darkins, MD, Cathy Cruise, MD, Michael Armstrong, MD, John Peters, MS, Michael Finn ABSTRACT. Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat-wounded veterans to specialist rehabilitation services: the VA Polytrauma Telehealth Network. Arch Phys Med Rehabil 2008;89:182-7. Operations Iraqi Freedom and Enduring Freedom have resulted in U.S. military personnel sustaining combat wounds of unprecedented severity and complexity that necessitate longterm rehabilitation. To meet what are often conflicting requirements in providing severely wounded veterans with timely and convenient access to specialist rehabilitation care, and to enable them to return to their local communities, the Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network that enhances access to such services by linking Veterans Administration rehabilitation facilities. This article describes the clinical, technical, and business process issues involved in the development of this network. Key Words: Rehabilitation; Telecommunication networks; Telemedicine; Wounds and injuries. © 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ISTORICALLY, IMPLEMENTATION of new technologies to clinically manage the combat wounded has proH foundly changed battlefield care and the subsequent course of 1
rehabilitation for those who survive.2,3 Currently, patients who have sustained serious combat injuries during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) receive care in combat surgical hospitals by forward surgical teams,4 which represents further developments of this legacy. Personnel wounded in OEF and OIF are rapidly evacuated from the war zones, stabilized, and triaged at a regional medical center5 before being transferred, if necessary, to a Department of Defense (DOD) military treatment facility in the continental United States. The reduction in the elapsed time between injury (principally sustained from improvised explosive devices, against which body armor affords selective protection) and arrival in the United States means that combat wounded are arriving for rehabilitation services in DOD facilities and Department of Veterans Affairs (VA) medical centers (VAMCs) with treat-
From the U.S. Department of Veterans Affairs, Veterans Health Administration, Washington, DC (Darkins, Peters, Finn); U.S. Department of Veterans Affairs, Veterans Health Administration, Northport, MN (Cruise); and U.S. Department of Veterans Affairs, Veterans Health Administration, Minneapolis, MN (Armstrong). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Correspondence to Adam Darkins, MD, Office of Care Coordination 11CC, Department of Veterans Affairs, 810 Vermont Ave NW, Washington, DC 20420. Reprints are not available from the author. 0003-9993/08/8901-00285$34.00/0 doi:10.1016/j.apmr.2007.07.027
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ment needs of unprecedented complexity.6 To meet this challenge, the VA has established polytrauma rehabilitation center (PRC) hub sites at 4 major VAMCs that have specialist clinical expertise in polytrauma These hub sites—in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA—support “spoke” sites, or polytrauma network sites (PNSs), in regionally associated VAMCs. Thus, the VA has created a physical network of tiered interdisciplinary rehabilitation expertise to care for the combat wounded from OEF and OIF. This network receives from, and makes referrals to, DOD facilities in the United States and abroad. This article describes how the VA conceived and implemented a state-of-the-art telehealth network, the Polytrauma Telehealth Network (PTN), as a resource to supplement its medical services and make the rehabilitation specialists’ expertise in its PRCs widely available at PNSs, and to link these sites with their military counterparts. The advantages of doing this are: (1) it expedites access to care, (2) it improves clinical communication and transitions, and (3) it eliminates unnecessary travel for the severely combat wounded and their families. PTN FOUNDED ON PATIENT NEED The clinical requirements, information technology platform, and adaptations of the PTN (during and post deployment) are based on needs assessment data provided by the VA Physical Medicine and Rehabilitation Program Office. These data showed that between May 2003 and October 2006, the VA’s PRCs cared for 314 patients (96.5% were men). Their average age at admission was 28 years, and 50% were married. The majority of patients were referred from Walter Reed Army Medical Center (43%) and the National Naval Hospital (32%). Table 1 shows the types of injuries sustained by these patients. These data were used to determine the nature of the specialist rehabilitation services the PTN should offer, as well as what services would be required for variable periods of time, depending on each patient’s needs; for some patients, that would be for the remainder of their lives. Specialist consultation through telehealth support is appropriate for both acute and chronic problems; it makes it possible to redefine the site of care according to a patient’s needs, and to tailor that care to a patient’s circumstances rather than, by default, requiring it to be given where specialist providers are physically located. Although the intense initial stages of rehabilitation may require daily management from many disciplines and be best suited for an acute rehabilitation unit, ongoing care with the same specialist input can be given with telerehabilitation support in an outpatient setting within the veteran’s local community. For example, the later stages of rehabilitation for veterans with closed head injury can take place in their homes7 because their outcomes may be expectant8 over several years9 before they reach the ultimate plateau of recovery. In the interim, these patients benefit from ongoing access to the specialist care10 that telerehabilitation via the PTN can facilitate. In the polytrauma populations from OEF and OIF, the PTN can
VA POLYTRAUMA TELEHEALTH NETWORK, Darkins Table 1: The Site and Prevalence of Injuries to Patients Managed at VA PRCs, May 2003 to October 2006 Injury
N
%
Brain Fractures Wounds and shrapnel Vision Other Lung injuries Soft tissue and orthopedic Hearing Behavioral health Amputations Nerve injuries Burns Internal organ and other Spinal cord injury Gastrointestinal and bowel Cardiovascular Pain Infections
299 120 51 46 40 26 25 24 24 24 18 15 12 8 7 7 5 2
94.3 37.9 16.1 14.5 12.6 8.2 7.9 7.6 7.6 7.6 5.7 4.7 3.8 2.5 2.2 2.2 1.6 0.6
support complex care management. In this population, the compounding effects of amputation, visual impairment, and mental health problems on head injury rehabilitation can hinder return to independent living. For the less severely injured, coordination of care from associated support services via the PTN can maximize functional improvements and increase the likelihood that patients can return to an active, independent life.11 Many of these patients prefer to return to their families and local communities as soon as practicable, which adds a further consideration to an already complex and involved continuum of care, and is something that the PTN specifically addresses. Telehealth care involves the use of electronic information and telecommunications technologies when patients and providers are separated by geographic distances.12 The VA, recognized as a national and international leader in this field, builds on the capacity of its existing computerized patient record system13 to change the location of care for patients. In 2002, the VA formed a telerehabilitation fieldwork group to support the development and implementation of telerehabilitation services. This group helped model the development of the PTN and drew on existing parallel models of telehealth-based care. The VA provided 37,234 teleconsultations in fiscal year 2006 to care for 19,628 patients14 with mental health conditions, and supported with telehealth devices 25,586 patients15 at home who would otherwise have required long-term institutional care. Although the long-term goal of the PTN is to extend care to remote sites and into veterans’ homes, the immediate goal is to connect the 4 PRC hubs with their respective PNSs and create a 21-node (or site) network. THE VHA PTN IMPLEMENTATION The 21 locations in the PTN are shown in figure 1. The initial outline specifications for the PTN were developed between January and August 2005. Clinicians at prospective PTN sites determined the detailed specifications for clinical videoconferencing units and associated cameras, with support from the VA’s wide-area network managers. These specifications formed the basis for a national solicitation for off-the-shelf technology, its installation, and associated staff training. The
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high-bandwidth telecommunications connectivity to link technology at the 21 sites was supported by the VA’s existing telecommunications backbone. The requirements for this Internet protocol-based network were that it: ● ●
provide videoconferencing at a minimum of 384KB; support multiple simultaneous peer-to-peer networking of rehabilitation teams within the VA; ● link these VA teams with their DOD counterparts; ● enable patients and families to interact with distant sites; and ● support multicasting for clinical and educational activities, for example, grand rounds. A contract was awarded for the PTN in the fall of 2005 and the information technology was installed between January and November 2006. This installation was linked to the existing VA telecommunications infrastructures. This systems integration ensured the creation of a safe, appropriate, and effective platform for clinical care delivery, with delineation of responsibility between the technologies supplied by external vendors and the VA infrastructure that supported the PTN. PTN CLINICAL CONFERENCING TECHNOLOGY REQUIREMENTS A staff member at each of the 21 polytrauma sites (appendix 1) was recruited from each site’s existing polytrauma team to provide support, as a collateral duty, to the PTN. Their role was to prepare their site for the implementation of the technology, to embed the use of the PTN within clinical practice at the site, to coordinate training, and to troubleshoot problems. Information technology, telecommunications, and program staffs at both the local and national levels helped with the implementation. The rollout of the technology was sequential; once it was successfully installed and accepted at 1 site, it was then installed at a new site. In this way, lessons learned could be applied in later installations and the installation checklist updated. The technology was installed at each site in designated clinical areas where patient consultations take place. The equipment consists of clinical videoconferencing workstations at which information from Veterans Health Administration’s (VHA) computerized patient record system can be simultaneously viewed on a dedicated laptop personal computer. To view wounds or amputation stumps, for example, peripheral exam cameras can be attached to the clinical videoconferencing units, which are connected to the VAMC’s local area network (LAN). Through its local LAN, each PTN site has access to the VA telecommunications backbone and the wide area network serving the region in which it is situated. It cost $875,000 to establish the PTN. This cost covered clinical videoconferencing units, central bridging equipment, software, installation, and staff training. Ongoing maintenance costs are $64,500 a year. Maintenance and support of the PTN and the quality of service fall within the existing VA backbone and wide area network operations and do not incur additional costs. PTN TELECOMMUNICATIONS REQUIREMENTS The PTN was conceived as a mission critical, clinical application to meet the complex care needs of severely combat wounded patients. It is the first clinical videoconferencing application to be supported on the VHA telecommunications backbone. That backbone, as is true of those of other organizations, serves several functions related to data exchange associated with differing priority levels. Fundamental to the concept of the PTN was the creation of an integrated, interoperable network with quality of service standards for the Internet Arch Phys Med Rehabil Vol 89, January 2008
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Fig 1. VHA PTN sites.
protocol16 routing of data that would ensure that clinical videoconferencing data packets would have precedence over other nonclinical applications on the backbone. Typically, Internet protocol communication over telecommunication networks operates on a “best-effort” basis. This means that all network Internet protocol traffic, whether data, voice, or video, has equal priority. If there is network congestion because of a high volume of traffic, data loss or delay can occur. For some applications, such as e-mail, such data transmission issues may be minor or imperceptible. For a high-end application such as clinical videoconferencing, however, it may cause a frozen, “tiled,” blinking, or blank display of the motion-picture image, with or without sound. Such an occurrence would be untenable on the PTN, on which critical aspects of patient care depend on clear visualization of a patient’ responses, affect, physical findings, and associated functional ability. Under the VA’s Telecommunications Modernization Project (TMP),17 there are 4 classes of network traffic: voice, video, data1 (excellent effort traffic), and data2 (best-effort traffic). Arch Phys Med Rehabil Vol 89, January 2008
The quality of service standards the VA is implementing across its backbone and the wide area networks that interconnect with it, is a differentiated services18 model in which network traffic is classified; it adheres to routing or forwarding rules based on per-hop behaviors.19 In the TMP model, this involves differentiated services and per-hop behavior Internet protocol packet classification and conditioning takes place at the margins of the network where data enters and exits the “cloud” and is described as a differentiated services code point.20 Under TMP, other routers in the network follow these differentiated services code point requirements to designate Internet protocol packets according to their pre-prescribed traffic classes and to underpin quality of service across the network. Thus, by implementing the PTN under the umbrella of its TMP, this clinical videoconferencing application was assigned quality of service standards that have ensured how Internet protocol packets are prioritized. The VA backbone and its wide area network connections handle PTN traffic according to defined priorities, or classes, that allow quality of service to enable “congestion avoidance” to “condition” data traffic (ie,
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route higher priority traffic to empty or short traffic queues) for expedited delivery. Quality of service is critical to the concept of the PTN, which provides live (real-time) interactive clinical videoconferencing. This is because quality of service designates data traffic priority on bandwidth resources that are not dedicated and that must handle multiple applications; thus, problems that might arise when videoconferencing without quality of service can be minimized. A subset of differentiated services code point known as the class selector code point21 accommodates for any VA routers that cannot yet accommodate differentiated services. It should be noted that quality of service is a tool with which to prioritize traffic on Internet protocol networks and it cannot obviate for an absolute mismatch between network bandwidth capacity and over-subscribed demand. As an enterprise-supported capability, the PTN and its projected traffic is an application that will be factored into future projections for the VA’s bandwidth requirements. PTN CLINICAL IMPLEMENTATION REQUIREMENTS Implementation of a national videoconferencing network to facilitate the rehabilitation clinical care of patients severely wounded in combat required the incorporation of detailed clinical input inhibits design. The quality of service standards, the networking architecture needed to support the PTN, and the networking tolerances in terms of loss22 and latency, and jitter,23 were predefined. Nonetheless, once the PTN was implemented, and despite satisfactory performance of network elements within preset thresholds, attainment of these indices did not ensure that the resultant videoconferencing sessions would meet clinical requirements. Fine-tuning of the LAN and national gatekeeper24 functions was necessary to attain a video connection that was acceptable to clinicians. Of particular concern was the quality of multipoint videoconferencing sessions done according to session initiation protocols25 that were needed to ensure that grand rounds could be held for case conferences and educational purposes. The clinical videoconferencing uses of the PTN include: ● ●
Connecting PRC sites to polytrauma sites for patient referral; Connecting PRC sites to polytrauma sites for family and caregiver support; ● Connecting polytrauma sites to PRC sites for primary patient referral; ● Connecting polytrauma sites to PRC sites for family and caregiver information and support; ● Connecting polytrauma sites to PRC sites for follow-up consultation; ● Conducting grand rounds between all PTN sites (the multipoint control unit is in Kansas City, MO); and ● Making virtual referrals between military treatment facilities and PTN sites. The appropriate criteria for governing these various clinical uses were defined by the PTN leaders at each site in conjunction with their respective clinical counterparts. The needs of patients, the support of caregivers, and the clinicians’ scope of practice determine the processes of clinical videoconferencing on the PTN, and its associated inclusion and exclusion criteria. Pertinent legal and regulatory issues that must be factored in are the licensure, credentialing, and privileging of physicians. Federal supremacy26 permits VA physicians with a medical license in 1 state to practice in other states. State licensure was not a barrier to developing the PTN, as it can be elsewhere.27 The VA makes a distinction between
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consultation and care in relation to telehealth that involves clinical videoconferencing, and credentialing and privileging must be undertaken accordingly.28 The VA has a national web-based credentialing system called VetPro29 that facilitates the development of telehealth. Clinicians who support the PTN use VetPro to as a means to ensure that people who provide consultation support via telehealth in the VA have the required competencies. The VA and DOD have separate electronic patient record systems; work is ongoing to support the direct exchange of clinical data that is mediated via telehealth, and to replace interim paper-based, electronic document and digital radiology exchange systems. PTN BUSINESS PROCESS IMPLEMENTATION REQUIREMENTS Each of the 21 PTN sites is managed locally and its staff is employed by the VAMC in which it is situated. The local information technology staff and the local wide area network manager provide information technology support for the PTN. The VHA backbone is managed by telecommunications in the VA’s central office and the VA’s National Teleconferencing System in Martinsburg, WV, oversees the gatekeeper function. Program support to coordinate these various elements is provided by the VA’s Office of Care Coordination in Washington, DC. Ensuring that clinical activity is monitored for both workload and outcomes measurement requires that teleconsultations on the PTN be suitably coded, captured, and measured. A combination of current procedural terminology30 coding and the internal VA coding system on its decision support system31 makes monitoring of this activity on the PTN a routine process as part of establishing new clinics. Activity on the PTN that occurs between its various sites is on the VHA intranet and complies with its cyber security requirements, as well as with the requirements of the Health Insurance Portability and Accountability Act and the Privacy Act, just as it must for VHA’s computerized patient record system.32 Connections between VHA and military treatment facilities use integrated services digital network and are similarly secure. CLINICAL CARE ON THE PTN To understand the PTN’s design, deployment, and function, an illustrative hypothetical case history is helpful. John Doe (JB) is a 21-year-old U.S. Army veteran from New York State who was injured in April 2006 while on routine patrol in Iraq. An improvised explosive device was detonated near his vehicle; he suffered head trauma and multiple severe soft tissue injuries from the resulting explosion. After receiving immediate emergent medical care in the theater of operations, JB was rapidly evacuated to the regional medical center in Landstuhl, Germany, where he underwent additional surgical interventions. From Germany, he was transferred to Walter Reed Army Medical Center in Washington, DC, where he received the remainder of his acute surgical and medical treatment and began rehabilitation for traumatic brain injury (TBI) and amputation of his right upper extremity. When that phase of his care at Walter Reed was completed, JB was transferred to the Richmond VAMC for intensive rehabilitation services. The Richmond VAMC is one of the 4 PRCs within VHA where specialized rehabilitation and medical services for injured service members with polytraumatic injuries are provided. Here, the next crucial step in the care of his injuries was managed. Before his transfer to Richmond, JB, members of his family, and his treatment team at Walter Reed met via the PTN with Arch Phys Med Rehabil Vol 89, January 2008
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the interdisciplinary rehabilitation team that would assume his care at the Richmond VAMC. The family and interdisciplinary care teams met “virtually,” deriving all the benefits of a faceto-face meeting without the inconvenience of traveling between facilities. Through the PTN, an ongoing bridge of communication was established that coordinated the care between treatment teams in a way that involved the patient and his family in the treatment decisions, and mapped out a proposed treatment plan throughout the continuum of care. JB and his family spent several months at the Richmond VAMC, where he received comprehensive inpatient rehabilitation for his TBI and upper-extremity amputation. During this time, there were further consultations between Richmond and Walter Reed though the PTN concerning his prosthetic right upper limb. When he had progressed sufficiently toward his agreed goals for functional recovery, and his need for specialized services had decreased, JB was ready to transition to the next level of care and return closer to his home and local community. He was scheduled for transfer to the Bronx VAMC PNS, a regional polytrauma unit linked with the PRC in Richmond. Each of the 4 PRCs has geographically distributed regional sites they support, and through these they provide services across the continuum of care; the Bronx VAMC was the local polytrauma site for JB’s continuing care. Again, before his transfer, JB, his family, and his Richmond treatment team held a PTN videoconference with the interdisciplinary rehabilitation team at the Bronx VAMC. As previously, the PTN enabled communication across hundreds of miles, during which JB’s biopsychosocial needs were discussed and his transfer coordinated in a manner that provided him and his family with comfort, support, and reassurance. In this way, his care was not seemingly being assumed by a treatment team that they would have met for the first time after a long journey on the day of transfer. After his transfer to the Bronx, the specialized rehabilitation team at the Richmond VAMC was able to monitor JB’s progress and receive feedback on his care through the PTN. It was comforting for JB and his family to continue to see the Richmond team “virtually.” Because there were complex treatment decisions to be negotiated, the unanimity between his current and previous providers about those decisions provided a consistency of care in his ongoing rehabilitation. Ultimately, through the efforts of patient, family, and providers, JB’s independence progressed to a level at which he was ready to be discharged home. Today, he continues to receive outpatient treatment through the Bronx VAMC, and he is working on his goal of returning to college and participating in local athletic events. His treatment team continues to regularly consult with the rehabilitation team in Richmond through the PTN to deal with such issues as surgical follow-up, prosthesis evaluation, and TBI management. INITIAL EXPERIENCE AND LESSONS LEARNED The PTN has been operational since December 2006. In the first quarter of FY 2007, it was used for 320 calls. Challenges associated with its operations have been clinical, technical, and managerial. Clinical issues have included refining indications for the PTN’s use and integrating it into routine clinical practice. Technical issues have included implementing the quality of service and local area network links to the PTN, and finetuning the communications bridge. The business issues have involved coding and workload capture. CONCLUSIONS The essence of the PTN concept is its ability to connect a tiered network of interdisciplinary teams of rehabilitation speArch Phys Med Rehabil Vol 89, January 2008
cialists at all of the PRCs to facilitate the continuum of care throughout the VHA. The PTN adds to VHA’s armamentarium with which to provide safe, effective, and compassionate care to those who have sustained polytraumatic injuries in support of their country. Early experience with the PTN has shown that it can provide continuity and coordination of care across a continuum to help patients in their transition back to their local communities. In addition to direct patient care, the PTN provides patients and families with initial introductions to clinicians, and promotes ongoing relationships with treatment teams across the continuum of care. The PTN makes possible easier transitions for families through the intensely stressful process of rehabilitating patients with polytraumatic injuries received in combat. The VA in FY 2007 will implement telemental health services in more than 300 sites in community-based outpatient clinics that will increase to 45,000 the number of subjects with mental health conditions who are receiving care via telehealth. The VA will also increase to 50,000 the number of patients receiving care in the home via home-telehealth by October 2009. By extending the quality of service standards for clinical videoconferencing to the 21 VHA networks that connect to the VHA backbone, the PTN could extend and connect to more than 300 additional sites (those undertaking telemental health services) within 3 years. Additionally, possible development in home-telehealth could extend the PTN directly into homes within 10 years. The PTN is therefore the first step in the clinical, technological, and business re-engineering of care within the VHA that may lead to a large national consultation network for polytrauma patients that extends across the continuum of care. The systematic model underlying the PTN means there can be ongoing evaluation of the program to establish its continued appropriateness, clinical effectiveness, and cost effectiveness in support of the care for severely wounded patients and help them live independently in their own communities. APPENDIX 1: PTN SITES ● ● ● ● ● ●
Richmond PRC Boston PNS Syracuse PNS Bronx PNS Washington, DC PNS Philadelphia PNS
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Tampa PRC Augusta PNS Lexington PNS Houston PNS Dallas PNS
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Minneapolis PRC Cleveland PNS Indianapolis PNS Hines PNS St. Louis PNS
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Palo Alto PRC Tucson PNS Denver PNS Seattle PNS West Los Angeles PNS References 1. Bricknell MC. The evolution of casualty evacuation in the 20th century (Part 4)—an international perspective. J R Army Med Corps 2003;149:166-74.
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2. Eldar R, Jelic M. The association of rehabilitation and war. Disabil Rehabil 2003;25:1019-23. 3. Childress D. Development of rehabilitation engineering over the years: as I see it. J Rehabil Res Dev 2002;39(6 Suppl):1-10. 4. King B, Jatoi I. The mobile Army surgical hospital (MASH): a military and surgical legacy. J Natl Med Assoc 2005;97:648-56. 5. Tenuta JJ. From the battlefields to the states: the road to recovery. The role of Landstuhl Regional Medical Center in US military casualty care. J Am Acad Orthop Surg 2006;14(10 Suppl):S45-7. 6. Montgomery SP, Swiecki CW, Shriver CD. The evaluation of casualties from Operation Iraqi Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 2005;201:7-12; discussion 12-3. 7. Salazar AM, Warden DL, Schwab K, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA 2000;283:3075-81. 8. Dikmen SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to 5 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2003;84:1449-57. 9. Millis SR, Rosenthal M, Novack TA, et al. Long-term neuropsychological outcome after traumatic brain injury. J Head Trauma Rehabil 2001;16:343-55. 10. Goka RS, Arakaki AH. Brain injury rehabilitation; the continuum of care. J Insur Med 1994-1995;26:420-5. 11. Pasquina PF, Gambel J, Foster LS, Kim A, Doukas WC. Process of care for battle casualties at the Walter Reed Army Medical Center: Part III. Physical medicine and rehabilitation service. Mil Med 2006;171:206-8. 12. Health Resources and Services Administration. Available at: http://www.hrsa.gov/telehealth. Accessed February 15, 2007. 13. U.S. Department of Health and Human Services. Health IT strategic framework. Attachment 2. V. Other VA approaches - knowledge and technology transfers to benefit target populations. Available at: http://www.hhs.gov/healthit/attachment_2/v.html. Accessed February 15, 2007. 14. Office of Care Coordination, Department of Veterans Affairs. Routine telemental health activity data report. Dec 2006. Available at: https://klfmenu.med.va.gov/dss_ssl/TeleMental_ health.asp. Accessed February 15, 2007. 15. Office of Care Coordination, Department of Veterans Affairs. Routine home-telehealth activity data report. Dec 2006. Available at: https://vaww.etech.med.va.gov/telehealth/. Accessed February 15, 2007. 16. Wetherall DJ, Tennenhouse DL. The ACTIVE IP option. In: Proceedings of the 7th workshop on ACM SIGOPS European workshop: systems support for worldwide applications. New York: ACM Pr; 1996. p 33-40. 17. Office of Information Technology, Department of Veterans Affairs. Available at: http://www.va.gov/oirm/telecom/default.asp. Accessed February 15, 2007. 18. Luyuan Fang Bita N, Le Roux JL, Miles J. Interprovider IP-MPLS services: requirements, implementations, and challenges. Communications 2005;43:119-28. 19. Black D, Blake S, Carlson M, Davies E, Wang Z, Zeis W. An architecture for differentiated services. Reston: The Internet So-
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ciety; 1998. Available at: http://www.mosteiro.hpg.ig.com.br/ RFC/rfc2475.pdf. Accessed February 15, 2007. Differentiated Services Code Point (DSCP) overview. Available at: http://technet2.microsoft.com/WindowsServer/en/library/ d818f74b-de00-4590-a44f-56fce1b06f3c1033.mspx?mfr⫽true. Accessed February 15, 2007. Babiarz J, Baker F. Configuration Guidelines for DiffServ Service Classes draft-ietf-tsvwg-diffserv-service-classes-01. Reston: The Internet Society; July 15, 2005. Available at: http://www3.ietf.org/ proceedings/05aug/IDs/draft-ietf-tsvwg-diffserv-service-classes01.txt. Accessed February 15, 2007. Jacobson V, Nichols K, Poduri K; Differentiated Services Working Group (IETF-47), Internet Engineering Task Force. The ‘virtual wire’ behavior aggregate. March 28, 2000. Available at: http://www3.ietf.org/proceedings/00mar/slides/diffserv-vw00mar.pdf. Accessed February 15, 2007. Telecommunication Standard Sector, International Telecommunication Union (ITU SG-12). Analysis, measurement and modeling of Jitter. January 31, 2003. Available at: http://www.telchemy. com/reference/ITUSG12_JitterAnalysis.pdf. Accessed February 15, 2007. Johnson T, Okubo S, Campos S; Network Working Group. H.350 directory services. Reston: The Internet Society; Dec 2004. Available at: http://tools.ietf.org/html/rfc3944. Accessed February 15, 2007. SIP Forum. Available at: http://www.sipforum.org/content/view/ 17/47/. Accessed February 15, 2007. Radcliffe M, Brinson D. The U.S. legal system. Available at: http://library.findlaw.com/1999/Jan/1/241487.html. Accessed February 15, 2007. Goodwin K. Payment, licensure are barriers to telemedicine. State Health Notes 2000;21:330. Available at: http://www.ncsl.org/ programs/health/barriers.htm. Accessed February 15, 2007. VHA directive 2001-055. Credentialing and privileging of telemedicine and telehealth services provided in hospitals and clinics. Washington (DC): Department of Veterans Affairs, Veterans Health Administration; Sep 2001. Available at: http:// www1.va.gov/vhapublications/ViewPublication.asp?pub_ID⫽127. Accessed February 15, 2007. VHA directive 2001-022. Implementation of VetPro, VHA’s national credentials databank. Washington (DC): Department of Veterans Affairs, Veterans Health Administration; April 2001. Available at: http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID⫽ 87. Accessed February 15, 2007. CPT (Current Procedural Terminology). Available at: http:// www.ama-assn.org/ama/pub/category/3113.html. Accessed February 15, 2007. VHA decision support system (DSS). Washington (DC): Department of Veterans Affairs; Aug 2006. Available at: http:// www.virec.research.va.gov/DataSourcesName/DSS/DSSintro.htm. Accessed February 15, 2007. VHA directive 2002-045. Guidance on access to CPRS read only functionality for authorized users. Washington (DC): Department of Veterans Affairs, Veterans Health Administration; Jul 2002. Available at: https://www1.va.gov/vhapublications/ViewPublication.asp? pub_ID⫽191. Accessed February 15, 2007.
Arch Phys Med Rehabil Vol 89, January 2008
SPECIAL SECTION: SPECIAL COMMUNICATION
Enhancing Access of Combat-Wounded Veterans to Specialist Rehabilitation Services: The VA Polytrauma Telehealth Network Adam Darkins, MD, Cathy Cruise, MD, Michael Armstrong, MD, John Peters, MS, Michael Finn ABSTRACT. Darkins A, Cruise C, Armstrong M, Peters J, Finn M. Enhancing access of combat-wounded veterans to specialist rehabilitation services: the VA Polytrauma Telehealth Network. Arch Phys Med Rehabil 2008;89:182-7. Operations Iraqi Freedom and Enduring Freedom have resulted in U.S. military personnel sustaining combat wounds of unprecedented severity and complexity that necessitate longterm rehabilitation. To meet what are often conflicting requirements in providing severely wounded veterans with timely and convenient access to specialist rehabilitation care, and to enable them to return to their local communities, the Veterans Health Administration has developed a state-of-the-art Polytrauma Telehealth Network that enhances access to such services by linking Veterans Administration rehabilitation facilities. This article describes the clinical, technical, and business process issues involved in the development of this network. Key Words: Rehabilitation; Telecommunication networks; Telemedicine; Wounds and injuries. © 2008 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ISTORICALLY, IMPLEMENTATION of new technologies to clinically manage the combat wounded has proH foundly changed battlefield care and the subsequent course of 1
rehabilitation for those who survive.2,3 Currently, patients who have sustained serious combat injuries during Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) receive care in combat surgical hospitals by forward surgical teams,4 which represents further developments of this legacy. Personnel wounded in OEF and OIF are rapidly evacuated from the war zones, stabilized, and triaged at a regional medical center5 before being transferred, if necessary, to a Department of Defense (DOD) military treatment facility in the continental United States. The reduction in the elapsed time between injury (principally sustained from improvised explosive devices, against which body armor affords selective protection) and arrival in the United States means that combat wounded are arriving for rehabilitation services in DOD facilities and Department of Veterans Affairs (VA) medical centers (VAMCs) with treat-
From the U.S. Department of Veterans Affairs, Veterans Health Administration, Washington, DC (Darkins, Peters, Finn); U.S. Department of Veterans Affairs, Veterans Health Administration, Northport, MN (Cruise); and U.S. Department of Veterans Affairs, Veterans Health Administration, Minneapolis, MN (Armstrong). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Correspondence to Adam Darkins, MD, Office of Care Coordination 11CC, Department of Veterans Affairs, 810 Vermont Ave NW, Washington, DC 20420. Reprints are not available from the author. 0003-9993/08/8901-00285$34.00/0 doi:10.1016/j.apmr.2007.07.027
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ment needs of unprecedented complexity.6 To meet this challenge, the VA has established polytrauma rehabilitation center (PRC) hub sites at 4 major VAMCs that have specialist clinical expertise in polytrauma These hub sites—in Richmond, VA; Tampa, FL; Minneapolis, MN; and Palo Alto, CA—support “spoke” sites, or polytrauma network sites (PNSs), in regionally associated VAMCs. Thus, the VA has created a physical network of tiered interdisciplinary rehabilitation expertise to care for the combat wounded from OEF and OIF. This network receives from, and makes referrals to, DOD facilities in the United States and abroad. This article describes how the VA conceived and implemented a state-of-the-art telehealth network, the Polytrauma Telehealth Network (PTN), as a resource to supplement its medical services and make the rehabilitation specialists’ expertise in its PRCs widely available at PNSs, and to link these sites with their military counterparts. The advantages of doing this are: (1) it expedites access to care, (2) it improves clinical communication and transitions, and (3) it eliminates unnecessary travel for the severely combat wounded and their families. PTN FOUNDED ON PATIENT NEED The clinical requirements, information technology platform, and adaptations of the PTN (during and post deployment) are based on needs assessment data provided by the VA Physical Medicine and Rehabilitation Program Office. These data showed that between May 2003 and October 2006, the VA’s PRCs cared for 314 patients (96.5% were men). Their average age at admission was 28 years, and 50% were married. The majority of patients were referred from Walter Reed Army Medical Center (43%) and the National Naval Hospital (32%). Table 1 shows the types of injuries sustained by these patients. These data were used to determine the nature of the specialist rehabilitation services the PTN should offer, as well as what services would be required for variable periods of time, depending on each patient’s needs; for some patients, that would be for the remainder of their lives. Specialist consultation through telehealth support is appropriate for both acute and chronic problems; it makes it possible to redefine the site of care according to a patient’s needs, and to tailor that care to a patient’s circumstances rather than, by default, requiring it to be given where specialist providers are physically located. Although the intense initial stages of rehabilitation may require daily management from many disciplines and be best suited for an acute rehabilitation unit, ongoing care with the same specialist input can be given with telerehabilitation support in an outpatient setting within the veteran’s local community. For example, the later stages of rehabilitation for veterans with closed head injury can take place in their homes7 because their outcomes may be expectant8 over several years9 before they reach the ultimate plateau of recovery. In the interim, these patients benefit from ongoing access to the specialist care10 that telerehabilitation via the PTN can facilitate. In the polytrauma populations from OEF and OIF, the PTN can
VA POLYTRAUMA TELEHEALTH NETWORK, Darkins Table 1: The Site and Prevalence of Injuries to Patients Managed at VA PRCs, May 2003 to October 2006 Injury
N
%
Brain Fractures Wounds and shrapnel Vision Other Lung injuries Soft tissue and orthopedic Hearing Behavioral health Amputations Nerve injuries Burns Internal organ and other Spinal cord injury Gastrointestinal and bowel Cardiovascular Pain Infections
299 120 51 46 40 26 25 24 24 24 18 15 12 8 7 7 5 2
94.3 37.9 16.1 14.5 12.6 8.2 7.9 7.6 7.6 7.6 5.7 4.7 3.8 2.5 2.2 2.2 1.6 0.6
support complex care management. In this population, the compounding effects of amputation, visual impairment, and mental health problems on head injury rehabilitation can hinder return to independent living. For the less severely injured, coordination of care from associated support services via the PTN can maximize functional improvements and increase the likelihood that patients can return to an active, independent life.11 Many of these patients prefer to return to their families and local communities as soon as practicable, which adds a further consideration to an already complex and involved continuum of care, and is something that the PTN specifically addresses. Telehealth care involves the use of electronic information and telecommunications technologies when patients and providers are separated by geographic distances.12 The VA, recognized as a national and international leader in this field, builds on the capacity of its existing computerized patient record system13 to change the location of care for patients. In 2002, the VA formed a telerehabilitation fieldwork group to support the development and implementation of telerehabilitation services. This group helped model the development of the PTN and drew on existing parallel models of telehealth-based care. The VA provided 37,234 teleconsultations in fiscal year 2006 to care for 19,628 patients14 with mental health conditions, and supported with telehealth devices 25,586 patients15 at home who would otherwise have required long-term institutional care. Although the long-term goal of the PTN is to extend care to remote sites and into veterans’ homes, the immediate goal is to connect the 4 PRC hubs with their respective PNSs and create a 21-node (or site) network. THE VHA PTN IMPLEMENTATION The 21 locations in the PTN are shown in figure 1. The initial outline specifications for the PTN were developed between January and August 2005. Clinicians at prospective PTN sites determined the detailed specifications for clinical videoconferencing units and associated cameras, with support from the VA’s wide-area network managers. These specifications formed the basis for a national solicitation for off-the-shelf technology, its installation, and associated staff training. The
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high-bandwidth telecommunications connectivity to link technology at the 21 sites was supported by the VA’s existing telecommunications backbone. The requirements for this Internet protocol-based network were that it: ● ●
provide videoconferencing at a minimum of 384KB; support multiple simultaneous peer-to-peer networking of rehabilitation teams within the VA; ● link these VA teams with their DOD counterparts; ● enable patients and families to interact with distant sites; and ● support multicasting for clinical and educational activities, for example, grand rounds. A contract was awarded for the PTN in the fall of 2005 and the information technology was installed between January and November 2006. This installation was linked to the existing VA telecommunications infrastructures. This systems integration ensured the creation of a safe, appropriate, and effective platform for clinical care delivery, with delineation of responsibility between the technologies supplied by external vendors and the VA infrastructure that supported the PTN. PTN CLINICAL CONFERENCING TECHNOLOGY REQUIREMENTS A staff member at each of the 21 polytrauma sites (appendix 1) was recruited from each site’s existing polytrauma team to provide support, as a collateral duty, to the PTN. Their role was to prepare their site for the implementation of the technology, to embed the use of the PTN within clinical practice at the site, to coordinate training, and to troubleshoot problems. Information technology, telecommunications, and program staffs at both the local and national levels helped with the implementation. The rollout of the technology was sequential; once it was successfully installed and accepted at 1 site, it was then installed at a new site. In this way, lessons learned could be applied in later installations and the installation checklist updated. The technology was installed at each site in designated clinical areas where patient consultations take place. The equipment consists of clinical videoconferencing workstations at which information from Veterans Health Administration’s (VHA) computerized patient record system can be simultaneously viewed on a dedicated laptop personal computer. To view wounds or amputation stumps, for example, peripheral exam cameras can be attached to the clinical videoconferencing units, which are connected to the VAMC’s local area network (LAN). Through its local LAN, each PTN site has access to the VA telecommunications backbone and the wide area network serving the region in which it is situated. It cost $875,000 to establish the PTN. This cost covered clinical videoconferencing units, central bridging equipment, software, installation, and staff training. Ongoing maintenance costs are $64,500 a year. Maintenance and support of the PTN and the quality of service fall within the existing VA backbone and wide area network operations and do not incur additional costs. PTN TELECOMMUNICATIONS REQUIREMENTS The PTN was conceived as a mission critical, clinical application to meet the complex care needs of severely combat wounded patients. It is the first clinical videoconferencing application to be supported on the VHA telecommunications backbone. That backbone, as is true of those of other organizations, serves several functions related to data exchange associated with differing priority levels. Fundamental to the concept of the PTN was the creation of an integrated, interoperable network with quality of service standards for the Internet Arch Phys Med Rehabil Vol 89, January 2008
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Fig 1. VHA PTN sites.
protocol16 routing of data that would ensure that clinical videoconferencing data packets would have precedence over other nonclinical applications on the backbone. Typically, Internet protocol communication over telecommunication networks operates on a “best-effort” basis. This means that all network Internet protocol traffic, whether data, voice, or video, has equal priority. If there is network congestion because of a high volume of traffic, data loss or delay can occur. For some applications, such as e-mail, such data transmission issues may be minor or imperceptible. For a high-end application such as clinical videoconferencing, however, it may cause a frozen, “tiled,” blinking, or blank display of the motion-picture image, with or without sound. Such an occurrence would be untenable on the PTN, on which critical aspects of patient care depend on clear visualization of a patient’ responses, affect, physical findings, and associated functional ability. Under the VA’s Telecommunications Modernization Project (TMP),17 there are 4 classes of network traffic: voice, video, data1 (excellent effort traffic), and data2 (best-effort traffic). Arch Phys Med Rehabil Vol 89, January 2008
The quality of service standards the VA is implementing across its backbone and the wide area networks that interconnect with it, is a differentiated services18 model in which network traffic is classified; it adheres to routing or forwarding rules based on per-hop behaviors.19 In the TMP model, this involves differentiated services and per-hop behavior Internet protocol packet classification and conditioning takes place at the margins of the network where data enters and exits the “cloud” and is described as a differentiated services code point.20 Under TMP, other routers in the network follow these differentiated services code point requirements to designate Internet protocol packets according to their pre-prescribed traffic classes and to underpin quality of service across the network. Thus, by implementing the PTN under the umbrella of its TMP, this clinical videoconferencing application was assigned quality of service standards that have ensured how Internet protocol packets are prioritized. The VA backbone and its wide area network connections handle PTN traffic according to defined priorities, or classes, that allow quality of service to enable “congestion avoidance” to “condition” data traffic (ie,
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route higher priority traffic to empty or short traffic queues) for expedited delivery. Quality of service is critical to the concept of the PTN, which provides live (real-time) interactive clinical videoconferencing. This is because quality of service designates data traffic priority on bandwidth resources that are not dedicated and that must handle multiple applications; thus, problems that might arise when videoconferencing without quality of service can be minimized. A subset of differentiated services code point known as the class selector code point21 accommodates for any VA routers that cannot yet accommodate differentiated services. It should be noted that quality of service is a tool with which to prioritize traffic on Internet protocol networks and it cannot obviate for an absolute mismatch between network bandwidth capacity and over-subscribed demand. As an enterprise-supported capability, the PTN and its projected traffic is an application that will be factored into future projections for the VA’s bandwidth requirements. PTN CLINICAL IMPLEMENTATION REQUIREMENTS Implementation of a national videoconferencing network to facilitate the rehabilitation clinical care of patients severely wounded in combat required the incorporation of detailed clinical input inhibits design. The quality of service standards, the networking architecture needed to support the PTN, and the networking tolerances in terms of loss22 and latency, and jitter,23 were predefined. Nonetheless, once the PTN was implemented, and despite satisfactory performance of network elements within preset thresholds, attainment of these indices did not ensure that the resultant videoconferencing sessions would meet clinical requirements. Fine-tuning of the LAN and national gatekeeper24 functions was necessary to attain a video connection that was acceptable to clinicians. Of particular concern was the quality of multipoint videoconferencing sessions done according to session initiation protocols25 that were needed to ensure that grand rounds could be held for case conferences and educational purposes. The clinical videoconferencing uses of the PTN include: ● ●
Connecting PRC sites to polytrauma sites for patient referral; Connecting PRC sites to polytrauma sites for family and caregiver support; ● Connecting polytrauma sites to PRC sites for primary patient referral; ● Connecting polytrauma sites to PRC sites for family and caregiver information and support; ● Connecting polytrauma sites to PRC sites for follow-up consultation; ● Conducting grand rounds between all PTN sites (the multipoint control unit is in Kansas City, MO); and ● Making virtual referrals between military treatment facilities and PTN sites. The appropriate criteria for governing these various clinical uses were defined by the PTN leaders at each site in conjunction with their respective clinical counterparts. The needs of patients, the support of caregivers, and the clinicians’ scope of practice determine the processes of clinical videoconferencing on the PTN, and its associated inclusion and exclusion criteria. Pertinent legal and regulatory issues that must be factored in are the licensure, credentialing, and privileging of physicians. Federal supremacy26 permits VA physicians with a medical license in 1 state to practice in other states. State licensure was not a barrier to developing the PTN, as it can be elsewhere.27 The VA makes a distinction between
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consultation and care in relation to telehealth that involves clinical videoconferencing, and credentialing and privileging must be undertaken accordingly.28 The VA has a national web-based credentialing system called VetPro29 that facilitates the development of telehealth. Clinicians who support the PTN use VetPro to as a means to ensure that people who provide consultation support via telehealth in the VA have the required competencies. The VA and DOD have separate electronic patient record systems; work is ongoing to support the direct exchange of clinical data that is mediated via telehealth, and to replace interim paper-based, electronic document and digital radiology exchange systems. PTN BUSINESS PROCESS IMPLEMENTATION REQUIREMENTS Each of the 21 PTN sites is managed locally and its staff is employed by the VAMC in which it is situated. The local information technology staff and the local wide area network manager provide information technology support for the PTN. The VHA backbone is managed by telecommunications in the VA’s central office and the VA’s National Teleconferencing System in Martinsburg, WV, oversees the gatekeeper function. Program support to coordinate these various elements is provided by the VA’s Office of Care Coordination in Washington, DC. Ensuring that clinical activity is monitored for both workload and outcomes measurement requires that teleconsultations on the PTN be suitably coded, captured, and measured. A combination of current procedural terminology30 coding and the internal VA coding system on its decision support system31 makes monitoring of this activity on the PTN a routine process as part of establishing new clinics. Activity on the PTN that occurs between its various sites is on the VHA intranet and complies with its cyber security requirements, as well as with the requirements of the Health Insurance Portability and Accountability Act and the Privacy Act, just as it must for VHA’s computerized patient record system.32 Connections between VHA and military treatment facilities use integrated services digital network and are similarly secure. CLINICAL CARE ON THE PTN To understand the PTN’s design, deployment, and function, an illustrative hypothetical case history is helpful. John Doe (JB) is a 21-year-old U.S. Army veteran from New York State who was injured in April 2006 while on routine patrol in Iraq. An improvised explosive device was detonated near his vehicle; he suffered head trauma and multiple severe soft tissue injuries from the resulting explosion. After receiving immediate emergent medical care in the theater of operations, JB was rapidly evacuated to the regional medical center in Landstuhl, Germany, where he underwent additional surgical interventions. From Germany, he was transferred to Walter Reed Army Medical Center in Washington, DC, where he received the remainder of his acute surgical and medical treatment and began rehabilitation for traumatic brain injury (TBI) and amputation of his right upper extremity. When that phase of his care at Walter Reed was completed, JB was transferred to the Richmond VAMC for intensive rehabilitation services. The Richmond VAMC is one of the 4 PRCs within VHA where specialized rehabilitation and medical services for injured service members with polytraumatic injuries are provided. Here, the next crucial step in the care of his injuries was managed. Before his transfer to Richmond, JB, members of his family, and his treatment team at Walter Reed met via the PTN with Arch Phys Med Rehabil Vol 89, January 2008
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the interdisciplinary rehabilitation team that would assume his care at the Richmond VAMC. The family and interdisciplinary care teams met “virtually,” deriving all the benefits of a faceto-face meeting without the inconvenience of traveling between facilities. Through the PTN, an ongoing bridge of communication was established that coordinated the care between treatment teams in a way that involved the patient and his family in the treatment decisions, and mapped out a proposed treatment plan throughout the continuum of care. JB and his family spent several months at the Richmond VAMC, where he received comprehensive inpatient rehabilitation for his TBI and upper-extremity amputation. During this time, there were further consultations between Richmond and Walter Reed though the PTN concerning his prosthetic right upper limb. When he had progressed sufficiently toward his agreed goals for functional recovery, and his need for specialized services had decreased, JB was ready to transition to the next level of care and return closer to his home and local community. He was scheduled for transfer to the Bronx VAMC PNS, a regional polytrauma unit linked with the PRC in Richmond. Each of the 4 PRCs has geographically distributed regional sites they support, and through these they provide services across the continuum of care; the Bronx VAMC was the local polytrauma site for JB’s continuing care. Again, before his transfer, JB, his family, and his Richmond treatment team held a PTN videoconference with the interdisciplinary rehabilitation team at the Bronx VAMC. As previously, the PTN enabled communication across hundreds of miles, during which JB’s biopsychosocial needs were discussed and his transfer coordinated in a manner that provided him and his family with comfort, support, and reassurance. In this way, his care was not seemingly being assumed by a treatment team that they would have met for the first time after a long journey on the day of transfer. After his transfer to the Bronx, the specialized rehabilitation team at the Richmond VAMC was able to monitor JB’s progress and receive feedback on his care through the PTN. It was comforting for JB and his family to continue to see the Richmond team “virtually.” Because there were complex treatment decisions to be negotiated, the unanimity between his current and previous providers about those decisions provided a consistency of care in his ongoing rehabilitation. Ultimately, through the efforts of patient, family, and providers, JB’s independence progressed to a level at which he was ready to be discharged home. Today, he continues to receive outpatient treatment through the Bronx VAMC, and he is working on his goal of returning to college and participating in local athletic events. His treatment team continues to regularly consult with the rehabilitation team in Richmond through the PTN to deal with such issues as surgical follow-up, prosthesis evaluation, and TBI management. INITIAL EXPERIENCE AND LESSONS LEARNED The PTN has been operational since December 2006. In the first quarter of FY 2007, it was used for 320 calls. Challenges associated with its operations have been clinical, technical, and managerial. Clinical issues have included refining indications for the PTN’s use and integrating it into routine clinical practice. Technical issues have included implementing the quality of service and local area network links to the PTN, and finetuning the communications bridge. The business issues have involved coding and workload capture. CONCLUSIONS The essence of the PTN concept is its ability to connect a tiered network of interdisciplinary teams of rehabilitation speArch Phys Med Rehabil Vol 89, January 2008
cialists at all of the PRCs to facilitate the continuum of care throughout the VHA. The PTN adds to VHA’s armamentarium with which to provide safe, effective, and compassionate care to those who have sustained polytraumatic injuries in support of their country. Early experience with the PTN has shown that it can provide continuity and coordination of care across a continuum to help patients in their transition back to their local communities. In addition to direct patient care, the PTN provides patients and families with initial introductions to clinicians, and promotes ongoing relationships with treatment teams across the continuum of care. The PTN makes possible easier transitions for families through the intensely stressful process of rehabilitating patients with polytraumatic injuries received in combat. The VA in FY 2007 will implement telemental health services in more than 300 sites in community-based outpatient clinics that will increase to 45,000 the number of subjects with mental health conditions who are receiving care via telehealth. The VA will also increase to 50,000 the number of patients receiving care in the home via home-telehealth by October 2009. By extending the quality of service standards for clinical videoconferencing to the 21 VHA networks that connect to the VHA backbone, the PTN could extend and connect to more than 300 additional sites (those undertaking telemental health services) within 3 years. Additionally, possible development in home-telehealth could extend the PTN directly into homes within 10 years. The PTN is therefore the first step in the clinical, technological, and business re-engineering of care within the VHA that may lead to a large national consultation network for polytrauma patients that extends across the continuum of care. The systematic model underlying the PTN means there can be ongoing evaluation of the program to establish its continued appropriateness, clinical effectiveness, and cost effectiveness in support of the care for severely wounded patients and help them live independently in their own communities. APPENDIX 1: PTN SITES ● ● ● ● ● ●
Richmond PRC Boston PNS Syracuse PNS Bronx PNS Washington, DC PNS Philadelphia PNS
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Tampa PRC Augusta PNS Lexington PNS Houston PNS Dallas PNS
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Minneapolis PRC Cleveland PNS Indianapolis PNS Hines PNS St. Louis PNS
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Palo Alto PRC Tucson PNS Denver PNS Seattle PNS West Los Angeles PNS References 1. Bricknell MC. The evolution of casualty evacuation in the 20th century (Part 4)—an international perspective. J R Army Med Corps 2003;149:166-74.
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2. Eldar R, Jelic M. The association of rehabilitation and war. Disabil Rehabil 2003;25:1019-23. 3. Childress D. Development of rehabilitation engineering over the years: as I see it. J Rehabil Res Dev 2002;39(6 Suppl):1-10. 4. King B, Jatoi I. The mobile Army surgical hospital (MASH): a military and surgical legacy. J Natl Med Assoc 2005;97:648-56. 5. Tenuta JJ. From the battlefields to the states: the road to recovery. The role of Landstuhl Regional Medical Center in US military casualty care. J Am Acad Orthop Surg 2006;14(10 Suppl):S45-7. 6. Montgomery SP, Swiecki CW, Shriver CD. The evaluation of casualties from Operation Iraqi Freedom on return to the continental United States from March to June 2003. J Am Coll Surg 2005;201:7-12; discussion 12-3. 7. Salazar AM, Warden DL, Schwab K, et al. Cognitive rehabilitation for traumatic brain injury: a randomized trial. Defense and Veterans Head Injury Program (DVHIP) Study Group. JAMA 2000;283:3075-81. 8. Dikmen SS, Machamer JE, Powell JM, Temkin NR. Outcome 3 to 5 years after moderate to severe traumatic brain injury. Arch Phys Med Rehabil 2003;84:1449-57. 9. Millis SR, Rosenthal M, Novack TA, et al. Long-term neuropsychological outcome after traumatic brain injury. J Head Trauma Rehabil 2001;16:343-55. 10. Goka RS, Arakaki AH. Brain injury rehabilitation; the continuum of care. J Insur Med 1994-1995;26:420-5. 11. Pasquina PF, Gambel J, Foster LS, Kim A, Doukas WC. Process of care for battle casualties at the Walter Reed Army Medical Center: Part III. Physical medicine and rehabilitation service. Mil Med 2006;171:206-8. 12. Health Resources and Services Administration. Available at: http://www.hrsa.gov/telehealth. Accessed February 15, 2007. 13. U.S. Department of Health and Human Services. Health IT strategic framework. Attachment 2. V. Other VA approaches - knowledge and technology transfers to benefit target populations. Available at: http://www.hhs.gov/healthit/attachment_2/v.html. Accessed February 15, 2007. 14. Office of Care Coordination, Department of Veterans Affairs. Routine telemental health activity data report. Dec 2006. Available at: https://klfmenu.med.va.gov/dss_ssl/TeleMental_ health.asp. Accessed February 15, 2007. 15. Office of Care Coordination, Department of Veterans Affairs. Routine home-telehealth activity data report. Dec 2006. Available at: https://vaww.etech.med.va.gov/telehealth/. Accessed February 15, 2007. 16. Wetherall DJ, Tennenhouse DL. The ACTIVE IP option. In: Proceedings of the 7th workshop on ACM SIGOPS European workshop: systems support for worldwide applications. New York: ACM Pr; 1996. p 33-40. 17. Office of Information Technology, Department of Veterans Affairs. Available at: http://www.va.gov/oirm/telecom/default.asp. Accessed February 15, 2007. 18. Luyuan Fang Bita N, Le Roux JL, Miles J. Interprovider IP-MPLS services: requirements, implementations, and challenges. Communications 2005;43:119-28. 19. Black D, Blake S, Carlson M, Davies E, Wang Z, Zeis W. An architecture for differentiated services. Reston: The Internet So-
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