Wolfgang Ward enlisted with the United States Marine Corps fresh from high school in 2001. The September 11 attacks occurred while he was at boot camp. Within two years, he was deployed to Northern Iraq.
He didn't see much action there, but the next year he was sent back to Iraq for another tour – this time to the Sunni Triangle, for an eight-month deployment with the 26th Marine Expeditionary Unit.
"In late 2004, we were getting ready to invade the city of Fallujah," says Ward. "I was a squad leader ... I had a sniper team attached to me, and two Navy Seals. We went in through the south of Fallujah, and within about a week of going house to house in close-quarters combat, my unit suffered from about 75 wounded, and 21 of us were killed in action."
Ward was one of the wounded. "I had shrapnel wounds in my leg and back and second-degree burns on my arm," he says. "I was medevacked in November 2004 to Baghdad hospital and then flown into Germany and then to Walter Reed." From there, he was released, went home, convalesced and "transferred to the VA system in California."
Ward says he's only marginally satisfied with his experiences with the Veterans Health Administration: "On a scale of one to 10? I would rate it as a six."
"The reason I say that is that the doctor-patient relationship is kind of lacking," he says. A civilian family practitioner will help you get in touch with your chiropractor, your personal trainer. With the VA, it seems like you go there, you get your number, you sit down, you wait until your doctor sees you, and he says, 'Come back in six months and go wait in line for your medicine.'"
Ward recognizes that the sheer number of returning service members are a big reason why that's so. "It's an assembly line," he says. "I can understand that. There are so many veterans out there getting healthcare. But it just seems like there can be a better way."
With the Iraq War officially over and Afghanistan scheduled to draw down by 2014, and with scores of service members now returning home, an array of innovative public- and private-sector health IT initiatives – EHRs and PHRs, telerehabilitation and telepsychiatry, mobile health and wellness apps, even virtual reality and video games – are at work trying to make that "better way" happen, seeking to improve quality and, especially, access to care.
Nearly 2 million service members have deployed to Afghanistan or Iraq (or both) since 2001. Approximately 20 percent of those who return home will suffer from post-traumatic stress disorder (PTSD) or depression, and some 320,000 of them have sustained a traumatic brain injury (TBI), according to the RAND Corporation.
According to the Department of Veterans Affairs, nearly 90 percent of seriously wounded military service members are surviving. Fifty-four percent of Afghanistan and Iraq veterans are getting care from VA – compared to just 40 percent after World War II.
The demographics of this generation of warriors are striking. Compared to, say, Vietnam, where the draft was in place, the all-volunteer military has led to some skewed numbers with regard to income and geography.
Nearly 45 percent of U.S. military recruits come from rural areas – compared with fewer than 15 percent from major cities. Those who live in "the most sparsely populated ZIP codes are 22 percent more likely to join the Army," according to The Washington Post.
Now scores of these returning service members are coming home to these same remote small towns, where they might not have access to (or even be aware of) the specialty care they need.
Casualties of war
"As the tide of war recedes, we have the opportunity and the responsibility to anticipate the needs of returning veterans," Secretary of Veterans Affairs Eric K. Shinseki has said.
The numbers are sobering. More than 48,000 people have been wounded in action since 2001. About 18 veterans commit suicide each day. The grievous physical wounds and deep psychological scars would be a challenge even in ideal circumstances. But for veterans who might be living in remote towns in Mississippi or Montana, the problem is acute.
"One of the biggest challenges to the current health system is to meet the needs of warriors who may be facing polytraumatic injuries," says Maggie Haynes La Rocca, director of combat stress recovery at the Wounded Warrior Project.
Under Shinseki's leadership, the VA has made big strides to modernize and expand its operations to better serve this massive influx of patients with such a wide array of medical and mental health needs.
The VA Innovation Initiative (VAi2) seeks to transform it into "a 21st-century organization that is people-centric, results-driven, and forward-looking, laying the foundation for "safe, secure, and authentic health record interoperability."
VA's advances with VistA open-source EHR, Virtual Lifetime Electronic Record (VLER) and Blue Button initiatives have been well documented. Its joint iEHR with the Department of Defense (DoD) holds even more promise.
Recently VA has also made some news with its telemedicine initiatives as it works to bring care to veterans in far-flung corners of the country. On July 12, it announced the rollout of the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), which will deploy video conferencing equipment to rural and underserved locations. (See Kate Spies' story, page TK.)
Fortuitously, also in July, a bipartisan group of more than a dozen members of the House of Representatives introduced the Veterans E-Health & Telemedicine Support (VETS) Act of 2012, which aims to allow VA care providers to deliver telemedicine services across state lines. The law would circumvent "overly cumbersome location requirements" that "make it difficult for veterans – especially those struggling with mental health issues – to get the help they need and deserve," wrote the bill's co-sponsor, Democratic New York Rep. Charles Rangel.
From a distance
"In general, mental health care is less prevalent in rural areas. Much of this has to do with the stigma of going to a mental health provider," says Haynes La Rocca.
VA has been bolstering its medical centers from Maine to California to Hawaii to Guam. In June, it announced that Harris Corp. would help it deploy one of the world's largest wireless mobility infrastructures, a $19 million initiative that will support voice, video and real-time location services at 26 medical centers nationwide.
But in the wake of Iraq and Afghanistan, more and more critical care is being delivered outside the hospital walls.
Sure, the VA is "very advanced in terms of its computerized patient record" says Adam Darkins, MD, chief consultant for care coordination services at the VA, who oversees its telehealth offerings.
But since the late '90s, the VA's goal has been to "build on top of that, [using] telehealth to change the location of care."
VA started doing telemedicine pilots as far back as the 1970s. The program evolved in fits and starts. But "from 2003 onward, VA really began to systematize how it did telehealth," he says.
The past decade or so has seen the development of a "really robust infrastructure," a national videoconferencing network "with more than 4,000 video endpoints, every single one of which can link to each other by direct dial via IP," says Darkins.
It's all in service to a three-pronged approach to distance care delivery. "One provides video conferencing between hospitals and clinics, and essentially replicates a face-to-face visit if someone were to attend the clinic. The second area is called home telehealth: monitoring people with chronic diseases in their homes.
The third area is called store and forward telehealth – taking digital images to be able to review elsewhere." Last year, roughly 380,000 veterans of all ages received remote care in one of those three areas, he says.
For the younger generation of veterans, telepsychiatry consultations are especially prevalent these days.
"We're anticipating this year that we'll do 212,000 mental health consultations to veteran patients by video," says Darkins. "That's increased from about 120,000 last year."
Since it started delivering telemental healthcare, VA has logged some 550,000 patient encounters, he adds. "We've seen a ten-fold increase over the past eight years."
Spreading the word
"Telehealth, when done responsibly and with the appropriate resources, including high-speed Internet and a local crisis intervention plan or team can be effective," says Haynes La Rocca. After all, "without having access to care, quality becomes irrelevant."
But she warns that "if the provider is not able to build trust with the warrior or family member and explain the treatment modality," that means a veteran could be "less likely to be compliant to a treatment plan."
Clinicians need to adapt as well. Many are eager to adapt to this new way of business, but many "are used to doing things in the way that they've done them: seeing patients in person," says Darkins. "One of our challenges has been we've got to train the workforce."
But one other pitfall has to do with lack of awareness. Wolfgang Ward, the Marine Corps squad leader who was wounded in Iraq, didn't know anything about the VA's vast telehealth services. "It would be nice to just get on a Skype platform and talk to your doctor," he said. "But as far as I know the VA doesn't do anything like that."
Indeed, "most warriors are not aware of the wide variety of mental health options that are available and so often are not the best consumers of mental health," says Haynes La Rocca.
"The VA, partnered with Department of Defense, I think they do a good job," adds Alfred Hamilton, a research manager at U.S. Army Medical Research and Materiel Command who was Medical Chief Information Officer at U.S. Central Command during the Iraq war. "But perhaps they could do a more integrated marketing effort."
Ironically, Ward has spent much of his time since getting home spreading the word to his fellow service members about the benefits they're due. His militarybenefitsreport.com website, based on a book he wrote, is aimed at active-duty military, veterans and their families, generating personalized reports that detail what military benefits they could be entitled to and showing how they can claim them.
The site's custom software scans a continually updated database of benefits, generating a personalized report for each visitor, based on an online questionnaire.
"Nobody quite knew what was all out there," says Ward. Most people know about VA home loans and the GI Bill, but there are a lot more benefits out there, health-related and otherwise. (A free trip to a beautiful state park can have salutary benefits for mental health.) "I wanted to turn my book into a software program that delivers customized benefits reports, instead of a book where 75 percent of the information is useless," says Ward.
So far, the site has generated about 25,000 reports, he says – as many as 150 a day. "When people get out of the military, when they transition to being a civilian, they're given a big stack of paperwork, a big folder: 'Here's a bunch of companies and contacts, for help. Go out there and good luck,'" he says. "The easier it is to connect the military member with the benefit, the more likely it is that they will actually use it."
Another database, developed by Iraq and Afghanistan Veterans of America (IAVA), also pledges to help ensure veterans get their due. In June, IAVA announced it would develop a digital storehouse designed to track the gaps and wait times faced by veterans when seeking healthcare – which, in the wake of two wars, have often been considerable.
Based on feedback provided IAVA members, the interactive site could resemble an interactive, ever-updated map that tracks wait times at VA centers nationwide "Veterans are waiting too long to get even the most basic exams and services," IAVA Executive Director Paul Rieckoff told Forbes. “We can use [the data] to stay ahead of these issues, instead of calling foul after something major goes wrong.”
Opening new fronts
Some of the technology being put to use to serve soldiers' needs is truly pushing the envelope of what care delivery can mean. Take the remote sensor technology developed by Charlestown, Mass.-based Cogito, which enables providers to remotely monitor the psychological and behavioral health status of service members and veterans.
Cogito’s Social Signal Processing (SSP) Platform can be integrated with telehealth interactions to offer clinicians real-time assessments of mental and emotional states, enabling caregivers to identify signals of psychological distress by viewing the SSP data on computerized dashboard during telehealth consultations.
In July, Cogito – which traces its beginnings to MIT's Human Dynamics Lab – contracted with DoD and the Defense Advanced Research Program Agency (DARPA) to develop a series of early detection and monitoring programs. One will target PTSD in active-duty military personnel. Another seeks to help veterans recover from depression and traumatic brain injury, aiming to offer early warning of relapse.
Video games and virtual reality are also finding a foothold, offering vivid and immersive ways to deal with acute psychological trauma or intense physical pain. Earlier this year, GQ published a riveting feature story about Sam Brown, who was badly burned by an IED on his first tour of duty in Afghanistan.
His recovery was unimaginably painful, and the dilaudid could only do so much. So he experimented with playing SnowWorld, which the magazine describes as "a painkilling video game supposedly more effective than morphine," during his excruciating wound cleanings.
Other users found similar results, the story found: On average, "time spent thinking about pain, which is an inextricable contributor to actual pain, dropped from 76 percent without SnowWorld to 22 percent with SnowWorld."
In another head-mounted simulator, Virtual Iraq, veterans suffering with PTSD or related anxiety confront and try to overcome sensory stimuli: sights, sounds (muezzin calls, explosions), and even smells (aromatic spices, burning rubber) that remind them of being in a war zone.
Smartphone apps – just as they are nearly everywhere else in healthcare – are also starting to play a much bigger role in veterans' health and wellness. This past May, the VA was lauded with an innovation award from the American Telemedicine Association for its PTSD Coach mobile app, which offers tools for screening and tracking symptoms and tips for handling them. More than 50,000 people have downloaded it.
Apps that can help returning service members "track how they are feeling and keep track of their resources" are increasingly valuable says Haynes La Rocca.
Mobile platforms are also coming to the fore on the provider side of the equation. If the VA has been a pioneer in the development and deployment of technologies such as the VistA EHR, they've been slower in the mobile arena. Once upon a time, not very long ago, there were fewer than 1,000 smartphones and tablets in use across the agency.
That changed in a hurry. This past fall, VA placed an order for some 100,000 tablet computers. In May, the department launched a new program to put them to work in care settings. The Clinic-in-Hand program is a pilot meant to gauge the benefits of mobile devices when it comes to care coordination: 1,000 family caregivers of veterans are being outfitted with preloaded iPads, with the aim of improving communication between them, the veterans and VA physicians.
Taken together, all these IT initiatives – whether undertaken by VA or vendors or veterans themselves – point to big shift in ways care is delivered for wounded service members. With so many coming home, with so many different injuries, there's never been a better time for it to happen.
"As a country, we haven't experienced" anything quite like this, says Alfred Hamilton, who spends his days thinking about the most advantageous ways to deploy healthcare technology to serve people in the Military Health System and beyond.
He's not just speaking of the vast numbers of returning veterans, and the array of mental and physical afflictions from which so many of them are suffering. He's talking about the demographics of this cohort, and its members' willingness to embrace technology.
"Most people think of the VA as you're old, your broke, [it's] only for Vietnam-era folks," says Hamilton. "A large number of veterans are young people. That stigma has to be changed. This generation now is much more in tune with and accepting of technology."
We owe it to them to make that technology as widely available as possible, and put it to work in their care and convalescence.