Abstract
The Telemedicine and Advanced Technology Research Center, U.S. Army Medical Research and Materiel Command, in conjunction with the American Telemedicine Association's Annual Mid-Year Meeting, conducted a 1-day workshop on how maturing and emerging processes and applications in the field of telemental health (TMH) can be expanded to enhance access to behavioral health services in the Pacific Rim. The purpose of the workshop was to bring together experts in the field of TMH from the military, federal agencies, academia, and regional healthcare organizations serving populations in the Pacific Rim. The workshop reviewed current technologies and systems to better understand their current and potential applications to regional challenges, including the Department of Defense and other federal organizations. The meeting was attended by approximately 100 participants, representing military, government, academia, healthcare centers, and tribal organizations. It was organized into four sessions focusing on the following topic areas: (1) Remote Screening and Assessment; (2) Post-Deployment Adjustment Mental Health Treatment; (3) Suicide Prevention and Management; and (4) Delivery of Training, Education, and Mental Health Work Force Development. The meeting's goal was to discuss challenges, gaps, and collaborative opportunities in this area to enhance existing or create new opportunities for collaborations in the delivery of TMH services to the populations of the Pacific Rim. A set of recommendations for collaboration are presented.
Introduction
The U.S. Military has deployed nearly 1.5 million men and women in Operation Iraqi Freedom and Operation Enduring Freedom, since 2003. These Warfighters have had multiple deployments, and many have sustained injuries that result in some impact on mental health. 1 Many returning Warfighters have experienced posttraumatic stress disorder (PTSD), traumatic brain injury (TBI), and/or some mental health issue. 1 –5 Warfighters who leave the military use Veteran's Administration (VA) facilities across the United States. The funding to support these returning Warfighters continues to grow and will so for the coming decades. 5 The challenge to the Department of Defense (DOD) and the nation is how to provide the necessary medical care, including mental healthcare, to those Warfighters who return to their homes. Many may not live in close proximity to a VA hospital or to resources they require to maintain their health and mental status.
The U.S. Army Medical Research and Materiel Command (USAMRMC) and the Telemedicine and Advanced Technology Research Center (TATRC) are investing in technologies and research to develop the best approach to providing the necessary care. Integrating telemedicine and telehealth technologies into mental health (telemental health [TMH]) is one area that shows great promise. In 2011, the U.S. Congress passed the National Defense Authorization Act, which has a provision for expanding federal exemptions for behavioral telehealth consultation across state lines. This effectively eliminates what was considered a significant barrier to patients and providers who are in different states. 6
TATRC has a robust research portfolio that is exploring mobile applications, including smartphones, Web-based tools, and the patient-centered medical home (PCMH)—all designed to benefit the Warfighter wherever he or she may be. Although the U.S. Army, through TATRC and the other services, has similar activities underway, there are academic institutions, government agencies and industry that have developed approaches for addressing mental health and behavioral issues when patients and their providers are separated by great distances.
To gain a greater understanding and appreciation of what has been done and how collaborations could be developed to leverage technologies and capabilities, TATRC organized a conference to bring experts together. This conference, “Challenges, Solutions, and Best Practices in Telemental Health Service Delivery Across the Pacific Rim,” was held September 19, 2011 in Anchorage, AK. It was intentionally scheduled to coincide with the American Telemedicine Association's (ATA's) mid-year meeting in Anchorage. Although there is no dearth of rural or remote areas in the Continental United States, the population dispersed across Alaska, Hawai'i, and islands in the Pacific region is enormous. The U.S. Military has personnel stationed across the Pacific Rim that provide healthcare, including mental healthcare, to populations with limited access to medical expertise. Trends nationwide have shown a shortage of adequately trained mental health specialists both in the military and in the civilian community. This is especially true for the Pacific Rim, which faces challenges in mental healthcare service delivery for both military and nonmilitary populations. This shortage will continue to grow juxtaposed to an increasing patient base requiring care, especially in rural areas. 7 –12 TATRC is interested in utilizing technologies to ameliorate the barriers of distance and geography. It has developed unique tools to support and evaluate TMH. 1
TATRC's intention for this conference was to facilitate discussions on programmatic and organizational activities across military, federal, and civilian agencies in the Pacific Rim to identify shared experiences, gaps, and lessons learned to enhance or create new opportunities for collaborations in the delivery of services in TMH to the populations across the Pacific Rim.
Summit Organization
The TATRC workshop was chaired by telemedicine and TMH experts: Dr. Stewart Ferguson of the Alaska Native Tribal Health Organization, Anchorage; Drs. Patricia Jordan and Stanley Saiki of the Pacific Telehealth & Technology Hui, Honolulu, HI, a satellite office of TATRC; and Dr. Jay Shore, TATRC Behavioral Health Portfolio and of the Department of Psychiatry, Centers for American Indian and Alaska Native Health, University of Colorado, Denver. The organizers brought together speakers based on their regional areas and activities in this discipline. Colonel Ronald K. Poropatich served as the TATRC leadership representative.
Four panels were organized, each with a facilitator and three subject matter experts (SMEs). Panels were developed around four constructs: (a) remote monitoring; (b) post-deployment; (c) suicide prevention; and (d) education and training. Table 1 lists the focus areas and facilitators. The speakers in each of the panels, highlighted in Table 2, shared their experiences and activities from their region—Hawai'i, Alaska, and DOD. The fourth panel member served as an SME. The facilitators summarized each panel and led the discussion among panel members and the attendees. Attendance at the workshop was approximately 100 individuals with an interest in TMH and behavioral health (BH). A formal report, summarizing the workshop, was prepared and submitted to TATRC.
Sessions and Panel Descriptions
List of Speakers and Presentation Titles
Denotes Conference Chair.
DOD, Department of Defense; PRMC/TAMC, Pacific Region Medical Command/Tripler Army Medical Center; PTSD, posttraumatic stress disorder; USAMRMC, U.S. Army Medical Research and Materiel Command; VA, Veterans Administration; VACO, Veterans Administration Central Office.
Summit Summary
The panel format, with perspectives from Alaska, Hawai'i, the DOD, and SMEs, provided an excellent foundation for eliciting different experiences and approaches to a growing concern. Colonel Poropatich and Dr. Shore got the conference started by sharing the overall goals and intent.
Panel 1: Remote Screening and Assessment
Panel 1 was focused on remote screening and assessment with a focus on the integration of health information technology and the electronic medical records. The panel members each presented materials on their work. Dr. Jim Spira discussed the challenges in providing services across the vastness of the Pacific Ocean. Although distance in time and geography can be overcome, there is a stigma that veterans or active duty personnel have towards mental health treatment, and individuals are often reluctant to seek help. There is also a significant lack of recognition in one's own condition. Lack of awareness in conditions like PSTD, which can have a slow progression or delayed onset, can cause problems during the re-integration process to the family or other relationships. The importance of introducing and utilizing remote screening using telemedicine is seen as a beneficial tool in this region. The use of Web-based tools, video-teleconferencing (VTC), MyHealtheVet, and the Defense Automated Neurobehavioral Assessment tool in the field are all part of the armamentarium that is being integrated.
Dr. Dennis Pilgrim discussed the challenges in Alaska. For several years, VTC has been used in Alaska successfully for TMH, primarily because of the great distances, limited resources, and insufficient number of properly trained personnel. The technology is used to support clinical psychology assessment. The challenges that Alaskans face are similar to those in other areas, but efforts in Alaska are further exacerbated by weather and patients not showing up to their appointments. The tools also provide a system that supports education between remote locations.
A DOD perspective was provided by Major Sebastian Schnellbacher. Warfighters in Operation Enduring Freedom in Afghanistan experience a high degree of BH issues because of the tempo of operations and remote location of troops. Often BH specialists must travel to various locations across the country to augment access to BH care. Telemedicine is used to enable flexibility so that the BH specialist can optimize resources and minimize the occupational hazards of traveling to various locations in Afghanistan. BH over telemedicine using Skype-like VTC tools has been helpful, but perceptions, comfort level, and overall satisfaction are confounding. Face-to-face interactions are more favorable, but there is extreme interest in utilizing technology when human resources are scarce.
Dr. Leslie Morland, an SME, provided a summary of Hawai'i, indicating that only 14% of Warfighters returning from combat duty live in or near an urban area; thus, a majority live in rural or even isolated areas. Some make this choice because of PTSD, and this can further exacerbate the condition because of a break in the care continuum. Efforts in applying telemedicine in the VA Pacific Island Health Care Service Area are building a solid evidence base. 12 –14 Patient-centered care using Web-based tools and cell phones is providing high useful tools such as PSTD Coach.
Panel 1 summary/synthesis
There was concurrence across the panel about the need and value of technology-facilitated mental health screening that can be integrated and utilized to address shared geographic access issues. Although geographic access is a shared challenge across the region, each of the populations and environments described by the panelists (Alaska, Pacific, and Theater) represents a unique environment, which may require different sets of screening tools and technologies. There currently are not common methodologies and models to help select, adapt, and implement to specific environments and populations.
Stigma around mental health, as well as patient and provider acceptance and adaptation of TMH screening, is shared across all environments. A better understanding of factors contributing to successful adaptation and how these factors can be used to support future endeavors could be extremely beneficial.
Panel 2: Post-Deployment Adjustment Mental Health Treatment
Panel 2 was focused on post-deployment adjustment mental health treatment for conditions including TBI, PTSD, depression, and addiction. Dr. Morland commented on the issues in the Pacific with respect to the growing evidence of clinical outcomes, process outcomes, therapist fidelity, and design issues of research studies. The VA in this region utilizes VTC extensively for training and TMH for PTSD, cognitive-behavioral therapies, prolonged exposure, and cognitive processing therapy. This work indicates that VTC is shown to be as effective as face-to-face and that veterans indicate an acceptance of this approach.
The Alaska Federal Health Care Access Network program, specifically its push of TMH programs to the home, was discussed by Dr. Jennifer Hightower. Programs in Alaska are accomplished through partnerships and collaborations between the VA and its community partners such as the Alaska Federal Health Care Access Network.
The DOD perspective on the panel was provided by Dr. Michael Lynch. He discussed the Northern Regional Medical Command and its hub-and-spoke model and its push of services to the PCMH. This system works quite well but faces similar challenges in access and mobility, and its success is dependent on multiple collaboration and partnerships.
Dr. Matt Mishkind, an SME, commented on the focus by DOD, VA, and industry on care related to tele-behavioral health (TBH). Although there are challenges as described, an underlying theme is that the application of TMH or TBH must be a substitute or better than traditional care as well as it must be safe and efficacious.
Panel 2 summary/synthesis
Across programs there are tremendous growth and use of TMH services targeted at supporting treatment of deployment-related mental health conditions, which is contributing to a growing and large body of clinical and research evidence supporting the efficaciousness and acceptability of VTC treatment in this population. Although there are still questions within various systems and from the public about the equivalence of TMH with traditional face-to-face care, the panelists' experiences in clinical, research, and programmatic activities were all positive in endorsing general equivalence in TMH with this population.
Each panelist emphasized the importance of collaboration with either internal or external organizational partners for successful TMH projects. A deeper understanding of how explicitly how to design, select, configure, and implement successful collaborations for Pacific Rim TMH would be of critical value for growing TMH in this region.
Panel 3: Suicide Prevention and Management
Panel 3 was focused on suicide prevention and management. The U.S. Military is concerned about veterans who face crisis and may kill their family and/or themselves. Dr. Julia Whealin commented on the challenges of addressing mental health issues in the Pacific Islands. These challenges for suicide prevention include (1) lack of infrastructure, (2) logistical barriers (e.g., physical distance), (3) lack of anonymity, (4) mental health stigma, (5) issues of varying government structure (e.g., island states), and (6) retaining staff, recruitment, technical costs, travel, location, and assessment. TMH is seen as a useful tool in for suicide avoidance and reduction in hospitalization, and it promotes a continuum of care across many layers of healthcare.
Ms. Kimberlee Jones commented on her work with a call service—Careline Crisis Intervention—that is used throughout Alaska. Often staff travels to sites to establish a relationship and then use TBH to follow-up. Ms. Jones emphasized the interaction between the use of technology (call service) and importance of onsite follow-up and its importance in the establishment of both trust and rapport at individual and the community interface.
The DOD perspective was provided by Dr. Ronald Hoover. USAMRMC's mission is to develop effective medical countermeasures against combat and operational stressors to maximize Warfighter health, performance, and fitness. Four areas of focus included (1) psychological health and resilience, (2) injury prevention and reduction, (3) physiological health, and (4) environmental health and protection. Each of these areas has numerous threats such as PTSD, mild TBI, suicide behavior, sleep deficit, and TBI. Research is currently being conducted. This research is structured and is based on meeting a growing set of requirements, and it involves a variety of projects. The U.S. Army's Study to Assess Risk and Resilience in Service Members (
Dr. Peter Shore, an SME, highlighted a VA project, the VISN20, which incorporates home-based TMH. He discussed how this program targets veterans directly in their home and successfully navigates safety issues. He shared a growing number or resources, including guidelines from the ATA and the VA's Office of Telehealth Services, that are being developed in this area based on this project's success.
Panel 3 summary/synthesis
Suicide and safety issues are shared and common challenges across Pacific Rim populations. They are receiving increasing attention from leadership, healthcare systems and through public awareness. Stigma remains a significant barrier to dissemination of care to individuals and communities.
A range of technologies (telephone, VTC, and home-based VTC) offer promise in addressing these issues. These technologies represent a continuum of possible interventions/solutions from basic education to acute versus chronic treatment and intervention in a variety of settings (home, clinic, community).
The technology component of the solution needs to be well integrated with a larger system of mental healthcare that provides a package of wider health services and engages not only the individual patient but also the family and community. Individual, programmatic, and community relationships into the mental healthcare delivery systems are critical in successful management of suicidal issues with technology. Developing common methodologies and models to help select, adapt, and implement suicide interventions to specific Pacific Rim environments and populations could be critical.
The panelists emphasized the importance of preplanned standard operating procedures and procedures for any TMH/technology-based service in mental health for handling and managing psychiatric emergencies.
Panel 4: Delivery of Training, Education, and Mental Health Work Force Development
This final panel was focused on delivery of training, education, and mental health workforce development. Dr. Eduardo Cua provided the Pacific Perspective. He commented on the training and provider specialization associated with the Pacific Region Medical Command and Tripler Army Medical Center. The objective is to provide BH services to areas where there are limited BH assets. Training is available in areas such as military psychology, PTSD treatment using evidenced-based modular models (e.g., prolonged exposure therapy, cognitive processing therapy), neuropsychology/TBI, psychological assessment/learning disabilities, psychiatry, substance abuse, and pain management. Training is also essential for preparing people who must train others to manage change and deal with change.
Dr. Alexander von Hafften discussed the development of the Alaskan Psychiatry Residency. There is a growing shortage of psychiatrists in Alaska and the United States, primarily due to an increase in demand for service and an aging pool of experts who will soon be retiring. To mitigate this, a residency program is in development and will include a TMH component. In addition, the residency will include four key elements: (1) clinical care, (2) supervision, (3) psychotherapy, and (4) didactic instruction. In addition, to TBH, the PCMH and rural/remote consultation also will be key elements of the curriculum.
Dr. Anthony M. Hassan provided the DOD perspective regarding the Center for Innovation and Research on Veterans and Military Families at the University of Southern California. The Center is focused on improving the lives of veterans through four pillars: (1) applied research, (2) education and training, (3) innovation, and (4) partnerships. The goal of the research is to give emphasis to promising interventions that have broad applicability and scalability toward improvements in veterans' lives. The Center for Innovation and Research is involved in several research initiatives, including the use of virtual reality in the Virtual Patient. This system includes 14 vignettes that can be used to train care providers through different simulations.
The SME for this final panel was Dr. Peter Yellowlees. His comments were focused on learning and teaching methodologies, emphasizing the teaching utility of different methodologies. For example, collaborative simulations have a retention rate of 90%, whereas a lecture is only 5%, which supports the type of teaching methodologies supported by TMH and described by the other panelists (interactive VTC, virtual patient).
Panel 4 summary/synthesis
Telemedicine is a key component to address the training issues across the Pacific Rim, which is directly related to the need for increasing the mental health workforce as well as the workforce expertise to serve the needs of Pacific Rim populations, including addressing service members' mental health concerns.
A range of available (e.g., VTC) and expanding technologies (e.g., virtual patients) can be applied to the Pacific Rim workforce to help increase active/experiential learning over passive learning, increase problem-based learning, provide just in-time learning as needs develop (e.g., returning post-deployment units), and provide meaningful continuing education and workforce develop in mental health. Developing a better understanding, coordination between agencies, including sharing learning resources, and a strategic roadmap for mental health training in specific content areas via technology in the Pacific Rim could bolster the mental health workforce in this region.
Conclusions/Recommendations
Shared Themes Across Panels
Although each panel was focused on a specific area, it was clear that central themes and challenges were apparent. Below we highlight the themes generalized across the topic areas.
Challenges
Each panel highlighted challenges faced in addressing healthcare. Both Alaska and Hawai'i are characterized as remote juxtaposed to the Continental United States. Within each state or region there are larger population centers and remote villages and towns that are some distance from definitive care. While these barriers in distance, geography, and time are significant, the lack of nascent technology or even updated technologies can be similar to those that DOD faces. The approaches taken in the Pacific Rim and the lessons learned can be of value to DOD. Integration of TMH can overcome these barriers.
Stigma
Regardless where someone is located or how his or her mental health issues came about, there is a stigma about seeking treatment, and this impacts mental health response and utilization of resources. Several of the presenters indicated personnel who leave the military may choose to return to an isolated or rural area to minimize interaction with others. Other presenters commented that individuals who suffer from mental illness often cannot be isolated because others in their community know them. This is especially apparent in native peoples both in Alaska and in Hawai'i. Integration of TMH can overcome the issue of stigma and provide individuals the treatment they need with dignity and privacy.
Shortages
Each panel highlighted issues related to shortages: shortages in technology, highly trained clinicians, funding, resources, etc. One of the most important is the shortage of psychiatrists and BH specialists. This is an issue on the battlefield as highlighted from Operation Enduring Freedom and throughout the Pacific Rim, where patients can be thousands of miles away from care providers.
Education
There are insufficient numbers of properly trained individuals to address mental health needs across the Pacific Rim and within the U.S. Military. Education—training programs for DOD, whether within the VA, at Tripler, or at the University of Southern California School of Social Work, or the development of a residency in Alaska to meet unmet needs—is a key element in preparing for a growing need. Panel members and the peer-reviewed literature highlighted the importance of education and preparedness for addressing mental health issues that result from trauma. Telemedicine can play a key role, and the lessons learned by DOD and non-DOD activities provide a solid foundation for engagement.
Technology
All four panels included a variety of technologies, from VTC to handheld devices and Web-based solutions to virtual reality. There is a wealth of knowledge from all four components of the workshop—Alaska, DOD, Hawai'i, and the SMEs.
Telemedicine is a significant tool in which the U.S. Army has invested and has integrated into the operational tempo across the entire world. TMH is certainly a useful tool and recently garnered support in the 2012 National Defense Authorization Act signed by President Obama in late December 2011. 6 There are several similarities in the work presented. The Conference achieved its goal of bringing together the expertise and establishing a foundation for collaboration.
Key Recommendations
As discussed previously several key recommendations for next steps emerge in the themes of the conference, as highlighted below. These represent potential areas for near-term collaborative programmatic development in the region. 1. Development of common methodologies and models to help select, adapt, and implement specific screening (e.g., PTSD) and mental health interventions (suicide) to specific environments and populations. 2. Examine and describe best practices in how explicitly to design, select, configure, and implement successful collaborations for Pacific Rim TMH would be of critical value for growing TMH in this region. 3. Developing a better understanding and coordination between agencies, including sharing learning resources, and a strategic roadmap for mental health training in specific content areas via technology in the Pacific Rim could bolster the mental health workforce in this region.
The workshop afforded an opportunity for academic and government organizations to share challenges, solutions, and lessons identified in using technology to augment BH care. Numerous organizational capabilities were discussed, and opportunities exist to disseminate these capabilities if dedicated funding can be identified. Aside from the use of technology, other sustainment issues such as training and equipping the workforce, to include establishing shared training programs across agencies, will do much to expand the needed BH services to all communities discussed at this workshop. Organizations such as the ATA's Special Interest Group for Mental Health has contributed much to standardizing BH care by developing procedure guides to implement TMH. Leveraging other documents, to include educational curriculum for TMH providers, and promoting TMH needs to senior government leaders to garner dedicated funding will be ongoing efforts that this dedicated group of providers will need to continue.
Footnotes
Acknowledgments
We acknowledge the USAMRMC TATRC for its support of the meeting. The authors also express thanks and appreciation to the ATA for their support in making the meeting possible. Most importantly, we acknowledge all those men and women who have served valiantly in harm's way and those who have supported disaster recovery in some way.