Telemedicine and the Military

Throughout our 20th anniversary we are bringing to you expanded editorials that highlight those manuscripts that have focused on key issues. In addition, we have added pieces we call “Perspectives.”

The global implementation of telemedicine would not be possible without the research and development supported by the military over the past two decades. Although the military in various countries did not develop telemedicine, telehealth, e-health, m-health, or any other term one wishes to use, it has refined and integrated it into the care of the men and women—the warfighters—who serve in the military. The U.S. military became fully engaged in telemedicine for enhancing medical care in the early 1990s by integrating telecommunications and imaging in a project known as the Medical Diagnostic Imaging Support (MDIS) system within the Army, and the Navy was looking at how to develop better tools of ships at sea.

Over the years, the U.S. military has continued to develop strategies and innovative approaches for using telemedicine on the battlefield and wherever the military is deployed in noncombat roles such as humanitarian missions. In the early part of the 1990s, the MDIS project served as the foundation for the development of the Medical Advanced Technology Management Office (MATMO) and the eventual development of the Telemedicine and Advanced Technology Research Center (TATRC). TATRC emerged as a key research entity player in the growing field of telemedicine. Many of its leaders have been pioneers and subject matter experts in telemedicine. Partnering with academic institutions, industry, and government agencies helped the military promulgate new technologies and innovative approaches to healthcare challenges in far away and austere environments such as Afghanistan. The U.S. military, and through collaboration with the North Atlantic Treaty Organization (NATO), has deployed telemedicine in support of military personnel in Iraq and Afghanistan.

As a result of the investment in telemedicine, there has been a steady stream of manuscripts from a wide variety of military-funded activities. In 1996, Dr. Rashid Bashshur and Dr. Mark Goldberg, the Journal's first two editors, collaborated on a special issue on “Telemedicine in the Military” with General Russ Zajtchuk, the commanding officer of Ft. Detrick, MD, in 1995. ¹ This special issue covered a wide variety of areas related to the military's efforts in telemedicine in the early 1990s. These included strategies on medical readiness, telepathlogy, virtual reality, humanitarian missions, ² telemedicine in Bosnia, ³ a survey on Department of Defense telemedicine, ⁴ and efforts on the World Wide Web. ⁵ In 1996, this special issue provided an comprehensive review of military telemedicine.

By the beginning of the 21st Century, telemedicine was becoming a much more useful tool in military and civilian medicine. It wasn't until 2002 when Grady et al. ⁶ reported on a comparative cost analysis of telemedicine in the U.S. Navy, specifically at the National Naval Medical Center. One year later, Vice Admiral Richard Carmona, Surgeon General during the George W. Bush administration, provided a thoughtful editorial on “Military Health Care and Telemedicine.” ⁷ In his editorial he discussed several subjects that are still relevant today, including bandwidth, cellular phone capabilities, and emergency medical capabilities. Of course, the application of telemedicine in the military grew to a number of areas, including behavioral health and ear–nose–throat, incorporating early videoteleconferencing capabilities in remote locations. ^{8 –10}

Additional research has been conducted from 2003 onward to the present that supports not only mobility but also human factors. Although the human factors study was predominately focused on teledermatology, ¹¹ the knowledge gained has provided insight for further work. Kosaraju et al. ¹² aptly reported on the utility of mobile phones as a tool for diplomacy, as telemedicine has been used in humanitarian events ² and within NATO as well. In two different articles, Lam and co-workers discussed the applications of telemedicine in U.S. military forces in Europe as well as its deployment with NATO forces. ^13,14

Since its inception, TATRC has been at the forefront of research initiatives with innovation and new technology being evaluated each year, thus prompting Romano et al. ¹⁵ to say “the future of military medicine has not arrived.” In recent years, TATRC and the National Center for Telehealth Technology (T2) have continued to work in developing telemedicine and telehealth solutions. In recent successive years, TATRC partnered with the American Telemedicine Association to hold discipline-specific meetings on (1) traumatic brain injury (2010), ¹⁶ (2) humanitarian response (2011), ¹⁷ and (3) telemental health in the Pacific Rim (2012). ¹⁸ These meetings were well attended and help set the stage for further development and collaboration.

As the conflicts in Iraq and Afghanistan have wound down, a key issue for the U.S. military and the Veteran Health Affairs (VHA) is the continuity of care for the warfighter. Research has been reported in this Journal on use of Web-based self-care ¹⁹ and on behavioral health and telepsychiatry conditions. ^20,21 Many of the solutions or tools for warfighters and veterans are the devices we all have—the mobile phone. In 2012, Luxton et al. ²² reported on the use of video capabilities on smartphones, and Bush et al. ²³ reported on personal technologies in the warfighter's home. In 2013, Poropatich, ²⁴ a retired military physician and long-time proponent of telemedicine in the military, and co-workers provided a well-stated article on how the U.S. Army's efforts have made a difference at home and abroad.

Many other articles presented in this Journal have been supported by military funding. Each research initiative and the subsequent knowledge and technology have made a difference in the lives of both the warfighter and those individuals who support him or her, including their family members, their community, and those in the medical field who look after them. The knowledge gained from the military and its efforts in telemedicine has benefited us all in many ways.

Perspectives from the Veteran Administration

Beginning with the first issue of our 20th year, it has been our intent to provide you with perspectives from real pioneers and leaders in the field. What would be more appropriate with an editorial on the best of the articles on the military and telemedicine over the past 20 years than to include a perspective from the VHA? We asked Dr. Adam Darkins to provide a summary of how telemedicine has evolved over the past two decades. ²⁵ It is clear that the utilization of telemedicine in the VHA has been of great value, and the evidence base continues to grow.

Chronic Disease and Telemedicine

This issue is pretty hefty, and the reason is the article by Bashshur et al. ²⁶ entitled “The Empirical Foundations of Telemedicine Interventions for Chronic Disease Management.” Dr. Bashshur discussed this article on Capitol Hill in the spring with both Congressional Representatives and the Congressional Budget Office. We were delighted to serve as contributing authors, and we are very happy to provide you with the article in its entirety.

We hope you enjoy this issue!