Utilization of Telemedicine in the U.S. Military in a Deployed Setting

Transcription

1 MILITARY MEDICINE, 179, 11:1347, 2014 Utilization of Telemedicine in the U.S. Military in a Deployed Setting Capt Jane S. Hwang, USAF MC*; Charles M. Lappan, BS ; Leonard C. Sperling, MD ; LTC Jon H. Meyerle, MC USA ABSTRACT Background: A retrospective evaluation of the Department of Defense teledermatology consultation program from 2004 to 2012 was performed, focusing on clinical application and outcome measures such as consult volume, response time, and medical evacuation status. Methods: A retrospective review of the teledermatology program between 2004 and 2012 was evaluated based on defined outcome measures. In addition, 658 teledermatology cases were reviewed to assess how the program was utilized by health care providers from 2011 to Results: As high as 98% of the teledermatology consults were answered within 24 hours, and 23% of consults within 1 hour. The most common final diagnoses included eczematous dermatitis, contact dermatitis, and evaluation for nonmelanoma skin cancer. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. Biopsy was most commonly recommended for further evaluation. Following teleconsultation, 46 dermatologic evacuations were avoided as the patient was not evacuated based on the consultants recommendation. Consultants recommendations to the referring provider facilitated 41 evacuations. Conclusion: Telemedicine in the U.S. military has provided valuable dermatology support to providers in remote locations by delivering appropriate and timely consultation for military service members and coalition partners. In addition to avoiding unnecessary medical evacuations, the program facilitated appropriate evacuations that may otherwise have been delayed. *San Antonio Uniformed Services Health Consortium, 3551 Roger Brooke Drive, Fort Sam Houston, TX Southern Regional Medical Command, U.S. Army, 3551 Roger Brooke Drive, Fort Sam Houston, TX Department of Dermatology, Uniformed Services University, 4301 Jones Bridge Road, Bethesda, MD This article was presented in poster format at the Uniformed Services University of the Health Sciences Research Symposium in Bethesda, MD, 17 April The opinions expressed herein belong solely to the authors. They should neither be interpreted as representative of nor endorsed by the Uniformed Services University of the Health Sciences, the U.S. Army, the Department of Defense, or any other federal government agency. doi: /MILMED-D INTRODUCTION Telemedicine is the delivery of health care to a distant or remote location through technology and communication systems. 1 The U.S. military is involved in worldwide combat actions, operational assignments, and humanitarian and disaster relief missions in remote environments that are defined as austere since limited health care resources are available. One of the primary missions of military medicine is to maintain the health of service members in support of missions locally and overseas. Telemedicine supports that mission by providing sophisticated health care resources at the point of care, allowing the soldier to return to duty and avoid medical evacuation. 2,3 With the expansion of Internet and , teleconsultation has become a viable tool for improving health care delivery. 2,4 Diagnoses and treatment plans can be developed at sites remote from the patient. Referring providers can easily submit digital images of the skin with supporting clinical history electronically from remote locations; as a result, dermatology has become the most heavily utilized teleconsultation service in the Department of Defense (DoD). For this reason, in 2004, the U.S. Army Medical Department established a centralized telemedicine program by utilizing the Army Knowledge Online (AKO) electronic portal. 1,2 Since that time, teledermatology consultations have comprised up to 40% of the total teleconsultations from all specialties. In this study, we review the history of the teledermatology consultation program from 2004 to 2012 with specific emphasis outcome measures such as clinical volume, response time, and medical evacuation status. In addition, individual consults from 2011 to 2012 were evaluated to assess clinical information generated for each encounter as a way to assess program utilization at the point of care. METHODS The teleconsultation program utilizes the AKO electronic system to collect, organize, and consolidate incoming consults from military health care providers from around the world (Fig. 1) via a store-and-forward process. 5 The use of store-and-forward, which is asynchronous, processes to transmit clinical information that involves capturing the clinical history and images at the point of care. This information is then uploaded to a common access site such as a server where it can be assembled for review. This process is distinct from synchronous processes that usually involve live videoconferencing. All military service members have access to AKO and the AKO teleconsultation program is available to DoD health care providers (physicians, health care extenders such as physician assistants, special forces medics, and medical technicians working under a physician), with an emphasis on those that are deployed or in isolated environments. Incoming electronic consultation requests from field providers are imbedded in an and routed to a project manager who assigns a unique tracking number. Pictures are obtained via MILITARY MEDICINE, Vol. 179, November

2 FIGURE 1. Military locations utilizing teleconsultation services. Figure 1 lists the locations and shows the worldwide utilization of teledermatology services both on land and at sea. Supported Facilities are listed and annotated on the map. phone or digital camera and attached in the . The project manager receives and monitors all teleconsultations to ensure Health Insurance Portability and Accountability Act (HIPAA) compliance, operational security, integrity of the clinical images and medical history, and routing to the on-call medical consultant. All materials are stored by the project manager on a DoD secure server. After the consultant closes the consult by replying to the with his/her recommendations, the program manager transmits the consultant s completed consult within 24 hours back to the referring medical provider via or other form of secure communication. The project manager routes the consults to a location where specialty providers are available, typically at a major Military Treatment Facility in the Continental United States (CONUS). However, it is not unusual to route consults to a consultant stationed in the theater of operation, Europe or Asia. The project manager also facilitates collaboration between subspecialists such as a surgeon, pediatrician, or infectious disease physician, if a multidisciplinary approach is needed. The quality of the teleconsultation is dependent on the referring provider s ability to obtain an appropriate history and other data such as clinical images. Each consult is evaluated separately and is answered based on the dermatologist s clinical practice style and past experience. Over the past decade, dermatology residents in military-sponsored dermatology residency programs have received training in teledermatology. Yet, some military dermatologists who trained in civilian residencies, or before the expansion of teledermatology, have received no formal training beyond the military-specific medical training provided to military physicians. Nonetheless, regardless of having or having not received formal training, many dermatologists have deployed to combat or other austere environments that provide first-hand experience in tactical environments and can place these clinical scenarios in the proper context. In many cases, the consults are reviewed by more than one military dermatologist, which ensures more consistency as well. To our knowledge, no study of interobserver variability in terms of diagnosis or treatment regimens has been performed in this context. For this study, aggregate data for the program from 2004 to 2012 was evaluated. In addition, all teledermatology consultations from January 2011 to December 2012 were assessed for patient demographic information (age, military status), geographic origin of consultation request, primary 1348 MILITARY MEDICINE, Vol. 179, November 2014

3 TABLE I. The 20 Leading Dermatologic Diagnoses Found in 658 Teledermatology Consultations From 2011 to 2012 Diagnosis Number Percent of Total Eczematous Dermatitis Contact Dermatitis 58 9 Evaluation for Nonmelanoma 33 5 Skin Cancer Psoriasis 26 4 Urticaria 25 4 Tinea Infection 24 4 Folliculitis 19 3 Arthropod Bite 18 3 Drug Eruption 17 3 Verruca Vulgaris 17 2 Pityriasis Rosea 16 2 Herpes Virus Infection (HSV, VZV) 16 2 Evaluation for a Suspicious 14 2 Pigmented Lesion (Melanoma) Impetigo 14 2 Leishmaniasis 13 2 Acne 12 2 Nevus 12 2 Alopecia 10 2 Reaction to the Smallpox Vaccine 10 2 Lichen Planus 8 1 Total HSV, herpes simplex virus; VZV, Varicella zoster virus. Tables I and II show the numerous and diverse skin conditions encountered by providers in remote and austere environments. Eczematous dermatitis accounted for the small majority of diagnoses with skin cancer the next most common. Conditions such as psoriasis and atopic dermatitis are disqualifying conditions for military service, which is reflected in the relative paucity of these diagnoses in a military cohort relative to the general population. diagnosis or differential diagnosis, and treatment recommendations to include recommendations for evacuation. From 2011 to 2012, 658 consultations were grouped by the most common diagnoses: eczematous dermatitis, contact dermatitis, etc. (Table I). Although more than half of the consultant s responses resulted in a differential diagnosis, the consulting physician s most likely diagnosis was recorded in a spreadsheet. After the 20 most common diagnoses were recorded, additional diagnoses were categorized into more general categories of dermatoses: benign, infectious, inflammatory/autoimmune, vascular, genetic, exposure-related, and malignant (Table II). Evacuation was defined as the movement of the patient from the remote location to a higher level of care, where a dermatologist was available. Depending on the geographic location of the patient, this movement could have occurred within the same country, within the same region, to Europe, or to CONUS. An evacuation was considered facilitated if the referring provider stated they were going to evacuate the patient based on the recommendations of the consultant. Evacuations were recorded as avoided if the patient was not evacuated based on the recommendation of the consultant. Concordance between the diagnosis of the referring provider and consultant was not evaluated in this study. RESULTS From April 2004 to December 2012, 40% of 10,817 AKO teleconsultations were for teledermatology (Table III). All consult requests were answered with an average reply time of 5 hours and 14 minutes (standard deviation of 6 hours 20 minutes); 98% of the consults were answered within 24 hours, and 23% of consults were answered within 1 hour. The majority of the consults originated from Iraq (55% of total) and Afghanistan (23% of total) with the remainder from locations worldwide. Consults from Iraq peaked in 2008, while consults from Afghanistan peaked in 2011 (Fig. 2). For every 100,000 troops on the ground, roughly 319 teledermatology consultations were generated each year. Seven of all the dermatology consultations taking place between 2004 and 2012, 84% were for U.S. military personnel and the majority of these were Army service members, whereas 11% of the consults were non-u.s. personnel, with the largest group being local nationals (Table III). Following teleconsultation, 46 dermatologic evacuations were avoided (32% of 145 among all specialties). Consultants recommendations facilitated 41 evacuations (8% of 508 among all specialties). In 2011, the diagnoses requiring evacuations included rule-out skin cancer, guttate psoriasis, mastocytosis or urticaria pigmentosa, and methicillin-resistant Staphylococcus aureus (MRSA) infection. The specialties with which dermatologists most often collaborated included infectious diseases (47% of recorded cases facilitated by telemedicine in 2012), vaccine health care center personnel/allergy (28%), rheumatology (28%), pediatrics (11%), vascular surgery (6%), preventive medicine, dental, and ophthalmology. Some cases involved several specialties collaborating together. The demographic information of the 4,328 teledermatology consults is summarized in Table III. The average age of the patient was 28 years, with the ages ranging from 3 days to 90 years. Additional demographic information on patients is not available as protected health information to include rank or time in service is not included in the consultation. From January 2011 to December 2012, 658 consult requests were analyzed further for the most common diagnoses; these are summarized in Table I. The most common diagnoses were eczematous dermatitis, contact dermatitis, evaluation for nonmelanoma skin cancer, psoriasis, urticaria, tinea infection, folliculitis, arthropod bite, drug eruptions, and verruca vulgaris. The remaining diagnoses were organized into general categories (Table II). The most common treatment modalities were divided into four categories: (1) medications, (2) provider education, (3) need for further evaluation, and (4) immediate intervention at the point of care. The most common medications recommended included topical corticosteroids, oral antibiotics, antihistamines, and emollients. The most common topics of provider education included behavioral modification, skin hydration techniques, and sun protection. The most common recommendation for further evaluation was a skin MILITARY MEDICINE, Vol. 179, November

4 TABLE II. General Categories of Dermatologic Diagnoses Found in the 658 Teledermatology Consultations From 2011 to 2012 (The 20 Leading Dermatologic Diagnoses Are Excluded) Category of Dermatoses Number Percent Description (Listed in Order of Frequency) Benign 54 8 Epidermal Inclusion Cyst, Seborrheic Dermatitis, Keloid, Angiokeratoma, Pseudocyst, Skin Tag, Hemangioma, Lipoma, Milia, Postinflammatory Hyperpigmentation, Male-pattern Baldness, Calcinosis Cutis, Eruptive Nevi, Papilloma, Peyronie s Disease, Pilar Cyst, Pilomatricoma, Pityriasis Alba, Postinflammatory Desquamation, Punctate Keratosis, Steatocystoma Multiplex, Syringoma, Telogen Effluvium Infectious 51 8 Viral Exanthem, Abscess, Cellulitis, Condyloma Accuminatum, NonDermatophyte Fungal Infection, Pitted Keratolysis, Scabies Infestation, Cutaneous Anthrax, Molluscum Contagiosum, Pyoderma, Carbuncle, Ecthyma, Erysipelas, Erythrasma, Furuncle, Paronychia, Wound Infection, Folliculitis, Syphilis, Buruli Ulcer, Hand-foot-mouth Disease Inflammatory/Autoimmune 50 8 Seborrheic Dermatitis, Pyogenic Granuloma, Dissecting Cellulitis of the Scalp, Vitiligo, Erythema Multiforme, Lichen Nitidus, Acne Keloidalis Nuchae, Hidradenitis Suppurativa, Pseudofolliculitis Barbae, Anaphylaxis, Confluent and Reticulated Papillomatosis, Discoid Lupus, Erythema Annulare Centrifigum, Erythroderma, Granuloma Annulare, Parapsoriasis, Pityriasis Lichenoides, Pseudocellulitis, Relapsing Polychondritis, Rosacea, Sweets Syndrome Exposure 30 5 Lichen Simplex Chronicus, Trauma, Miliaria Rubra, Pernio, Burn, Onycholysis, Prurigo Nodularis, Axillary Granular Parakeratosis, Exuberant Granulation Tissue Vascular 10 1 Chronic Pigmented Purpura, Lichen Striatus, Cholesterol Emboli, Henoch Schonlein Purpura, Lichen Aureus, Vascultis, Port-wine Stain Genetic 6 <1 Xeroderma Pigmentosum, Ichthyosis Malignant 5 <1 Actinic Keratosis, Skin Cancer Removal, Evaluation for Malignant Tumor Total Table I and II show the numerous and diverse skin conditions encountered by providers in remote and austere environments. Eczematous dermatitis accounted for the small majority of diagnoses with skin cancer the next most common. Conditions such as psoriasis and atopic dermatitis are disqualifying conditions for military service that is reflected in the relative paucity of these diagnoses in a military cohort relative to the general population. biopsy. Recommendation for immediate intervention with cryotherapy or debridement was also tabulated. This information is summarized in Table IV. DISCUSSION Military health care providers in remote and austere environments face unique challenges communicating with medical specialists and obtaining specialty care for their patients. This problem is more apparent given the trend over the past TABLE III. Teleconsultation Summary and Teledermatology Consultation Demographic Data Teledeconsults Total 10,817 ( ) Teledermatology Consults 4,379 Total ( ) Average Teledermatology 482 Consults/Year ( ) Gender of Patient a Male: 559 (85%) Female: 99 (15%) Average Age of Patient a 28 Years (Range 3 Days 90 Years) Patient Affiliation a Army: 395 (60%) Navy/Marine Corps: 99 (15%) Air Force: 59 (9%) Noncombatant: 28 (7%) Other: 33 (5%) Contract Personnel: 20 (3%) Detainee: 6 (1%) a From 2011 to 2012, a total of 658 teledermatology consults were analyzed to generate gender, average age range, and patient affiliation. decade for forward deployment small, mobile fighting units embedded in local communities away from the main military element. These forward-deployed troops have limited access to medical care and their isolation makes medical evacuation more difficult and dangerous to perform. Evacuation of a patient in a combat zone or similar austere environment not only entails the risks associated with stateside emergency response, but also includes exposure to hostile enemy fire, hazardous environmental conditions, significant logistical coordination with incoming aircraft, extra personnel for security, and the need to hold and stabilize the patient during the evacuation. Removing the patient from the battlefield or hazardous environment also has a broader impact on the patient s unit and can require replacement with additional troops. 4,6 8 For these reasons, the military has made an investment in telemedicine to provide sophisticated medical care and prevent avoidable medical evacuations while hastening those that are critical. The success of telemedicine in the military since 2004 has paralleled strides in information technology infrastructure, principally bandwidth and access to the Internet, in combat or austere environments. 2 4 Secure access to the Internet has facilitated over 400 teledermatology consultations a year (the highest number of all individual medical specialties) since the inception of the program in 2004 and over 10,000 telemedicine consults for all medical specialties. The heavy use of teledermatology demonstrates the significant impact that skin disease has on deployed troops in terms of nonbattle injury diseases and the unique contributions dermatologists make to the warfighter mission MILITARY MEDICINE, Vol. 179, November 2014

5 FIGURE 2. Comparison of number of dermatology consults vs. the number of troops on the ground in Afghanistan and Iraq. Figure 2 shows the number of teledermatology consults in Afghanistan vs. Iraq and the number of troops in Afghanistan vs. Iraq. There is a strong correlation between the number of troops on the ground and the number of teledermatology consults generated. Troop surges from 2007 to 2008 in Iraq and 2011 in Afghanistan resulted in an uptick in teledermatology consultations during those periods. This rapidly declined in Iraq beginning is 2009 as the American troop withdrawal commenced. The drop in teledermatology consults beginning in 2012 likely reflects the transition to a noncombat role for U.S. service members in Afghanistan following the surge. The military has come a long way since 1992 when the state-of-the art telemedicine program consisted of a satellite transceiver dish, laptop computer, and digital camera. 1,8 With the widespread availability of reliable Internet access, a digital image collection device is all that is required to generate a teleconsultation. Ironically, patients can receive a diagnosis and treatment regimen faster in a combat zone via the teleconsultation program than they can be seen CONUS by a military dermatologist or in the civilian sector, where the wait time is often 4 to 8 weeks. The typical teledermatology consult originating from Afghanistan was answered with an average response time of less than 6 hours, and a quarter of the responses in less than 1 hour. The ability to respond in a short amount of time is critical, as delays in treatment can hamper individual and unit capabilities and may lead to unnecessary medical evacuations. This is one of the most important components of the program, as it returns the patient to duty quickly and frees up medical resources for other patients. The number of teledermatology consults remained high and relatively stable since 2004, whereas the number of total consults for all specialties continued to slowly increase, peaking at 1,819 consults in 2011 just before the drawdown from Iraq. This increase in the number of teleconsultations from other specialties reflects the expanding use of telemedicine for surgical consultations such as orthopedics, otorhinolaryngology, and ophthalmology, as well as for mental health care. The number of teledermatology consults, on the other MILITARY MEDICINE, Vol. 179, November

6 TABLE IV. Common Consultant Recommendations From 658 Teldermatology Consultations From 2011 to 2012 Consultant Recommendations N (%) Medications Topical Corticosteroid (Class 1, 2): 91 (13) Clobetasol Proprionate, Fluocinonide Topical Corticosteroid (Class 4, 5 7): 71 (11) Triamcinolone, Hydrocortisone, Desonide Oral Antibiotics: Sulfamethoxazole and 54 (8) Trimethoprim, Doxycycline Antihistamines: Hydroxyzine 49 (7%) Emollients: Petrolatum or Vaseline 34 (5) Oral Corticosteroids: Prednisone 26 (3) Antibacterial Wash: Benzoyl Peroxide, 22 (3) Chlorehexidine, Dilute Bleach Topical Antifungal 21 (3) Oral Antifungal 16 (2) Oral Antivirals: Acyclovir, Valacyclovir 14 (2) Skin Cleansers: Dove, Cetaphil 10 (2) Topical Antibiotics: Bacitracin, Neomycin, 9 (1) Polymyxin, Mupirocin Provider Education Discontinue Topical Treatments 38 (6) Encourage Use of Skin Emollients 34 (5) Encourage the Use of Sunscreen 20 (3) Natural Ultraviolet Exposure 12 (2) Encourage the Use of Insect Repellents 5 (<1) Removal From Warm Environments and 5(<1) Placement in Cool Environment Further Evaluation Skin Biopsy 92 (14) Skin or Wound Culture 45 (7) Syphilis Serologic Evaluation 20 (3) Potassium Hydroxide Preparation of 13 (2) Skin Scrapings Blood Work: Blood Count, Metabolic 12 (2) Panel, Sedimentation Rate, Liver Function Testing HIV Serologic Evaluation 6 (1) Immediate Interventions Cryotherapy 13 (2) Debridement 5 (<1) Consultant recommendations are demonstrated by total number of recommendations over a 2-year period and percent of the total consults (658) during the period analyzed from 2011 to The high number of recommendations reflects the diversity of dermatologic disease addressed by teledermatology as well as the ample number of interventions available to providers. hand, appears to correlate with the rise and fall in cumulative troop numbers in Afghanistan and Iraq (Fig. 2). 9,10 Cumulative numbers of troops correlate well with the number of teledermatology consultations generated. However, during periods of drawdown as observed in Iraq, the numbers of teledermatology consults drop by a greater proportion than is expected. This has many possible explanations, but reflects a military in transition. During times of transition, the utilization of medical services often is much less than during periods of steady state or stability. Nonetheless, the consistent utilization of teledermatology services demonstrates its continued importance to the military mission. A careful analysis of 2 years of teledermatology consultations demonstrated that the two leading diagnoses were general eczematous dermatitis and contact dermatitis, both allergic and/or irritant in nature. Many of the consultation requests from patients with eczematous conditions revealed documented treatment with topical antifungals before referral and most were not using skin moisturizers while in dry climates. Most of the patients evaluated for eczematous conditions were ultimately treated with aggressive emollients and a brief course of potent (Class 1 or 2) topical corticosteroids, making it the most frequent drug recommended. This is consistent with what Henning et al 6 observed in their evaluation of teledermatology consultations from Iraq. Evaluations for skin cancer in a deployed setting were not common until Operation Iraqi Freedom. With an increase in skin cancer surveillance measures by the Armed Forces and access to the teledermatology program, skin cancer screening has become routine via teledermatology consultation. In the AKO teledermatology program, patients with malignant skin tumors such as melanoma were evacuated rapidly, whereas those with less critical tumors such as basal cell carcinoma were reassured that although evacuation was eventually needed, it was not urgent. 11,12 Of the evacuations that were prompted by teleconsultation in 2011 and 2012, the diagnoses included suspicion for melanoma, MRSA infection, guttate psoriasis, and mastocytosis. The patients that were evacuated for the evaluation of a suspected skin cancer were often sent to Germany, where a proper biopsy and pathologic examination was performed. McGraw et al 12 found the most common causes of evacuations for dermatology conditions in the military from combat environments from 2003 to 2006 were due to dermatitis, benign melanocytic nevi, and malignant neoplasms. The decrease in evacuations for dermatitis and benign melanocytic nevi over time is likely because of several factors, such as a greater comfort utilizing the AKO teledermatology program by the military medical community, an increasing willingness of consulting dermatologists to render a diagnosis of a nonmalignant nevus via teledermatology, and the increasing skill and comfort level of referring providers implementing a dermatology care plan. Also, there was increasing complexity of evacuating patients from combat theaters such as Iraq and Afghanistan because of the effect that improvised explosive devices have had on ground-based transportation. It is difficult on a case-by-case basis to determine if the program effectively facilitated necessary evacuations or avoided unnecessary ones, since protected health information is not included in the teleconsultation. However, when it came to evaluating suspicious pigmented or nonmelanoma lesions, it is clear that the requesting provider sought the consultant s recommendation to determine the need for evacuation, and the dermatologist recommendation was critical. 12 This study has several limitations. The common diagnoses and treatments recorded came after the requesting provider had already performed a trial of antifungals or antibiotics, 1352 MILITARY MEDICINE, Vol. 179, November 2014

7 making the diagnosis of an eczematous condition more likely and skewing the most common diagnoses in favor of eczematous processes. In terms of clinical outcomes, consultations have no HIPAA information included, so there are limited ways to evaluate clinical outcomes. However, despite the fact that providers and consultants can communicate with relative ease via DoD , very few consultations resulted in the need for further communication between the consultant and referring provider, which suggests that the consultant s recommendations were generally successful. Collaboration between specialties has been ongoing since the program s inception, but it was only formally recorded beginning in Therefore, these numbers may not represent the actual frequency of collaborations that occurred the past 10 years, but likely provides a fair representation of the specialties that frequently collaborated with dermatology. The use of telemedicine in the U.S. military has provided valuable support to providers in remote locations by delivering timely consultation on military service members. The AKO telemedicine program is an example of the successful implementation of telemedicine program that has persisted without interruption since In addition to helping to avoid unnecessary medical evacuations, the program has prompted a number of evacuations that may otherwise have been delayed, while delivering specialty care to patients around the world. ACKNOWLEDGMENTS Dr. Jane Hwang and Dr. Jon Meyerle analyzed the data provided by Charles Lappan and wrote the manuscript. Dr. Leonard Sperling reviewed and edited the manuscript. Dr. Jon Meyerle, the corresponding author, had full access to all the data and take responsibility for the decision to submit for publication. REFERENCES 1. Vidmar DA: The history of teledermatology in the Department of Defense. Dermatol Clin 1999; 17(1): McManus J, Salinas J, Morton M, Lappan C, Poropatich R: Teleconsultation program for deployed soldiers and healthcare professionals in remote and austere environments. Prehosp Disaster Med 2008; 23(3): Gomez E, Poropatich R, Karinch MA, Zajtchuk J: Tertiary telemedicine support during global military humanitarian missions. Telemed J 1996 Fall; 2(3): Crowther JB, Poropatich R: Telemedicine in the U.S. Army: case reports from Somalia and Croatia. Telemed J 1995 Spring; 1(1): Armstrong AW, Sanders C, Farbstein AD, et al: Evaluation and comparison of store-and-forward teledermatology applications. Telemed J E Health 2010; 16(4): Henning JS, Wohltmann W, Hivnor C: Teledermatology from a combat zone. Arch Dermatol 2010; 146(6): 676,7. 7. Schissel DJ, Wilde JL: Operational Dermatology. Mil Med 2004; 169(6): Poropatich RK, DeTreville R, Lappan C, Barrigan CR: The U.S. Army telemedicine program: general overview and current status in Southwest Asia. Telemed J E Health 2006; 12 (4): Belasco Amy: Troop Levels in the Afghan and Iraq Wars, FY2001- FY2012. Congressional Research Service. Available at sgp/crs/natsec/r40682.pdf; accessed January 17, Joint Chiefs of Staff: Boots on the Ground Policy. Department of Defense. Available at C123/BOG+Policy-25Sep pdf; accessed January 17, Hsiao JL, Oh DH: The impact of store-and-forward teledermatology on skin cancer diagnosis and treatment. J Am Acad Dermatol 2008; 59(2): McGraw TA, Norton SA: Military aeromedical evacuations from central and southwest Asia for ill-defined dermatologic diseases. Arch Dermatol 2009; 145(2): MILITARY MEDICINE, Vol. 179, November