National Intrepid Center of Excellence to Provide Servicemembers with Best Technology
Written by Christian Bourge
MMT 2010 Volume: 14 Issue: 5 (August)
NICOE WILL FUNCTION AS THE HUB FOR NOT ONLY PROVIDING STATE-OF-THE-ART TREATMENT PLANNING FOR THE HARDEST-TO-TREAT PATIENTS WITH TBI, PTSD AND PSYCHOLOGICAL HEALTH CONDITIONS, BUT ALSO TO CONDUCT RESEARCH INTO IMPROVING TREATMENT WHILE PROVIDING A MEANS TO EDUCATE OTHER HEALTH CARE PROVIDERS.
The U.S. military has a challenge treating traumatic brain injuries. In an effort to address the issue, a new privately-funded treatment center that combines cutting edge technology with a holistic approach to patient care is scheduled to open this fall on the National Naval Medical Center campus in Bethesda, Md.
The National Intrepid Center of Excellence (NICoE) was designed to be the epicenter of Department of Defense efforts to address traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD) care by providing the latest in medical solutions for those suffering from the most complex injuries associated with the interaction between TBI and psychological health conditions, as well as assistance to their families through counseling. Built with money raised by the American people through philanthropic donations made through the Intrepid Fallen Heroes Fund, a nonprofit organization that turned over the center to the DoD, the $65 million, 72,000-square-foot facility was years in the making.
As envisioned, it will function as the hub for not only providing individualized treatment plans to the hardest- to-treat patients with TBI, PTSD and psychological health conditions, afflictions that are notoriously difficult to diagnose, but also to conduct research into improving treatment while providing a means to educate other health care providers. Rear Admiral Matthew Nathan, commander of the National Naval Medical center, praised the NICoE as the centerpiece of the DoD’s response to improving care of wounded warriors with brain injuries.
“This facility adds a tremendous dimension [to care of PTSD and TBI patients]...as well as to the aspects for family care,” said Nathan. “This facility is truly a blend of great art and great science, which is in many ways the way we approach wounded warrior care.”
Critics argue that official government estimates of around 115,000 troops experiencing “mild traumatic brain injuries” from fighting in Afghanistan and Iraq are much too low, while congressional criticism of the DoD’s handling of patient treatment on both sides of the aisle has intensified in recent months. This makes the NICoE not only important as a potential leap forward in the care of the nation’s wounded warriors, but an operation with important political ramifications as well.
At the heart of the center’s mission is technology, including the most advanced diagnostic and telemedicine applications that will allow the center’s health care team to reach across the vast expanse of U.S. military health care operations around the world.
Polycom Inc. and Avaya Government Solutions partnered to deliver a tightly integrated unified communications solution that makes up the core of NICoE’s collaborative communication and telehealth network. Polycom donated $500,000 worth of its high definition (HD) telepresence, voice and conferencing infrastructure solutions, to include a recording, streaming and content management solution. These solutions will enhance NICoE’s capabilities to deliver the highest quality of assessment, treatment, planning and long term follow-up care for patients worldwide by supporting a wide variety of telehealth services such as consultation and coordination, comprehensive evaluations, coordinated research, as well as training and education.
Avaya donated its carrier class Avaya Aura Application Server 5300 to include voice telephony from the IP-enabled Communication Server 1000 and data switching products from the Avaya 8000-series providing 10/100/1000 edge support as well as 10G connectivity, enabling very high-bandwidth applications such as the sharing of HD digital imagery of computer tomography scans and X-rays across the network.
The combination of Avaya’s voice and data systems with Polycom’s collaborative telemedicine solutions will enable NICoE to be the hub for a world class network of researchers and providers seeking and sharing vital information to be used for training and educating clinical providers, first responders, other warriors and family members, as well as for bringing together decision makers to recommend policy changes based on insights derived from clinical, educational and research activities.
Steve Derr, executive vice president of Sales and Sales Engineering for Avaya Government Solutions said that the firm’s unified communications client allows for computer desktop-based point-to-point video, Voice Over Internet Protocol telephony and video conferencing in the sort of secure environment critical for DoD and other government needs.
“With DoD requirements and the strictness surrounding security, we’re really putting in a DoD mission-critical command and control unified communications platform for their use at the NICoE facility,” said Derr. “It is a very robust solution that we provided.” That solution includes the ability to regularly upgrade the software systems to comply with changes to security parameters in order to meet National Institute of Standards and Technology and DoD guidelines for computer- based telephony.
“It is an evolving thing,” said Derr. “New vulnerabilities are found all the time, and we have to fix those on an ongoing basis. These kinds of requirements are unique to the government market, and Avaya is really leading in terms of defining the space in production for the DoD and military-type requirements.”
Bob Preston, Polycom’s chief collaboration officer, told MMT that for the NICoE, Polycom provided a variety solutions from its collaboration portfolio to support the needs of the NICoE facility. High Definition (HD) telepresence such as the JITC Certified HDX 9000 will be used to bring in remote medical experts to the Data Immersive Visualization Environment (DIVE) to conduct telehealth consultations, while interdisciplinary clinical teams can coordinate best course of care for patients. The HDX 9000 will be used in conjunction with the recording and streaming capabilities in the auditorium and classroom to support focused workshops, training, seminars and other events throughout the year, while the in-take and evaluation suites will use the and HDX 8000 for interviewing patients and for evaluations by medical professionals. Four conference calling suites were also equipped with SoundStation IP7000s. “We carefully crafted a solution set to enable NICoE to extend its services and to provide the highest quality of care to our veterans.”
According to Preston, the Polycom HDX 9000 Series room telepresence system will enable patients who are unable to travel—whether they are billeted, in a longterm psychiatric care setting, or recovering from battle wounds—to still get care from the center. Their open, standards based systems interoperate with a variety of legacy endpoints, while delivering high quality video, audio and content, so that meeting participants can pick up every nuance of a conversation, see facial expressions, make eye contact, and read body language and share medical records– all essential to effective communication and collaboration in a healthcare environment. Additional specialized medical equipment such as general examination and endoscopic cameras can be connected to the systems to support additional telemedicine applications.
“It allows for the doctors and experts to reach out to people in their locations to assess them and provide the diagnosis that is necessary,” said Preston. “This happens to be a pretty robust configuration with the ability to support one-on-one meetings between a patient and a physician during an assessment, to capturing, recording and disseminating live lectures to hospitals around the world for for training and establishing best practices in treatment of PTSD.”
He added that the true power of this network is the ability to bring people together using Polycom’s UC intelligent core. It consists of CMA which provides management, scheduling and gatekeeping, the RMX conferencing platform that supports hundreds of audio and video conferencing calls across a single platform, a VBP for connecting to sites outside the network, as well as the RSS recording and streaming server, and the VMC for managing and sharing recorded content. With these capabilities, experts can be brought together from around the world to share best practices and extend treatment to those in need.
The NICoE also houses traditional medical diagnostic and physical therapy equipment found in many hospitals—including a 3 Tesla MRI, 64-Slice PET/CT scanner, and functional transcranial doppler spectroscopy equipment—with the state of the art in neuroimaging, physical and physchological evaluation technology that will all be focused on healing the wounded warrior and helping them deal with their condition.
Radiologist Gerard Riedy, M.D., chief of neuroimaging at the NICoE, said that the center has “the best neuroimaging technology on the planet. It will allow physicians to better explore methods for objectively measuring the diagnosis of TBI and PTSD, as well as decide on disability levels with more objective measures than are currently in use.
“We need better methods to objectively measure this,” said Riedy. “It will help us design new therapies for the wounded warrior. Secondly, it will help the military decide whether these guys can return to combat or not.”
Arguably the most cutting edge medical diagnostic equipment at the center is Stockholm, Sweden-based Elekta NeuroMag’s magneto-encephalography (MEG) system for functional brain mapping, one of only nine in the world. The MEG is a diagnostic imagining system designed to measure the minute magnetic fields of the brain using 305 super conducting quantum interference devices. There are major advantages to the system over more traditional imaging techniques like MRI, which measure vascular activity, because it allows for full mapping of the brain.
Gordon Haid, director of North American technical marketing and sales for Elekta and a physicist by training, explained that there are billions of neurons in the brain that, when fired, create magnetic fields that can be used to not only map brain activity but also its physical features.
“Whenever there is current flowing, there is a magnetic field flowing around it,” Haid told MMT. “The currents are a billion times smaller than the typical battery. The firings are of the order of 15, a billion times smaller than the earth’s magnetic field. We need correspondingly sensitive sensors. We have electronics to monitor in the millisecond level, and through very fast sampling we can determine the time course of activities. We can see things that happen very briefly in the brain.”
The calculations are then superimposed on an anatomical image of the brain, allowing for the measure of specific stimuli on the brain, including visual, aural and other stimulus.
Elekta NeuroMag chairman Stephen Otto said that his firm is the only company currently producing such systems, which fully equipped are around 19 feet high and weigh about 13,000 pounds, costing over $3 million. More traditional diagnostic tools only measure impacts of the problem on the body of TBI and PTSD, making diagnosis of either condition difficult as they present with similar symptoms.
“It may be that some people only have traumatic brain injury and some only have post-traumatic stress disorder; sometimes they have both,” explained Otto. “There is ongoing research trying to see how both link together [using the MEG system].”
Research into this area is still being developed but shows great promise, as does the use of the MEG system for pre-surgical mapping of the brain. It allows for precise measurements of what parts of the brain seizures are coming from, to allow for easier surgical treatment for those who do not respond to medicinal therapy or for the removal of tumors.
Another cutting edge technology at the NICoE is Amsterdam, Netherlands-based Motek Medical’s Computer Assisted Rehabilitation Environment (CAREN) system, a multi-sensory virtual reality immersion system for diagnostic evaluation and rehabilitation. It features a 180-degree cylindrical screen designed to create an immersion environment with real-time feedback in a completely controlled environment to evaluate patients.
The screen is coupled with a surround sound system and a six degree, full motion platform allowing the recreation of almost any environment, from a city sidewalk to rocky land to a boat on the water, that can be used to test a patient’s physical and mental capabilities. Be they suffering from TBI, PTSD, a degenerative neurological disease like multiple sclerosis, or have an amputated limb, the system is designed to test patients’ abilities in the simulation of real world settings. All the responses are measurable with a lightning fast system of body and platform based sensors, including 12 motion capture cameras.
Elisabeth Wessels, vice president of Americas marketing and sales for Motek, explained that the software allows for the analysis of a patient’s balance response and interaction with stimuli of varying intensity, controlled by a medical professional. This allows for the sort of patient testing and rehab not typically available for treating TBI and PTSD patients.
“It’s like a Lego box,” she said. “You pick out of the box what you want to build your application. If you want to build a specific environment for a stroke patient that wants to cross the street or a PTSD patient that wants to learn to adjust to city life again with cars, noises and buildings, it can be done. The application [provides] a game-like approach to rehabilitation, but it is based on therapeutic principles.”
The CAREN system at the NICoE is actually the second one acquired by the Intrepid Fallen Heroes Fund, which raised the money to build the center, and one of only six in the world. A secondary system is currently being installed at the nearby Walter Reed Army Medical Center.
Dr. Thomas DeGraba, NICoE deputy director and chief of medical operations, explained that the intent is for these technologies to be used to care for the most difficult to treat TBI and PTSD patients. They will be brought to Bethesda for a two-week stay and complete evaluation along with their families. Up to 20 patients and families can be housed at one time at the Fisher House, dedicated housing on the Bethesda campus, with counseling also available to spouses and children from certified social workers.
“There are outstanding providers in the [DoD and VA health care] system,” said DeGraba. “However, there are some patients that do not recover. These patients that do not recover through traditional therapy will be referred to the NICoE.”
He added that the center’s importance and DoD’s hopes for its impact on patient care are immense. It will not only allow for patients to return to their units for treatment, but also for remote follow up at the center if needed and the sharing of developments in patient care with physicians outside the center.
“From a clinical standpoint, the interdisciplinary team assessment in a holistic, patient and family centered environment combined with the high tech diagnostic capability and follow-up, that is the next generation of patient care,” said DeGraba. ♦