Good afternoon. My name is Dr. Angela Michelide. I am the Vice President of Programs and Education at the American College of Preventive Medicine. I'm pleased to serve as your moderator today for this Grand Rounds on telehealth and telemedicine related to the Joint Incentive Fund Cardiovascular Disease Prevention Project. ACPM is tremendously grateful to be able to partner with the Department of Veterans Affairs and the Department of Defense on this exciting initiative. The American College of Preventive Medicine is a professional medical society of more than 2,000 physicians dedicated to improving the health and quality of life of individuals, families, communities, and populations through disease prevention and health promotion. Our members are licensed medical doctors who possess expertise in a broad range of healthcare skills, including biostatistics, epidemiology, management of health organizations, research, and the practice of prevention in clinical settings. They work in a variety of workplaces, including hospitals, government at the local, state, and national levels, the military, laboratories, business, and academia. Before we begin, I have a few housekeeping notes. The audience has been placed in listen-only mode. We will post a recording of this webinar in the ACPM Learning Management System on our website in a few days. We invite you to please type questions in the chat box throughout the webinar presentations, and we'll respond to them at the middle and towards the end of the session. And we will be emailing you a brief feedback survey after the webinar, so please respond so that we can improve our offerings and be able to attract additional topics and speakers. Today's Grand Rounds is brought to you by the Cardiovascular Disease Prevention Project, which is a collaboration between the American College of Preventive Medicine and the Veterans Affairs Loma Linda Healthcare System. The purpose of the JIC project is to facilitate both active duty and veteran military service members in addressing cardiovascular disease risk factors using a virtual avatar-based education platform, the Veterans Health Administration Virtual Medical Center, or VAVMC. We are working collaboratively and have positioned preventive medicine junior faculty at Veterans Affairs hospitals to develop and test content on CVD risk factors using the VAVMC. This initiative, funded by the Joint Incentive Fund, is an innovative model by which delivers quality medical care remotely. Through this Grand Rounds, you'll learn more about the VAVMC through an in-world demonstration at the end of our webinar. The goals of this Grand Rounds are to learn about the broad scope of telemedicine and telehealth applications, to compare the rapid expansion of capacity and use in the current COVID-19 pandemic environment, and to learn appropriate applications and limitations and frontiers of telemedicine as relevant to preventive medicine specialists in the federal healthcare system. I'm very pleased to introduce our four speakers to all of you. Dr. Timothy McKay is a professor at the University of California, San Diego, the director of the Global Health Policy and Data Institute, and also the CEO and co-founder of the healthcare startup company S3 Research, which develops big data, machine learning, and data visualization technology to detect illicit drug activity on the internet, social media, and the dark web. His work focuses on an array of multidisciplinary topics in domestic and global public health, including health technology, public health data, data science, health policy, and global health governance. Our second speaker is Dr. Antonio Eppolito. He's a family physician and flight surgeon with 27 years of clinical experience in the outpatient, inpatient, and deployed environment while serving on active duty. He is currently the Air Force Medical Service Chief of Telemedicine for the USAF Office of the Surgeon General. In this role, Dr. Eppolito has been a key architect in expanding both capacity and application of telehealth in the setting of the Air Force Medical Service. During his tenure, Dr. Eppolito has overseen the expansion of the telehealth program of the Air Force Medical Service to 33 initiatives in 15 different specialty areas. Beyond direct clinical practice applications, Dr. Eppolito has helped shape federal telehealth care policy and governance. Our third speaker is Dr. Ryan Vega, who is the Chief Officer for the Office of Healthcare, Innovation, and Learning as part of the VHA Discovery, Education, and Affiliate Networks Office. Dr. Vega holds appointments as an adjunct assistant professor in the Department of Healthcare Administration at Georgetown University, as well as a clinical assistant professor of medicine at George Washington University. Prior to his current position, Dr. Vega served as the Chief Quality Officer at the Richmond VA Medical Center and Assistant Professor of Medicine at the Virginia Commonwealth University Health System. He is the recent past chair of the National Quality and Value Council for the Electronic Health Record Modernization Initiative. Dr. Vega is board certified in internal medicine and has published research and practice in the area of health informatics, clinical quality improvement, patient safety, and clinical innovation and implementation. And our fourth speaker is Mr. Brian James, who is an Associate Director for the eLearning Division within the Employee Education System in the Department of Veterans Affairs. His team is responsible for the development and implementation of learning technology and online learning programs to ensure veterans and staff receive the highest quality educational resources. He has a team responsible for strategic planning, instructional design, program development, and education. Brian leads the development of a virtual medical center, which is a platform that provides veterans, staff, and providers with education, resources, and information. Brian is a Navy veteran. So in terms of flow of our webinar today, we'll first hear from our three speakers and engage in a question and answer session. Then we will turn the podium over to Mr. Brian James, who will take us on a tour of the VA VMC and answer any questions that you may have. Hi, this is Tim Mackey from UCSD. I wanted to first thank the organizers for the Telemedicine Grand Rounds for the invitation to give this talk around digital health. As just a disclaimer, I'm re-recording this video because of a technical issue that happened during the conference. So the content may not be exactly what I presented on during the meeting if you were live and able to attend at that time. But the purpose of this talk is going to really be to focus on the kind of broader scheme of what is available in digital health. And this ties in well with the other speakers who talked about very specific digital health initiatives that are going on at the VA and in other spaces in the government, especially the virtual tour you got of the VA Medical Center. So without any other stop, I'm going to go ahead and share my screen, and we'll get right into the presentation. So, today we'll be talking about why digital health is more important for health than ever. And we'll be couching this within the context of, of course, the COVID-19 pandemic and how it has acted as an accelerant for a lot of these digital health technologies. I'll be going pretty fast through these slides because we do have a lot of ground to cover and we only have about 20 minutes or so to cover all this material. So I want to start with the very beginning of what digital health was, and that is this concept of e-health. Back in 2005, a number of authors coined this concept and also included a systematic map of what different areas there were in e-health. One of the more predominant areas was, of course, telemedicine and then other related internet technologies, but telemedicine has been one of those areas that has been really a focus in the early beginnings of digital health and were one of the main modalities for delivering medicine in a different format than is traditional. So e-health is also one of those areas that's considered an information communication technology and it has lots of different areas of strengths and of challenges, and we'll be going over that throughout this presentation. So what we're going to pivot off into now is a discussion about digital health. And again, e-health was this earlier concept of digital health. And so there are lots of definitions of digital health, but I'm going to take you to one of the ones that is created by the World Health Organization that focuses on the use and scale up of digital health solutions and how they can revolutionize how people worldwide achieve higher standards of health and access to services to promote and protect their health and well-being. If you know anything about the Sustainable Development Goals, which is a group of goals that the world has agreed to in order to advance human society, you'll know that it's very much tied into health equity and also universal health coverage. So the World Health Organization sees digital health tools as a way to advance this universal health coverage objective and to make healthcare higher quality, better access, and potentially optimize the outcomes for health in the long term. So there are some typologies of digital health that I think are really important to go over to begin with. mHealth is the use of mobile phones or delivering health services and information on mobile devices. Of course, very important because almost all of us now have a mobile device, and they're getting more complex with their computational power and what they can do with sensors and things like that. So these are really many computers that can deliver health now. Digital medicine is the intersection between mobile, computational and connectivity, genomics, IT, wireless sensors, et cetera, and just gives you this feeling that medicine is becoming digitized through the different access points that you have to different forms of data and different devices. Precision medicine, of course, is the process of tailoring the medical experience to an individual patient. You hear about this a lot in genomics, of course, and powering a lot of precision medicine is data itself. The quantified self is this idea that people are engaged in self-tracking their health information. So a lot of our self-tracking actually happens outside of the clinical setting. And more and more people are using this information to improve their own health. And then, of course, telemedicine, the WHO definition is the use of information and communication technologies to improve patient outcomes by increasing access to care. Important in this definition is the fact that it's not specific about the type of modality that's used for telemedicine. And this gives us a lot of flexibility to examine how telemedicine can be delivered in different formats. One of the key components of all digital health applications is this idea of patient-centric design, that if we don't include the patient in the design process, we're really not going to have a high level of adoption and the application will not be effective. So there are a lot of benefits to gain when you involve the patient in your design and iteration process. You can gain insights into health care problems and solutions that you may not get from the perspective of, for example, a clinician or a technologist. You may be able to better validate the solutions, and you may also have opportunities to co-create something that really brings in these perspectives and is more effective. And we have this also concept called the e-patient, which is a patient who is now engaged and actively participates in their own treatment and health. And a lot of different organizations, including Medicine X at Stanford, have really tried to empower patients to be e-patients and take more control of their own care. So the question also is, is a digital health revolution underway? And at the beginning of the e-health era, this was an era where I would constitute it as focused on health information technology, a period when we were rapidly adopting electronic health records and all the growing pains that went into that, such as the HITECH Act. And then, of course, telehealth was this really big umbrella space where we were experimenting with a lot of telemedicine approaches. What we kind of are in now is a period of not health information technology, but digital health. And we're seeing new types of technology and new innovations that are filling the space. Things like mHealth, we talked about before, 5G, for example, how 5G can potentially revolutionize edge computing, big data in health care, a lot of machine learning, a lot of big data analysis, et cetera, to advance and improve health care decision making. And then more experimental technologies like blockchain, where I do a lot of work in that space looking at how distributed ledger technology can improve the quality of health care data and ensure more distributed data related to health care in a privacy-preserving way. So you know something is mainstream when the World Health Organization comes out with a resolution from its 170-plus member states. And that is because when the World Health Organization creates resolutions at this World Health Assembly, it really takes a lot of consensus building across all the member states. So in order to get this statement together, you not only have to get all the constituents from different state governments, but you also have to get civil society and all these other areas to kind of come up with and negotiate what the framework for digital health should look like. So the WHO has come up with a broad set of 10 recommendations focusing on things like supporting evidence that digital health actually works and it can improve your health and issues regarding implementation and limitations. Some key challenges they've identified are poor management, insufficient training, infrastructural limitations, and poor access to equipment and supplies. And again, tying this strategy into an overall approach to increase access to health care. The other thing that's very interesting, this is the Gartner-Hyde curve, is that different forms of digital health technology are also maturing at different speeds. So for example, medical device connectivity is one of those spaces that's really being adopted really rapidly versus, for example, virtual health assistance where there's a little bit less adoption in that kind of bot-assisted space. And so again, there are many forms of digital health and they're not all the same category and they're all maturing at different periods of time. Yet there is a lot of growth in the space and especially with the internet of medical things as more of our devices not only become connected, but also start to capture information that's related to either clinical outcomes or even behavioral health. There are so many opportunities to transform these devices in ways that they can actually hopefully improve your health. There also are, most critically, a number of different journals popping up in the space to establish the evidence base for why digital health technologies work or don't work. And that's extremely important because what we've had is a proliferation of health behavior and wellness apps that may not have the scientific basis or the evidentiary requirements to really show that they lead to good health outcomes. And so the evidence has to catch up to all of these digital health interventions and make sure that we're testing them rigorously and that we're showing that they actually do what they promise. And so I'm the editor-in-chief of a journal at the JMR family, and this was a journal that was one of the leading journals in the space, really focusing on e-health, digital health, et cetera. But now we have a number of different publishers that are also entering the space and really focusing on digital health as one of its key categories of interest. The other thing that's been very interesting in the space is the regulatory environment. So when it comes to the way that we regulate devices and drugs, it's a very different process than you would, for example, regulate a software or a medical app, et cetera. So the FDA has been very progressive in determining what the right regulatory approach is to developing a risk-based approach, but continuing to foster innovation. So hopefully not completely deregulating devices, of course, but also putting a risk framework behind it, but also encouraging people to continue to innovate. And so one of the programs they have is the pre-certification program, where they certify manufacturers or software developers instead of the app itself. And then, of course, the difference between a medical dictionary and a device that, or an app that controls, you know, an insulin pump, for example, are very different grades of risk. So the FDA is trying to evaluate what that risk should be and how they should approach it from a regulatory standpoint. And this is very encouraging because, again, hopefully it will enable more adoption of this technology, but also reduce the potential patient safety risk if these devices aren't appropriately monitored and reviewed. So again, this is the pre-cert program. I definitely recommend you taking a look at it if you're interested. And again, one of the major things here is there is some, you know, requirements for evidence to show that these digital health applications work, again, from a risk-based approach. Some of the other things I just wanted to highlight real quickly is some of the information that came out of the European Parliament that really talks about some of the overall structural barriers to deployment of e-health and digital health technologies. And I think this is very important because it wraps things around a broader picture. But things like adoption, technology literacy, a lot of people don't understand how to use or they may not have vocabulary associated with clinical care. These are very important things to tackle, and these are areas that we all have to improve on. The cost-effectiveness, we really haven't understood, are these devices and tools and digital health applications cheaper, and do they deliver care better? The startup costs, so, you know, a lot of people are interested in creating digital health applications, but how do you get it from a proof of concept all the way to minimally viable product and then into an actual production and implement it? And then the digital divide when it comes to connectivity and how, as we use more of these devices, how does that impact health equity and access? Things like interoperability, which is not a surprise to this audience, security of course, data management when you're dealing with larger volumes of data and also more multimodal forms of data, different types of data, the policy environment we talked about in the FDA section, but again, is our policy responsive to these new technologies? Of course, privacy issues, and then the sustainable funding needed to actually carry out these initiatives and make sure we have longitudinal data that can support their, you know, cost-effectiveness and clinical effectiveness. So overall, we have a number of different technology types in digital health I think are kind of interesting to look at. We have things like mobile, as we talked about, gamification and really interesting space to gamify apps, sensors and communications, IoT, robotics, social media, I do a lot of my work in social media now because so many people are using that as a platform for expressing their own health, you know, concerns and even expressing their health behaviors, data visualization, frontier technologies like blockchain and 3D printing, virtual reality and augmented reality and things, of course, like AI and big data. Some of the major things we're doing in digital health are disease diagnosis, prevention and management and improving patient safety, encouraging participatory medicine, health equity and access, again, we talked about that before, and the things we have to consider, again, are the cost considerations, the data privacy, the ethics, the evidence base, and of course, one of the bigger things, of course, is how do you actually reimburse for these services? And so some of the areas that are really growing is areas like home care, how do we do remote patient monitoring and enhance the home care environment? Looking at population health and, of course, looking at precision medicine as well. So I'm going to shift over this discussion and spend our last few minutes talking about how the COVID-19 pandemic is acting as an accelerant for a lot of these technologies and maybe looking at what that will look like, you know, in the future. So to put things into context, I'm actually a PhD in global health, so my passion is mostly in global health issues. I actually started in policy and then I moved over to technology, but I've published a lot on infectious disease outbreaks as well. A lot of people compare the COVID-19 outbreak to the Spanish flu, and this is a completely different era, of course, because we had no electronic TV and commercial radio was just beginning, so the media environment was very different. When SARS, it was the era of globalization, but still there was very limited digital tools available. For example, there was no Facebook at the time of SARS. And then as for H1N1, we did have more smartphone accessibility. We had things like the Apple App Store that started, but still not a saturated media environment like we have now. Fast forward to COVID-19, 53.6% of the world's population is on the internet. That's more than half. And Facebook has supposedly 2.5 billion monthly active users, which would make it one of the largest countries in the world if you counted all those users as human beings. So it's a very different environment, and digital health is here to stay. And so some of the things that we're leveraging for COVID are things, again, like mobile applications, like contact tracing applications for COVID, gamification to ensure that people who are vaccinated get more incentives, for example, AI big data for image recognition of lung injury, robotics devices for potentially augmenting the clinical setting with more health care access and capacity, data visualizations, which are really important, we'll go through a few of those, and then social media, where there's a lot of, unfortunately, misinformation occurring about vaccines, about public health interventions, et cetera, which we really need to combat in this new era of what we call the infodemic. So some of the things we're trying to do with this digital technology is, again, changing health behaviors, such as social distancing, encouraging people to get vaccinated, infection diagnosis or prevention, digital contract tracing systems, and early alert systems. We do a lot of infovalence, epidemiology in my lab, and, for example, we had a study where we found people, we used machine learning to detect people self-reporting their symptoms of COVID. And then we're dealing with some of the same issues, like data privacy and ethics during COVID, user adoption, and then the funding to actually implement a lot of these digital health-focused COVID interventions. We see some major things changing in telemedicine, of course, broader adoption and better reimbursement, changing regulatory regimes, where the regulatory regime has been flexible to a lot of COVID interventions, such as vaccines, and then this focus on digital public health, which is this new space that's really, really exciting. So some of the things that have happened, of course, in telemedicine side is, you know, very early at the stages of the pandemic, you know, telemedicine has become more mainstream, and definitely the scope of practice has become more flexible, and the reimbursement component has also really improved. And hopefully that is here to stay, because telemedicine is a very viable option for certain patients. We see data dashboards that, for example, the John Hopkins dashboard, which pretty much everyone uses for updated case counts around COVID. This is not from the government. This is not from the WHO. It's from a group of researchers who have created this dashboard because of the need, and now it's used widely throughout the world. So again, this form of technology may have not been available in previous pandemics, but now is liberalizing a lot of this data so that everyone can hopefully improve their public health outcomes. And there's a number of different dashboards we have at the state level on economic issues. There's a whole community of people developing dashboards, really fascinating stuff. And we develop our own dashboards as well, but really amazing that, you know, so many different organizations can come together, so many different individuals represent data in new ways for new insights, and hopefully help, you know, arrest the spread of this disease. So there's also platforms that are more active in, for example, trying to track symptoms of people. There's fascinating things going on in digital health in that the fact that we have, you know, algorithmic contact tracing or digital contact tracing. And this is an initiative that was spearheaded by Apple and Google, traditionally competitors in this space who would never cooperate on something, but have developed a privacy preserving manner to alert people, you know, because of Bluetooth proximity to the risk of, you know, being exposed to a potential case. Really fascinating stuff. And I'm not sure you would have seen this outside of a health crisis. And we at UCSD have done a lot of work in this space as well on different types of IoT devices. And as I mentioned, also looking at the ethics component associated with COVID-19. And some of the work that my lab does, just as an example, is really focusing on this concept of the infodemic and trying to figure out how misinformation spreads and how to combat it. And so unfortunately, one of the byproducts of this pandemic has also been the negative use of technology. So that's also something that we have to kind of assess moving forward is what are the negative externalities of the use of this technology, and how do we appropriately address those issues? So misinformation is a huge issue. We see so much misinformation every day. We're tracking it all the time, but it's really hard because it's all over the place and it can become viral on social media. Other things like blockchain are other technology spaces that are really starting to gain traction, but are untested. So a lot of the digital health tools that we have also need to be rigorously tested to ensure they really are fit for purpose for addressing a pandemic or any other health challenge. So definitely we are moving forward and after COVID, there's definitely going to be some acceleration of digital health. Some of our students in one of our recent classes in our digital health certificate said that the most important area that will grow is remote virtual patient care followed with drug discovery in the digital health space. We do have a certificate at UCSD extension. And so if you're interested in that, there's some additional information here, but this is really a growing field. Not a lot of master's programs available, but I anticipate that there'll just be much more education, training, and hopefully more opportunities for fellowship programs, et cetera, to really do specialized training on digital health interventions for clinicians, but also for technologists and also for public health professionals. So thank you again for your time and hope you enjoyed the conference. And again, I hope you enjoyed this presentation with the focus on digital health. Thank you. Okay then. Thank you for including me among such an expert panel of speakers. Thank you Dr. MacKay. Forgive me if I'm pronouncing as MacKay. I think that's how you were introduced. I learned a new word today, infodemiology. So as we just heard, that was a nice tour through the general landscape and the background of the technology in the industry that enables us to do healthcare now. And so I think that'll be a nice segue into, I'm going to focus on actual clinical applications of real world scenarios where we're using the technology directly in patient care. Next slide, please. As he alluded to in our previous speaker, everything changed with COVID. It proved to be a major accelerant for what we were already doing. Here's a snapshot in microcosm of what looked like in the Air Force. We had a four fold increase within nine months of the shutdown at the beginning of COVID such that we were doing 67% of all our care virtually. Most of it, seven to one was telephone and the remainder was video. And through the first year of COVID, we did some 800,000 virtual video visits. Of course, this is just a snapshot of the Air Force. The Army and the Navy do this as well and the VA much more extensively by several orders of magnitude. Next slide. And so virtual video visits is probably the future. It's become accepted as mainstream. Next slide. Okay. So there are a lot of different ways to categorize what we do in terms of telemedicine. And as Dr. McKay said, there are multiple definitions. The Air Force telehealth office, we cover the whole gamut. And so one way of looking at it, everything is included under the rubric of what we call telehealth, even though they are, of course, separate, known by separate different nomenclatures. But we do digital health, virtual health, telehealth, e-health, and mobile health. And so I've divided it here into nice three vertical columns, three pillars, three realms, if you will. On the left is enterprise imaging, which is the use of diagnostic digital images that are interpreted upon by a specialist. The second column is basically person to person, and that's either asynchronous using email or it's live synchronous using video. And then the third category on the right is mobile health applications for the patient to interact with the system, stuff like mobile apps, secure messaging, patient portal, remote home monitoring, and the such. So I'm going to give you a quick blitzkrieg tour through each of these realms as we go. And I'll highlight some of the ones that I think are germane to the preventative medicine audience that we have out there today. Next slide. So with enterprise imaging, you really are talking about teleradiology, cardiology, endoscopy, and pathology. Next. Air Force teleradiology is pretty much our mothership. It's our flagship. It's what we're most proud of. We were one of the leading institutions in getting teleradiology up and going 15 years ago. Basically, we have 75 Air Force hospitals around the world, and in two-thirds of the places, we have no radiologists there on the ground manning. And so it's really one-third of the world reading for the other two-thirds of the world. Next slide. This is what it looks like. It's a hub-and-spoke array across the world. We can basically read any image anywhere, anytime, 24-7, whether a radiologist is there on the ground or not. Many of our large medical centers, our four big hubs, do most of the reading for all the remote areas around the world. We do some 20% of all radiology reading is tele, and something on the order of 150,000 images per year. Over. Next slide. So changing gears, that's teleradiology. Telecardiology, same idea. Anything that can be done at a cardiopulmonary lab can be sent to our cardiologists at a hub site. Next slide. The report is read and sent back. And then, of course, you repeat that among 238 flight medicine clinics around the world, a single global hub at Wright-Patterson Air Force Base in Dayton, Ohio. Next slide. We published this, and we presented it at various conferences. We basically got the turnaround time for getting diagnostic digital imaging reports and finalized for aviators in the Air Force, which was a readiness issue, from a two-week turnaround down to two hours using this telecardiology. Next slide. The third category would be endoscopy. Any specialist that does endoscopy, and we are currently deploying this live at several centers. This is a DOD, Army, Navy, Air Force, and VA included in this as well. In fact, we were just out in Dr. McKay's neighborhood in San Diego at Naval Hospital Balboa deploying the endoscopy at several specialties there at the Naval Hospital there. Next slide. The IVIS has integrated video and image sharing system, so the specialists who do endoscopy can share the images and consult with each other in real time. They also have this as an available digital prior as relevant. They have it for peer review, for teaching, for grand rounds, for research, and it also, no matter where the patient goes, it can be pulled up from a global digital archive. Next slide. Same idea with pathology. Again, with radiology and cardiology, those are still images. With endoscopy, it's a video image, but with pathology, it's a whole different animal. These are whole slide images under microscopic magnification. Next slide. These are deployed at all the pathology centers at the major medical centers, Army, Navy, and Air Force. This is what the scanners look like. You basically take the day's worth of microscopic slides that you made on glass slides, and you load it like a dishwasher. You scan it overnight, and the next day, you have a batch of 400 of the day's specimens, all digitally magnified in a digital cavity. The pathologists can, in addition to using a microscope, they can actually do diagnostic imaging interpretation right off the high-resolution monitors. Of course, you have this digital image in an archive available for peer review, tumor board registry, grand rounds, teaching, research, etc. Over. Next slide. Let's change gears. That's enterprise imaging. That was that first realm on the far left. That middle column, if you remember, this is person-to-person. Person-to-person can be between docs or can be between a doc and a patient. The global teleconsultation portal is something we have where a primary care physician can speak with a specialty care physician. We call this teleconsultation or e-consultation. Next slide. We have two categories. We split the world in half. We have the Pacific area that is basically available to anybody in the Pacific Hemisphere through our major medical centers on the west coast called Pacific Asynchronous Telehealth, or PATH. Next slide. On the other side, we have health experts online, which is really the other half of the same portal, and that's covering the Atlantic seaboard, and that's the other half of the world. This is where in 24 hours turnaround time, any specialty of any sort can be consulted on from someone who's out in a remote region. Particular to this audience, you can also get feedback on population health, epidemiology, infectious disease, and whatnot if you have an outbreak and you're trying to come up with preventative strategies to get ahead of that. That's one of the options on this portal. Next slide. If it's an absolute emergency, you need to talk to someone live. We have an advisor telephone hotline where you can reach any specialty on call 24-7 directly through a menu, automated menu, and someone will answer the call. This is for medics who are in the field at the point of injury in deployed austere settings, and they need to talk with an expert immediately live via sat phone most usually. Next slide. So in addition to the asynchronous email, like we said, and the advisor hotline using a phone, we also have virtual ICU. Virtual ICU enables real-time teleconsultation between the specialist hospitalists, intensivists, and the nursing and primary care docs who are out in the ICUs at some of our community hospitals. It's a major, it's a, on the right there is a depiction of it looks like a air traffic control control room where they can be monitoring up to 150 beds. These are, there's, this is a partnership with the VA actually, and we have one of the VA control rooms actually monitors some of our Air Force hospitals. In fact, one of those connections is the VA in Chicago covering the Nellis Air Force Base ICU in Las Vegas. Next slide. And Project ECHO is another category of e-consultation. This is for a lower acuity, less of an urgent situation. This is for your chronic disease management cases. This is when you have a week or two and you're going to see the patient back and there's no urgency on it. This is akin to virtual grand rounds. I can't talk about Project ECHO without giving kudos to the originator of the model at the University of New Mexico, but the Air Force and the Army and the Navy and the VA have been partners in the family of Project ECHO for 10 years now. Next slide. We have several specialties, not as many as the VA offers, but complicated diabetic management was our original one, and then we just celebrate our 10th anniversary with Diabetes ECHO. Next slide. Now that's teleconsultation between docs. Now if you switch gears, teleconsultation between a doc and patient, this is virtual video visits. This is what everyone has become very much aware of because of COVID, and we have six specialties where we are operational in that realm in the Air Force. They're listed there. Next slide. And telepsychiatry is one of our big ones, or telemental health. That's a hub and spoke array in a regional pattern where the teleprovider sits at the hub and the spoke sites are the patient spoke sites. Next slide. We also do the same with teledietary or more specifically telemedical nutrition therapy. Next slide. We do it with telegenetics. Next slide. We do both consultation and counseling, and we have a single global hub where we operate out of Keesler Air Force Base, which is Biloxi, Mississippi on the Gulf Coast, where we have a genetics lab and an Air Force Center of Excellence for genetics. Next slide. Teledermatology, we have two hubs in teledermatology. Next slide. One covering both the East Coast and the West Coast, and there's a smattering of some of the patient spoke sites that utilize it where you basically are taking a photo, you're sending it into the dermatologist, they're making a diagnostic and a treatment regimen based on the photo, and emailing you back with a treatment plan. Next slide. We also do this with developmental pediatrics. Next slide. And so you saw those were selected specialties. We don't do everything. We pretty much do the ones that are most needed, the ones that you don't really have a local specialist in the area on the economy who you can consult with, and you need to do it via tele. So that's why we are selective in which ones that we actually offer. The VA, of course, offers, I believe, pretty much every specialty, more so than we do in the Air Force. Now, switching gears, we're in that third realm. If you remember from that original slide, this is the third pillar, and this is mobile applications. This is where the patient is interacting with the system. And so smartphone mobile applications have been around for a while. There are thousands of them out there on the economy, but we in the DoD at the Telehealth and Technology Center have built our own so that they have truly been tested for clinical efficacy. Some of them are listed there. They're free off download up of iTunes for applicable to iOS and Android. Next slide. And I'll just point out PTSD coach. That's one of them. That's our screen capture. That's the one we're most proud of. That's the one that was independently reviewed and given a blue ribbon for its clinical efficacy as a use case for a mobile application. This is something that a mental health provider can basically prescribe to their patient to use at home as an adjunct to the in-clinic therapy. Next slide. Okay. Remote home monitoring is another category. We do this particularly with diabetic patients. This is where you have an RN who schedules telephonic or video surveillance with an array of patients. We ran this as a research originally with 240 patients out of our faculty residency programs in Las Vegas and in Tacoma, Washington, and now we've expanded it across the continental United States. Next slide. Remote home monitoring or patient home monitoring, we tend to do it with the diabetics and weight management patients. I know in the VA, they do it much more involved. They're actually doing it with heart failure patients and for continuous monitoring, the end point being to keep them from recurrent readmission to the ICU and emergency room visits. This challenge for remote home monitoring was first given by Dr. Eric Topol in a TED Talk back in 2009 and it has become relatively commonplace across institutions, civilian and military. Next slide. Virtual pre-op is something else we're doing so that patients who are in a catchment area of some 100 miles with rush hour traffic around major metropolitan areas, if they can get that pre-op visit done virtually and then actually come into the hospital for the actual surgery, it saves everybody a lot of time and heartache. Next slide. Okay. Current web-based platforms, I just want to mention here that we have nine different video platforms that we use in the DOD. The one that's really that we're going to is going to be the idealized end state is MHS Video Connect, which is in fact, the same thing that the VA has, VA Video Connect. So that's kind of what I want to footstomp there is that in the idealized end state, as you've probably heard, the VA and the DOD will have the same EHR, the Cerner product, MHS Genesis, and we will have the same video platform for doing virtual video visits known as VA Video Connect, or as we're going to call it, MHS Video Connect, but it is in fact, the same background, backbone, it's the PECSIP video platform. Next slide. And this is, of course, the idealized end state where you're going to have, in this screenshot, you have all three realms of telemedicine going on. You have in the top left, you have video chat between doc to doc. So that's that virtual consultation I was talking about. Then in the bottom left, you have the image sharing, that's enterprise imaging with diagnostic digital images with the image and the interpretive report. And then the bottom right, you have multi-user collaboration, and that's where the patient is coming in through their patient portal and they're syncing their patient remote monitoring data and their biometrics. And then the top right, you have your EHR, which of course in the future is going to be the Cerner product, which is going to be DOD to VA seamless through the same patient population. Next slide. And so all of these pieces of the puzzle are not yet there, but this is a schematic of what it should look like in the idealized end state where you have a fully integrated image-enabled electronic health record that's web-based and remote applicable for all providers and patients to use. Next slide. Okay. I just want to quickly go over some of the other things that we had been doing there. You might find a particular interest. We did a lot of virtual reality work. Next slide. This is a screen capture of what we did for virtual reality exposure therapy with our PTSD patients and our mild TBI patients, our wounded warriors who were coming back from Iraq and Afghanistan. This is done with a mental health specialist who's trained on the equipment. Next slide. This is a picture of what it looks like. The patient sits in the chair. The doc is sitting there at the control room and they're actually doing exposure therapy under the clinician's guidance using the virtual reality immersion for exposure therapy techniques of therapy. These are sessions that you do two, three times a week over the course of 10 to 12 weeks. Next slide. We expanded the patient base to include those who were suffering from other things like phobias and addictions. We had software programs built specifically to those. In fact, the fear of public speaking was the most popular one where we would have troops come in who were not necessarily patients in any way, but they just wanted to practice their briefing and their speaking techniques and so they would get into the system and they would practice through an avatar to the audience to help with their public speaking skills. I'm getting myself tongue-tied. Perhaps I need to go back into the virtual reality modem myself. Okay, next slide. Virtual reality simulation training at some of our sim centers. We have several of these across the DoD. I also want to point out that the VA has a state-of-the-art one down in the VA Orlando Medical Sim Center. Next slide. Okay, index of programs on the horizon. What's coming? We have some exciting stuff in the future. Next slide. We have tele-exercise physiology. Next slide. Where we basically have our active duty troops, they come into the fitness center, the gym, they get on the treadmill. We have the treadmill wired with software programs with sensors and with video cameras set up on the tripod and we can take measurements. We can do gait analysis. All of this can be beamed to a sports physiologist or a sports medicine doc and that virtual appointment can be done in an enhanced fashion because we have some biometric data to go by in addition to the physical exam. Next slide. We do this with tele-pharmacy. Our pharmacists cannot be at all locations. We have multiple satellite locations across the bases and so the pharmacist in fact can be in multiple locations virtually. Next slide. Tele-pulmonology. I mentioned in tele-cardiology we did everything that's in a cardiopulmonary lab, but we've also added PFTs, pulmonary function tests, to that as well. So in effect tele-pulmonology. Next slide. Tele-genetics, as Dr. McKay already touched on, Air Force has started to begin building the personalized medicine, personalized genomic database. Next slide. We had some 6,500 active duty members who volunteered to start their personalized genome for testing and that database is being built. This is our closest foray into what Dr. McKay would be interested in in terms of big data and this is only of course going to get bigger and this is pretty much going to be the future of medicine. This is all being run out of our bio, our genome project and our bio genetics lab at Keesler Air Force Base as I previously mentioned. This will all be in-house data so as not to be commercially available but secure since it is active duty members. It is specific to the active duty readiness force in terms of the data that we're collecting. Next slide. We're doing a lot of research in the field where we have these little carry packs, backpacks, telehealth in a bag if you will. These are being field tested. Next slide. We have several research projects that are being done in the field as well as in the lab. Now we have telehealth and technology research center here at Fort Dedrick in Frederick, Maryland just north of Washington, D.C. where a lot of this stuff is being done as well as the Air Force Research Lab in Dayton, Ohio. Next slide. This is an example of one of the things that's being field tested. This is a ruggedized telehealth kit akin to everything that you have in a big cart in the hospital but it's in basically a suitcase. This thing is ruggedized so we can have a Marine throw this off the back of a truck in the desert and it won't get damaged. You pick up a satellite link and you can do point of care injury with a specialist. Next slide. Mobile telemetry. This is where you can do labor and delivery, the contractions, the fetal heart monitoring and whatnot and you can have it be to the OBGYN who is on call at home and they can pick it up the telemetry there on their smartphone. Next slide. This one here is actually still in prototype still being field tested. The idea of basically enabling your smartphone to take a magnified image of a microscopic slide, a blood test say for instance if you're in the field testing for malaria or TB or other parasites and then the stuff is the captured digital image is sent back to a pathologist who's sitting in a medical center stateside and can give you the interpretive report since you don't have a laboratory out there in the field. Next slide. The telemedicine portable cart. You're familiar with these. This is the specialist making rounds virtually through the mobile cart. Next slide. We have the same version of it but this is equipped for aeromedical evacuation. These are our flying ICUs that the Air Force has. Next slide. The wireless stethoscopes that can be used with the telemedicine kits. Next slide. The mobile webcams which can be handheld. They can also be mounted on the helmet or on the visor of our troops in the field, our medics, our first responders. Next slide. Future telehealth innovations also include the Da Vinci robot telesurgery which everyone is pretty much aware of at this point. Next slide. We have vaccine mediated disease gene therapy which is very exciting obviously with the new message the success of the messenger RNA vaccines against COVID. This is really where we're going to see this take off. Next slide. Nanotechnology mediated cell specific diagnostics molecular level imaging and directed pharmacology. We are not doing anything with this clinically yet. This is still just in the research phase at the Air Force Research Lab. Next step. Next slide. Smartphone applications as I indicated those are developed at our research center in Tacoma, Washington. Next slide. We have this available. Our medics use it in the field an adapter to their smartphone for doing ultrasounds in the field. Next slide. Again telemetry not only to your mobile device but also to your smartwatch, your smartphone. Not only the fetal monitoring like I said but even EKG and continuous cardiac monitoring. Both as a diagnostic tool and as a monitoring tool. Next slide. And then of course with all the wearables and all the Fitbit technology where you can track vitals not only to your own smartwatch but this can then be beamed to commanders so that they can keep the vitals and the biometric and data on all their troops in terms of readiness and it helps with field operations. Tracking everybody's sleep cycle, everybody's activity level, everybody's hydration level, etc. Next slide. And then of course 3D printing for prosthetics. Several major medical centers around the country doing this. You know Massachusetts, Texas in particular come to mind but also at the Walter Reed here at Bethesda for prosthetics for wounded warriors. Next slide. And of course the digital pill transmitting to external wireless receiver. This is still in prototype phase. Next slide. And then the XPRIZES which our telehealth and technology center always makes a go at. The first XPRIZE there decoding the individual human genome under a thousand dollars that one has been given already. I need to update my slides. The second one there the little more sci-fi is the Tricorder like the Star Trek scanner. A wireless mobile platform for self-diagnosis basically you know you're talking about an MRI scan in your pocket. So we'll see if they can come up with this one. Next slide. And then Google Glass didn't really take off in terms of the public but there might be a role as a so-called third hand in the OR sort of as a complement to the da Vinci robotic surgeries. And so we'll see how this plays out. Next slide. And then lastly here I skipped over we do have therapeutic video gaming for patients suffering from mild TBI as part of their neuro and cognitive rehabilitation. But we also have what's coming is training digital gaming for actual physicians to use. Here's a screen capture of one of the early ones for cardiology. And I think that was my last slide. I did it in just over by a couple minutes. Apologize for that. That's all I had. That's our whirlwind tour of what we're doing. I know it was very Air Force centric but it also applies to everything that the Army and Navy is doing DODY and then the VA as well. Thank you. Good afternoon. This is Ryan Vega. It's a pleasure to be with you all and just to continue on from the two excellent presentations we just heard of. I'll try to keep this a little bit more practically focused from the lens of healthcare innovation particularly. As you can see there are no shortage of ideas or solutions entering into the market. And the reality is simply that majority of them will not become standard of care or scale which is true of all sectors of the economy for innovation. An enormous amount of solutions particularly in the tech space will enter the so-called valley of death. And it's important to explore why particularly in the era of rapid evolution only accelerated by a pandemic and what that means for healthcare and what it means for graduate medical education and training and also what it means from a regulatory standpoint even in the VA considerations that have to be made despite the fact that we enjoy an enormous amount of opportunities that some of our commercial partners or academic health systems don't. So if you go to the first slide, I'll just briefly introduce you all to what connected care looks like in the VA and add the caveat that my teammates and my colleagues Neil Evans, Kathy Frisby and Kevin Galpin who really drive this work are really doing a tremendous job and have done so. And you'll see just by the sheer volume of growth that this sector of care has seen. And it really encompasses some of their core strategic goals and it's more so than just about telehealth. It's how does this modality of care actually become part of the overall experience. Meaning that in the same way that I FaceTime my parents, my kids' grandparents back home in New Orleans as the way that we communicate with them and we don't really think twice about it, how does that become part of the way that we experience health care. I know you may say well the technology exists today but there are two things in my experience from an innovation standpoint that will make or break whether these things take off. It's the workflow meaning how easy does it work. Does it actually work within the existing workflow. So for instance if you had to go to a corner light post to dial up Uber and you couldn't just do it in the comfort or convenience of your phone, what's the real competitive advantage over public transportation or taking a taxi? Not much. So how do new workflows evolve such that they become more effective and efficient in the way that we both either experience care as an evolving consumer or as a provider how we deliver it and then incentives. There's got to be some incentivization to utilize this which is where the regulatory component comes in. How do we pay for it more on the commercial side but even in the VA. How do we reimagine the way that we pay for care both within the VA and through our community care contracts to incentivize when appropriate the use of more digital or connected device care or more comprehensive care using non-traditional face-to-face or in-hospital. Next slide. So you can see that it spans a really broad range of the continental U.S. including some other territories and includes just everything you can imagine from tele-mental health to tele-sleep to tele-critical care which is inside the hospital locally to nationally and then moving into the home. Next slide. This is just a look at the volume and the growth. So tele-health has been around for a while. This isn't a new technology but you can see certainly that the pandemic accelerated not by the thousands but by the hundreds of thousands. Volume growth in clinical videos thrown forward in actual video encounters in the home obviously out of sheer necessity but does beg the question where do we go from here? When you go from averaging 30,000 to 40,000 to 700 and now we're close to a million encounters per month, it's hard to see that you're going to go backwards. Finding the balance of what this will look like is going to be part of the trick. Next slide. And you saw this sort of encompasses a large array of what we mean when we say connected health and it's both digital, it is both telephonic or virtual. It's all encompassing from these types of modalities and they can range from text message guided cognitive behavioral therapy to the ability to schedule an appointment directly with your provider. We're going to go to slide 10 and focus on one particular innovation. Next slide. I believe it's slide 10. Next slide. Stop here. Thank you. So I want to focus particularly on this project and the reason being is I can walk through sort of the evolution of how we got to where we are with remote temperature monitoring for chronic disease management, particularly this is for diabetic foot ulcer prevention. The evolving regulatory landscape, how we are thinking about this in the VA and what this means for the future. So this is what you're looking at as a simple format. I like to think of it as a thermometer for the diabetic foot. And what it has the capability to do is to tell us weeks in advance whether or not the patient is at risk for the development of a diabetic ulcer or the reoccurrence of an ulcer. So theoretically, if the patient has a fever, we can intervene sooner. The technology or I should say the concept has actually been around since 2007, 2008. And this is the important part of the story. There was a randomized clinical control trial done in 2007 that demonstrated that the use of thermographic detection, which is basically temperature differentiations in certain aspects of the foot, can lead to early detection of ulcer formation. You may say 2007, that was a long time ago. The world's certainly different. Why did it take from 2007 to now to start to see a proliferation of this actually become used? Well, the predominant reason is it goes to that first component that I mentioned about why innovations fail or succeed, the workflow. In that study, the best technology we had was that the patient had to take a device, hold it to the bottom of their foot for 15 to 20 seconds across multiple different places on their feet. Now, conceptually, how many patients do we really think would actually do that every single day? Now, there's certainly going to be some, right? And my point of this is that we really get excited about the use of biometric devices or wearables and sensors. And we say, well, the Alabama football team, they wear all these advanced biometric sensors and they are able to detect certain changes in the sodium level to know how much hydration they should take. And that's right. The technology is there. But do we think that the Alabama football team and the resources that are wrapped around them look like the average American? Highly unlikely. And so what that lends us to believe then is that these things have to be practical. It has to be easy for patients to use. It's not that they don't want to participate in their care. It's just when you make it impossible to do so or you have a large barrier in equitable access, they're not going to happen. So it took six or seven years for a company to recognize that there was something behind this technology. What they needed to do was figure out a way to make it practical. And so they took this idea of thermographic sensing and put it into a format to where now the veteran stands on the mat for 20 seconds a day and then becomes an equally important component. How do you then get that data and transmit it to be either in front of the clinician or in front of a team of care providers in a way that is actionable? So to pull on that thread slightly, as a provider myself, I'm certainly not really interested in having billions and billions of bits of data of a patient's heart rate from their Apple Watch sent to me. And just to be practical, at three o'clock every Wednesday, their heart rate goes up. Well, so what? Are they exercising? Are they watching a scary movie? I mean, without appropriate clinical context, it's really just noise. And there's no reason to overwhelm what's already a limited cognitive bandwidth with so much data being presented in front of us as to take the data and not to convert it into something other than actionable intelligence, meaning that it's got to be put in front of the clinician in a way or the patient in a way that we can do something about it, that there's a so what. And so in this same context of thinking of if you have a fever, either you call the doctor or you take some Tylenol, I mean, there's a next step, right? There's an actionable thing you can do to intervene that result. That's been a large part of the work since 2017 was to really work to take this information and make it meaningful and actionable, meaning that when we recognize the veteran has a fever in their foot, for lack of better words, that we have a care model and the ability to intervene. And what that has led to is about 90% compliance in veteran utilization of standing on the mat every day, about 78% long-term engagement, that's over the course of years. And we have seen a near elimination, I say near, it's quite dramatic, a near elimination of major amputations as a result of our most complex diabetic ulcers, a 40% reduction in ER visits and a near 50% reduction in hospitalizations for this patient population. Now, there's still a lot of work to be done. How do you get engagement to be 100%? We have to make it easier. We have to make it better and faster in terms of the data transmission. The other thing is how do you make this part of the standard way that we deliver care? There's twofold challenges to that. How do we pay for this? So if this is a, if we look at it sheerly as a durable medical device, there's an argument that it's just like prescribing CPAP. But perhaps there's a better way to look at it. Perhaps that we can begin to look at it as a bundle of the way that we care for diabetics. So where we can start bundling this intervention into a more comprehensive and more cohort-based payment model for diabetic patients because we know it works. And we can begin to incentivize the utilization of it because we know it works. The other thing is how do we also equally begin to train providers in residency on how to not only prescribe and utilize these types of devices and solutions, but how to optimize the integration of them into the way that they will provide care going forward. VA has a unique opportunity in that we train nearly 75, 70 to 75% of the GME workforce across the country. And that's just physician. We have 30, 40 plus other residencies. So allowing us the opportunity to begin to integrate these types of solutions into practice in residency is going to be paramount to encourage and allow physicians to be comfortable. You know, I have a group text message with a number of my good friends from medical school that we still sort of now it's sharing pictures of kids. But during the pandemic when it was taken off, it was interesting to watch the individuals going back and forth about how, these are orthopods mostly, I, you know, pick on them, they had no idea how to use telehealth. Were they even comfortable with using? I mean, they had actually never utilized this. And so they're going back and forth. How do you bill for this? How do you do this? And just watching them sort of interact increases the recognition that we've got to do a better job of incorporating this technology and the use of these types of care modalities far sooner in training. So that physicians are coming out more well prepared and more accepting of these tools as a viable solution. Next slide. There's also a breadth of opportunity to reach and to utilize these types of modalities of care for a whole host of interventions that we sometimes overlook, particularly in the VA. One of the projects we're very proud of that is scaling across the nation is the use of tele-lactation. We have an enormous amount of women veterans who receive care within the community and within the VA, and this is a benefit that we can make available to them through the use of our Video Connect. You can see the impacts and the results there. It's been quite impressive just from 16, the early pilots. I don't have the most up-to-date data now, but it certainly is something that women veterans across the country are now asking for. They're helping actually drive the demand and the spread, and it's a service that we should offer for them, but the system was not necessarily, we didn't have the infrastructure, more or less, to do that. Now with these types of care modalities and technologies, we can. Next slide. We've talked a little bit about virtual clinics, but this is something that we're starting to see particularly as we see the evolution of more advanced telecommunication systems and the evolvement, or I would say, hopefully, the improvement of broadband access across our rural and higher rural areas, the ability to utilize AR and VR for whether it is physical therapy, if it's sort of equine therapy, which is an interesting one, but this extended reality types of care delivery and increasing access to those is certainly something we see as a great interest. The data coming out on a number of different studies around, particularly for physical therapy as well as PTSD treatment, has been relatively exciting, and I think this is something that's going to continue to evolve and something that can happen in the comfort of the patient's home or even at work. Next slide. Well, again, we keep hearing about these types of connected devices. SmartHeart is a 12-week virtual visit. It's really just allowing the patient to undergo traditional cardiac rehabilitation in the convenience of their home or anywhere, and so, again, I think what you're seeing is an evolution and a movement towards taking traditional face-to-face or encounters that occurred in that brick-to-mortar, moving them further beyond or further upstream, not necessarily changing where point of care, how it occurs. It's where it occurs, and it's in the comfort of the home in some instances. Next slide. And I'll just let this be sort of the last two slides. Project Resilience is a really interesting project being driven by a number of my partners in collaboration with Fitbit. It's recognizing that instead of us trying to buy the next device or watch, it's a recognition that people are already using these devices. You have more information that's actually indicative of your health outcomes on your phone than you do in your electronic medical record, and that's true whether you're 18 or whether you're my parents. We know that 70% of health outcomes are attributed to genetics, and socioeconomics are behavior. And until we have genetic profiling integrated into the electronic record, behavior is our next best thing, knowing where you live and sort of some of your factors and your social determinants, and the ability to engage with you more 24-7. Resilience is really about can we look for signals in the large amounts of data that are being generated from devices like Fitbits or Apple Watches and try to start to understand if there are differences or patterns. So this is using AI and machine learning to really try to help sort through signal from noise. And then from there, if we do find signal and doing so quite rapidly, can we test these hypotheses and theories? So it's not so much as we say that's great, you have a Fitbit, we can measure your heart rate, and we should do so. It's what does it mean for us, and how do we move faster into pragmatic trials so that we can understand where there's going to be value for both the clinician and the patient. And Project Convergence is a really exciting partnership between the major telecommunications predominantly in this one, Verizon, Microsoft, and a company called Metavis, which has moved the use of advanced computer spatial technology into the operating theater and using and layering patient's anatomy through recreations in holographic images of CT scans or MRIs. What's really quite amazing about this is now you can layer this over the patient in the operating room. You can almost see below the surface. But what will transpire in the next decade, particularly through telesurgery, is the ability for a surgeon halfway across the world to be sort of seeing inside the operating theater or perhaps even feel like they are doing the operation while guiding a surgeon across the country through the actual procedure. So I'll leave you all with this. I know we're short on time. To move this forward, a lot will need to transpire. There was comments about the FDA. I think they're spot on. We meet with the FDA pretty regularly, predominantly because what you see is you see clearance. FDA clearance. And it's important to note that FDA clearance is not FDA approval. Most of these clearances of these devices are pre-market clearances for marketing. Right? They have the ability to market. But these are not therapeutics. There are a lot of companies now that are coming out. They're going through the 510K clearances. They're getting approval to utilize their solutions, whether they're digital therapeutics or interventions, for actual treatment purposes. And that's really exciting, that we're seeing companies willing to go through either the traditional RCTs or work with institutions like the VA to help move through and obtain the necessary data and the evaluations that are needed and required to know whether or not we're seeing something that's going to have immense value or whether it's something that, sure, it might work, it might not. There's probably very little harm. And they become more of that growing arsenal of digital solutions. And I also think training is going to be absolutely important. How we begin to incorporate the utilization of these types of technologies and care modalities into graduate medical education, getting physicians and clinicians more comfortable so when they come out and they're ready for independent practice, they have more comfort with the tools in their tool belt. I think that's going to be a growing need. I was really excited to see what's going on in UC San Diego, I believe, or UCF around training around this. There are no, again, fellowships in digital medicine. But they're going to be needed, and they're going to be vitally important. So appreciate the time. Again, I think an incredibly exciting moment for healthcare and an enormous amount of opportunity for how we shape what the future of healthcare will look like through just this explosion of technological possibilities. Thank you very much. If our three speakers are able to go on camera and take themselves off of mute, I have a few questions for you. Is there any data on racial and ethnic differences in use of telemedicine options in the VA among patients? You're on mute, Dr. Vega. That is a fantastic question. What I can tell you is the more starch differences that we see are in what we call the digital divide. And unfortunately, you are correct in your line of thinking. That generally does tend to follow along traditional socioeconomic lines and racial lines. And so the unfortunate answer is yes. There are a large majority of rural and highly rural veterans that still have difficulty with broadband access, so including those into the summation of this as well is a growing concern. But then you can also start to segment this out into our Vietnam population where we have an unfortunate high number of homelessness and substance abuse. And so their ability to have access to these types of technologies are limited. They're homeless. And so, you know, what good does it say to be in your care in your home if you don't really have a home, right? So I think these are all things that we need to better understand. The lens through which we view healthcare innovation and technology going forward must contain an equity lens. We must understand how these are developed and enhanced and scaled through a lens by which we don't further create disparities in the system. Thank you. Another question. What is the impact on work satisfaction of providers who practice in the Air Force homes? It seems like there might be an issue with monotony and lack of patient interaction. We actually did in-house surveys for patient satisfaction as well as provider satisfaction for the different telemedicine modalities. And particularly Project ECHO and virtual video visits scored the highest with over 95% satisfaction for both providers and patients. Thank you. And finally, more of a question or an ask is whether the VHA could develop a fellowship in telemedicine at some point. The DOD has a fellowship, tri-service Army, Navy, Air Force with two fellows in the program every year out at Madigan Army Medical Center in Seattle, Washington, Tacoma, Washington. And to whom would our interested parties send an email? Would that be for more information? And those physicians come out with the fellowship in medical informatics. Thank you. I'm not familiar with what the VA has. Yeah, it's a great question. We don't, and to my knowledge, I would foresee that the real opportunity is to create fellowships in digital health, digital medicine, including telemedicine being a component of that. And I think one of the opportunities that VA has because we don't have the traditional state-to-state limitations, I know DOD enjoys this as well, is that you can really advance cohorts and not necessarily have to have people physically in a space to do so. You could do the training in California while it's being conducted out of Fort, in essence, and still be able to see patients because we don't have those same regulatory barriers. And these questions, again, like licensure instances, all of that sort of goes away from a federal perspective. And there's a request if one of you could type into the chat the contact. And then just finally, what are the regulatory and environmental requirements for further development of telemedicine? For instance, licensure issues across the states or for countries for global telecommunications? Well, they lifted, during COVID, they lifted a lot of those restrictions temporarily. I think we would like to see them on a more permanent basis going forward with reciprocity across the states as telemedicine has become more mainstream acceptable. Well, thank you. There are, there's a few more questions. How could preventive medicine residency programs get plugged into the interdisciplinary field of digital health, given their training in epidemiology, or also known as infodemiology, that could be adventations to these efforts? So, how could our community of preventive medicine residency programs get more involved? Dr. Vega, I'll let you take that. The short answer, email me, and I'll connect you to the right folks within VA. Very good. We can, if we have time at the end, we can continue to answer some questions. But I think we should turn our time now to Mr. Brian James, who will give us a presentation on the VA VNC. So, let's start those slides, Stephanie. Brian, it's all yours. Thank you so much. I actually was enjoying that tremendously. So, I was okay. I was really enthralled hearing the different things and the great things that are happening. So, let me just start by saying, wow, what amazing presentations this afternoon. Thank you so much. You know, I'm really excited and honored to show you around and show you what the VA specifically employee education systems, where I'm at, what we're doing with virtual learning, virtual education platforms, and the different pieces. So, if you'd go to the next slide, and you can actually probably skip a couple here. So, that's just kind of an offshoot of the VA VNC, really, to let you see how we are a virtual space and what we can do in these kind of different areas. So, next slide, please. So, you're probably asking, what is the virtual medical center? You know, I keep saying the VA VMC, and I've heard it there. The virtual medical center is truly a 3D learning environment and education and medicine environment for patients, providers, and staff. The VA virtual medical center really does make it easy for veterans, service members, and providers around the world to connect and share information efficiently and effectively inside this virtual platform. It's not VA Video Connect. It's not a telephone. What it really is is an immersive virtual platform for everybody to join together, whatever room. And I'm going to show you around in just a minute here to really get a better feel of, wow, we can do that as an education. Oh, I can meet with a patient in here and do those kind of things. So, the medical center is really trying to implement a vision for virtual healthcare campus for our veterans and our service members with our partnerships. Next, please. The VA, the VMC has been around for over five years now. We have run different pilots, programs, and proof of concepts throughout it. Really, some of the early endeavors that we did was smoking cessation, diabetes programs, sleep, and weight management. We've really focused on where the needs were with veterans and service members alike. I would say additionally, you know, we've taken the feedback from all the pilots, the proof of concepts and the programs that we're running in there to kind of get to where we are today. We started out as a unity-based platform where you had a plugin and it was really challenging and then unity to spirit. So we moved to a desktop application which has been very successful and really a great platform, robust platform for us. But we're really excited. We're in the final phases now within the month, we're gonna be launching our web-based version. The web-based version really goes to the recommendations from the users, both providers, veterans and service members on, hey, we want that easy format so we can get in. Now we'll have a web-based version where they can click register, get a code and jump right in. No downloads, nothing else is needed at that point. And they can connect with other service members, veterans or providers like them from around the world in the VA. What led us to this though, has been a lot of the collaborations and the grants that we've received. One of the first ones we received a couple of years ago and we're calling GIF1 was with the DOD in collaboration. GIF stands for joint incentive funds. We were awarded money and came up with objectives that we wanted to show on how we could really increase the success from diabetes education programs. So we are training certified diabetes educators from the VA and from the DOD to deliver in a virtual platform, diabetes self-management education programs for our veterans and service members. However, one of the biggest things that came out of this grant besides the outcomes, and I'm gonna show you in a few minutes is one we received from the American Diabetes Association, a first of a kind recognition where we can deliver this program in all 50 states. But the other piece which was written in this grant allowed us to upgrade the technology and upgrade some of the things so we can make it easier to use. One of our newer ones, but it's still in full force right now is the second award that we had, the GIF award, the joint incentive funds number two, which is really about cardiovascular health and prevention. This one is really kind of exciting. We are taking junior faculty and hiring junior faculty MDs around the United States to really design virtual programs based on the risk factors. And we're gonna have new learning rooms within the Cardiovascular Health, Performance Health and Wellness Center within the Virtual Medical Center. And I'm gonna give you a quick sneak peek of that in just a couple of minutes here. But both these grants really have led to where we are today and very exciting where we can really serve more veterans, more service members worldwide. And the collaboration, the partnership, I can't stress it so as much with the DOD has been amazing. Partnering with them has really taken us to the next level. Next slide, please. So let me go ahead and I'm gonna take over the sharing here and we're gonna go ahead and jump in the Virtual Medical Center. I will take you to a couple of different areas to start and show you what we have going on. One moment, please. There we go. And as you can see, welcome to the Virtual Medical Center. And I'm just gonna stop for a second. Is everybody seeing the screen okay? And people waving, are the avatars waving at me? Everybody see that? I don't have the chat up. So I'm hoping that I didn't, perfect, awesome. Thank you so much. Awesome, awesome, awesome. So as you can see, welcome to the Virtual Medical Center. We are the avatar-based platform. It's a learning education telemedicine platform being utilized by both the VA and DOD right now. As you can see, we really try to make this feel like one of the areas where service members and veterans are comfortable. We have all the flags. We have the entrance like a traditional medical center. And Dr. Vega, I'm sure you're recognizing, hey, that's Orlando. Yes, we modeled this after Orlando VA to really make it feel welcoming to veterans. And yes, hi, Mike. I see Mike's waving at us too. Spinning around, you can see kind of the entryway. And we've got a busy day going on here today. Yes, there's some people joining us for this presentation, but there's other classes going on too. So it's really exciting when you're coming into here and you can connect with other people. You know, a lot of the veterans we deal with and work with, they don't wanna leave their house. And with this pandemic, it's even taken it to a new level. So this gives them that opportunity to be themselves, be in here and connect with others within the virtual world. Let me start real quick by just showing you a couple of things. We do have multiple ways to connect with people in here. We have hand gestures. So you saw a lot of people were waving at me. And, you know, if I'm doing a program in here and they get the right answer, I can give them a thumbs up. Let me spin around a little bit. So the thumbs up, if we're doing the classes, you know, our diabetes education classes, a lot of times I'm in here, as you can see with my red volunteer vest, follow me, let's go this way, let's do these things. So we can communicate with hand gestures. We have voice over IP. As you can see, the little microphone turned green. So everybody in the virtual medical center is hearing me talk in the lobby now. So we have voice over IP and you can teleport, jump around, walk around, however you want to get around the virtual medical center and show and meet those people and do those things. Up here, we have different ways to also connect. And I know my box is probably black a little bit, but this is the chat area. You can see, holy cow, we have Dr. Gandhi, Sherry King, Carmen, all these people are in here in the 3D world with me currently right now. I can connect with them. I can do a whisper, which is a private chat. I can invite them to a group or I can add them as a buddy. So along the way we can connect and do different things. So when you're working with your patients from a telemedicine, telehealth, just meeting one-on-one or veterans meeting veterans, it's a great way to connect and communicate. As you can see, I can add the chat piece to it too. So now again, we can communicate through chat. We can communicate through a lot of different ways. And I see Dr. Ferry said hi to everybody in here. So lots of different things that we can do within the virtual medical center. If I have a patient in here or somebody, I can connect with them immediately and create an instant meeting. We both teleport to that instant meeting and do different things. The other functions up here is the calendar and the teleport. I'll get to the teleport in a second, but the calendar is really important because the whole idea of telemedicine and working with your veterans and working with the service members to be able to create that area where we can deliver the education, the medicine, whatever program it may be, we have that ability to do that. As you can see here, we can do everything from an auditorium that'll have hundreds of people in it to a conference room, which has that boardroom setting to an exam room. If you're meeting one-on-one with somebody, you might wanna do the exam room. Or if you're looking at, I need a more relaxed area, you can go into the therapy room, which is just a whole bunch of couches or the hero's beach. Where else can you go to have a sunset 24-7 with waves crashing and have a meeting? It's a great location. And we're gonna teleport there in just a couple of minutes here. The other thing I'll say is when you're creating these meetings with this icon, you can make them public-private. You can invite users specifically. You can upload files. So everything that you wanna present. So if we were doing this Grand Rounds in the Virtual Medical Center, all the presentations would be loaded ahead of time. And you can do surveys. So if it's an education program, you know, I came from higher education, you can do a pre-test, post-test, knowledge check along the way. If you're doing medical, you can make sure that that patient in here is really understanding what you're trying to get to them and have that through a survey functionality within the Virtual Medical Center. The last piece, as I mentioned, is the teleport. You can look at a mini-map and see who's all around. Like I see the green dots all around, which is avatars. Or you can do the teleport to location and you can see all the different locations through the VMC and jump specifically right to that area. As you can see, we have 17 people in the lobby with us right now. Real quick, before we start jumping around and going places, I wanna show you some of the functionalities. You can see kiosks, everything is interactive in here. We can click, we can change, we can make these, modify them, they're web links. So we can take you to wherever. We partner with the Veterans Health Library. So all of our information that we have in the Virtual Medical Center is either vetted by the VHL, Veterans Health Library, the VA-specific SMEs that we work with. As I mentioned, Dr. Ferry's in here, Dr. Pogash, they're excellent and they vet this for us. Also, we work with DOD and through their process, they vet the information. So the veteran and you can feel comfortable that the information you're receiving is no different that you receive some other websites through the VA. We have poster boards, we have video boards, so we can vote. If you have a YouTube video you wanna share in there that's vetted through the VA, we can do that. We can post them up here. If you have a poster, we can post it on here. And I can show you right here, the American Diabetes Association. As I mentioned, we received that first-of-a-kind certification through our first JIF grant with the American Diabetes Association. We have this posted throughout the VMC so people can see and say, ooh, ow, look at the validation behind what we're doing here. So we can provide in 50 states a diabetes self-management education program for everyone. Let me jump back to the VMC. And you can see people are following us around. You can teleport, you can go to the event board and find where you wanna go. And everybody say, come over here. We can create groups. We have variety of clinics and centers throughout here that you can use. One of the most important ones we created a couple of years ago was the Health Equity Learning Hub. You can go in there and we have a wall of videos with all different concepts in there and ideas that you can click on and get more information. One of the other things that I forgot to show you is behind each desk, we have avatars. And those avatars are permanent fixtures, but they have eyes above their head. What that is, is an information avatar. So we can load them up with FAQs and different information. So when you're coming in, you can see those things. Let's take a, I'll take a quick breath and I'm going to go ahead and click on the calendar and see the different pieces that we have. I think one of the important areas for you to really look at is the auditorium. The auditorium is where we can have large conferences, large meetings. It can connect with our Virtual National Conferencing Center which is also avatar based, but many things can happen in here. And as you can see, it's built out like your traditional university auditorium or in a VA hospital, an auditorium. As you're presenting in here, one thing I'll show you is you're up on stage, you can see everybody. So when they're raising their hand or they have a question or they type it in, you can see that right away. You can also ensure that I can share the file so you can see, oh wait, we have files in here already. So I can click upload and share it so everybody can see it. I can expand the screen. So if I'm a participant in here, I can make that screen larger so everybody can see too, or as the presenter. And as I mentioned, I can be up on stage making sure that I see what's going on and they can see the presentation right behind me. So very exciting with the auditorium. I mentioned we have different formats too. So one of the other areas that I utilize a lot is our conference room. That one is set up more like an advisory board, more like, I guess the professional meeting room versus one room that's here where it's more education. So let me jump back to the auditorium and then I'm gonna jump right into the next meeting, show you that, and then we'll go around for a couple more places. And again, please in the chat box, and I see chats are popping on there, feel free to add any questions, comments. I wanna make sure that I address them after we're done here and please let me know if time-wise we're running out here, we're okay. Let me go to the conference room. And again, this was a pre-setup meeting that I did. It allows me to ensure that I have the room ready for when the veteran service members or other providers come in and you can see Stephanie and John and everybody's joining us already, joining here. We can click on the board, we can expand it, we can do the surveys, just like that. The other thing to remember, it is all self-contained. So we can add things to the boards in here if you want specific links, but it's also voice over IP. So we have the ability to communicate and talk with everybody in here without adding a second piece of technology, whether it's telephone or another area. So it's really important to ensure that it's all self-contained into this little area. You know, I think the next area I kind of want to show too is where we can go for more of the relaxation in that. We have other clinics that we'll get to, but you know, one of the more used areas throughout the virtual medical center is Heroes Beach. Heroes Beach was designed, you know, when Dr. Dominguez had the vision coming from the Air Force to bring this here, really to create that environment where veterans, providers, service members could go relax. You know, if you're at a conference, where can you go have that drink and talk to the other people? This is kind of that environment where we can go and do those kinds of things. Uh-oh, I am freezing up here. So I hope you guys are still hearing me. Heroes Beach is a wonderful area that just froze up on me. So what I'm going to do is jump to the other location real quick and show you some of the other pieces. So I had mentioned we are going from, and you can see I'm, unfortunately, tell the network may have dropped on that, but we're going from the desktop application version to the version of web-based. This one is click and you're in. Where I am now is in the development site and showing you where the second GIF grant, the cardiovascular health, and how we're going to really revitalize, kind of reinvent what we're doing with the patients. The junior faculty will be creating programs that they'll be running through here, but this is a very different format than what we've had before. Currently, we have a very, and I want to say clinical feel to our clinics and our centers where they're very square. They have the different rooms and it's very structured. Here, we're going to a hub and spoke format where you can really see everything when you come in. It's very open and it's very welcome. Dr. Ferry and her team have done an amazing job creating that environment where, you know, that veteran can come in and get the information. We can come to the computer screen. We can click on that and find what we need. We can watch the videos. We can sit in here and have our meetings going on, or if there's specific areas that you're working on, whether it's women's health or healthy roots, we can go to those specific rooms and do that. And I see Dr. Gandhi joined us in here. She's one of the drivers behind this clinic and a junior faculty that will be developing programs in here, so hi, Dr. Gandhi. You know, this is a very exciting area. The differences between the web-based version and the desktop app will not be seen by anybody, whether if you're in one, you can communicate with somebody in the other. We're going to have both up and running so that it makes it easy for service members, providers, and veterans to get in and do what they need to do in here, find those programs. I am going to jump from here and just kind of show you, see if I can get to some of the other things. We have some really neat areas too. Social media, I know in the other presentation, she talked about the connections in that. We have the gaming area and the social media. So we're taking this virtual platform and putting the gamification to it. And I'll say gaming more than gamification because we have everything from crash cart games that we've developed to different areas. We also have all the social pieces where you can connect on Facebook, Twitter, LinkedIn, all the different areas. So the veterans and service members can do that. We have the big board in the back where we can create, you know, that when you walk in and you have this a hundred foot TV screen with something going on there. We have the board on top that's scrolling that we can add things. So our media center is really going to become more of a focal point throughout the virtual medical center. So veterans, service members, everybody alike can get information. I am going to jump one last time to Heroes Beach as soon as I see it on my thing over here to kind of show you where we're at with that. After this, I will kind of head back to the lobby and answer any questions that you may have. So, as I mentioned, you know, Heroes Beach is that amazing area where, where can you go, have a meeting 24 seven and have that sun setting with you and the waves crashing. You can see, we have fire pits. We have chairs on the beach. The fire pits are set up in a ring. I mentioned voiceover IP. One of the things I really want to clarify because I hear, oh my God, what happens if I'm sitting here talking to other veterans or service members? Only people around this fire pit can hear you. Everything with voiceover IP is proximity based. We are breaking new grounds. Yes, we're not the VA Video Connect or that, but this has not been done on a web-based version like this before with this much detail. So, we're really exploring areas that haven't been explored before in how to have a virtual platform for education, telemedicine and learning. I'm going to go ahead and wrap it up. I will stop sharing, so that way I can get back to the last thing. But the last slide is really just asking if there's any questions. I just want to reemphasize, and I see you waving over there. The Virtual Medical Center is open to all to use. If you have any questions, don't hesitate to reach out to me. If you want to explore more usage in here, we can partner and do those things. Thank you so much, Brian. That was absolutely incredible. We do have some questions for you. Andrew Jones says that this is one of the most astounding virtual realities I've seen for healthcare. How long did this take to develop? Great question. So we have been in development for about five to six years complete. And I don't want to say, it's been taking us that long just to get here. Within the first two years or so, we started running our pilots and our programs. So it's been around, but very small user base. We really wanted that proof of concept. We have not marketed it yet. That's the one thing I will emphasize. You said, it's really cool and exciting. We have not really gone marketing yet. Once the web-based version is released, the JIF grant individuals, Dr. Ferry, Dr. Pogash, Dr. Burke, myself, the DOD, we are coming up with marketing plans and how we can release this. We want it to get out there. So each phase has taken about a year and a half to kind of go through as we're doing different things here, but we have ongoing programs. And I'll just say, Linda Ferry has been doing a program in smoking sensation in here for, I don't know, four years now. So, I mean, there are longstanding programs, but we're exploring. Hope that answers your question. I believe it does answer his question. When do you think the program will be active for veterans and providers? 100% now. We have the desktop application version that you can utilize right now with veterans, service members. You know, we actually have some outside providers that come in to consult with us and talk. So it is absolutely, and one of our partners here, the ACPM, you know, we utilize partners all around to make sure we're doing it. So it is open now. My email is there, my phone number, that's my cell phone. Don't hesitate to reach out. We can come up with ideas, how to pilot, how to do things and do that. So the web version, which is this, I'm so excited that you can see it in my face. We're not gonna have the downloads. Those pieces will be available within another month or so. So that will be really kind of groundbreaking. So there will be no downloads or computers on your computer. And are there plans to expand beyond smoking cessation, diabetes prevention and cardiovascular disease? Absolutely. And that was just a sampling of some of the programs. I mean, we have advanced care planning programs. We have primary care. We actually, in the web-based version, have added specialty care clinic and primary care clinic and already have been working with VA and outside people to really come up with what are the next programs that we wanna run in here. As I mentioned, it's open. So if a program office or somebody has an idea on what they wanna do, all they have to do is reach out. We create the plan. You know, we can do some development. And the one thing I'll say is not a lot of development's needed. If you wanna run education programs, you pick a room, you run them, you do those things. We can load information and we can document. So there's a lot of ways to do it already. Thank you, Brian. Just going back to a previous question for our three former speakers, does anyone know how many veterans now have some digital health input through the secure messaging to their providers? Essentially, is this becoming progressively more common? This is not in the VA, but in the DOD, in the Air Force. We have 50% of our eligible TRICARE beneficiaries that actively use their patient portal and their secure messaging with their PCM. Thank you. The presentation on the VA VMC raised a question of as to whether or not there's been any sort of focus group testing or other assessments to determine whether or not veterans find this program to be user-friendly. Great question. 100% yes. After every program we run, we do evaluations with them to get that information. We randomly reach out to people to get information on how we're doing it. We've contracted through one of our JIF grants with an outside source to, or outside group to make sure that we're evaluating, getting the feedback quantitatively about what, and qualitatively about how their user experience was. We really are striving to continue to grow this and make it, and I say a world-class learning platform because the only way it gets better is with that feedback and that information. So yes. The other thing too, and I saw somebody was typing it in there, we had some interesting results so far. You know, we are having an older population of veteran utilizing it more than the younger population at this time. And that's probably because of the programs we selected, but their overwhelming response has been extremely positive. I mean, out of, you know, on a scale of five, there are four to five every time. So it has been a success with the older veteran and now we're going to start going for a different group of veterans too. Fantastic. Thank you. And very exciting. So seeing no additional questions, let's move on to the next slide, which is I want to give a hearty thank you to all four of our presenters today, to the VA and to the DOD for working with ACPM and allowing us this opportunity. We plan to have additional webinars on telemedicine over the next several months. And we'll hope that you will come back and join us. But more immediately, we have a couple of upcoming events. On August 18th, we are having a webinar entitled Get Cooking, Culinary Medicine's Powerful Impact on Nutrition and Health for Patients and Clinicians. And then on September 21st, we're having a presentation on Innovative Technology in Preventive Medicine. Essentially, systems and products that are not necessarily within the federal healthcare delivery system, but more broadly talking about the various types, the strengths, the weaknesses, engagements of special populations. So that's going to be very exciting. You can find information about this, about these on our ACPM weekly newsletter. If you aren't signed up already, please go to the ACPM website and do so so that you can keep abreast of everything that we're offering, not only for our preventive medicine members, but also for population health and public health more broadly. So with that, I want to thank you. Please look out for the event survey that should be coming to you shortly and please complete it so that we can get some, understand how this telemedicine webinar wasn't effective and it can help you in practice, but also we have some open-ended questions asking for additional topics for the teacher. So with that, I'll bid you all adieu and wish you a good rest of your afternoon. Thank you.

telehealth

telemedicine

Joint Incentive Fund Cardiovascular Disease Prevention Project

COVID-19 pandemic

digital health

patient-centric design

US Air Force Medical Service

teleradiology

telecardiology

teleconsultations

mobile health applications

Veterans Health Administration

telepsychiatry

telepharmacy

tele-genetics