LANDSTUHL, Germany -- Camp Lemonnier, Djibouti, may be over 8,000 klicks (kilometers) away, but following a recent Virtual Health Europe site visit to the U.S. Navy Expeditionary Medical Facility (EMF), Service Members in Northern Africa can now connect to Landstuhl Regional Medical Center with a click of a button.

The visit linked the EMF with medical providers at Landstuhl Regional Medical Center enhancing the EMF's capabilities and virtually deploying LRMC physicians to Service Members throughout the Horn of Africa. With the implementation of virtual health, leaders aim to decrease the number of medical evacuations to LRMC while increasing access to care.

"The ultimate goal of bringing virtual health to EMF Djibouti is to support the combatant commands who reside on Camp Lemonnier," said U.S. Navy Cmdr. Jason Johnson, director of surgical services at EMF Djibouti. "Ultimately we want to better preserve the fighting force by leveraging all available means, virtual health being one that we have yet to tap in to here."

The implementation of virtual health at the EMF will decrease Service Members' time spent away from their units and mission, and expedite the return to duty of those who have to be medically evacuated to LRMC.

"Virtual Health Europe brings providers to that point of need; we're moving information, not moving patients," said U.S. Army Lt. Col. Robert Cornfeld, Virtual Health Medical Director, LRMC. Over 300 providers from LRMC, spanning 42 medical specialties, are available not only to support forward-deployed and remote medical teams in the operational environment, but also Military Treatment Facilities (MTF) across three continents.

According to Cornfeld, the all-in approach saved an estimated 14,000 mission days in 2018 alone, allowing Service Members to remain at their duty location rather than travel for healthcare. Over the last two years, 11,500 virtual health visits took place, connecting military medical facilities at 79 operational sites and 56 stationary medical facilities across three continents. Although it is an Army- funded program, more than half of the servicing health facilities are operated by other military branches. The Bahrain Naval Branch Health Clinic is the most recent MTF where virtual health was established, with 99 visits performed by nine different specialties from LRMC and Naval Hospital Sigonella over the last four months.

"Our role in Military Medicine is to keep the Service Member in the fight," said Cornfeld. "Virtual Health brings the [medical center] to the warfighter."

Overseas military medical treatment facilities and operations are categorized by service capabilities. EMF Djibouti is a Role 2 medical facility, indicating its ability to provide advanced trauma management and continuing resuscitation efforts at the point of injury. LRMC, a Role 4 medical center, serves as the strategic evacuation site for U.S. Africa Command, U.S. Central Command, U.S. Special Operations Command and U.S. European Command. Role Four facilities provide definitive care for patients requiring longer treatment or complex specialty care such as surgery, reconstruction or rehabilitation.

"The Horn of Africa is in a strategic location for U.S. Forces. The down side is that it is quite a distance away from any Role 4 facility," said Johnson. "The EMF is the only Role 2 facility on the continent with computerized tomography (CT) scan capability. Patient movement is always a logistical challenge, whether downrange to us, or from us to our Role 4 at LRMC. The ability to have virtual health consultations helps ensure we are providing the best and most appropriate local care while maintaining our fighting force."

The next steps for EMF Djibouti and Virtual Health Europe are to establish connections between the EMF and Service Members in austere environments, saving thousands in logistical costs and hours lost.

"The biggest impact that virtual health has on the warfighter is keeping them at their job for the longest period of time, and only [pulling] them away if a face-to-face appointment with the specialist is needed," said Johnson. "When [a] face-to-face in-person consultation is required, the provider-patient relationship already exists, streamlining their care and minimizing time away from the fight."

"After establishing ourselves [at] garrison [locations], for the last two years we have focused on operational virtual health," said Cornfeld, a pediatric gastroenterologist by trade. "We go to Role 1 and 2 levels of care, and bring the power of more than 40 specialties at LRMC to the joint warfighter."

The Military Health System is currently developing enterprise solutions for videoconferencing, store-and-forward imaging, streaming media, remote patient monitoring, and terrestrial and wireless communications. In Europe, although the technology behind the virtual exam room doesn't differ much from common video-conferencing applications, virtual health isn't as simple as plug and play, with medics requiring thorough training to take on the role as the hands, eyes and ears of the attending physician behind the screen.

"(Virtual Health) will decrease disposition time in soldiers coming to LRMC; we are now able to streamline their labs," said Dr. Mark Marilley, the first physician to utilize the technology from LRMC with a patient at EMF Djibouti. "Patients can get their data cooking now before the doctors even perform procedures. [And they] can also walk in to the clinic the next morning and immediately schedule procedures without having to be worked into our schedules. It's a positive impact for sure."

Although virtual medicine is drastically changing opportunities in health care delivery, Cornfeld says the greatest challenge is that final mile of connectivity.

"The goal is not only about pointing Djibouti Service Members to LRMC, but connecting forward-deployed teams toward their own organic medical providers," said Cornfeld.

Europe's platform, which utilizes web-based connectivity, makes it easy to connect with doctors around the area of operations, allowing Service Members and their family members to even visit their physician while at home. This ability increases continuity of care and decreases potential for health risks.

"I was a flight nurse in the Air Force and this goes against all my training because I used to (conduct aeromedical evacuations), that was my job," said Judith Parow, Virtual Health Nurse Director. "(Virtual medicine) keeps the warfighter working with their units, because most of these (Service Members) don't want to come back and be away from their team. If somebody needs surgery then, yes, you'll have to come (to a medical facility). But with virtual medicine, at least they can look at the patient and provide a diagnosis. It actually saves the patients' time and the component commanders' mission, because they don't have to send someone up here from Italy for five days when it's a 15-minute appointment."

"We're just starting to really figure the promise of virtual health for our nine million beneficiaries and Service Members in forward remote areas," said Cornfeld.

LRMC is the largest American medical center outside the United States, the only American College of Surgeons verified Level III Trauma Center overseas and is the hub for six community based primary care clinics throughout Germany, Italy and Belgium. The LRMC health system serves over 205,000 beneficiaries, including military Service Members, Department of Defense civilians, military retirees and family members.