Wolfgang Ward enlisted with the United States Marine Corps fresh from high school in 2001. The September 11 attacks occurred while he was at boot camp. Within two years, he was deployed to Northern Iraq.

He didn't see much action there, but the next year he was sent back to Iraq for another tour – this time to the Sunni Triangle, for an eight-month deployment with the 26th Marine Expeditionary Unit.

"In late 2004, we were getting ready to invade the city of Fallujah," says Ward. "I was a squad leader ... I had a sniper team attached to me, and two Navy Seals. We went in through the south of Fallujah, and within about a week of going house to house in close-quarters combat, my unit suffered from about 75 wounded, and 21 of us were killed in action."

Ward was one of the wounded. "I had shrapnel wounds in my leg and back and second-degree burns on my arm," he says. "I was medevacked in November 2004 to Baghdad hospital and then flown into Germany and then to Walter Reed." From there, he was released, went home, convalesced and "transferred to the VA system in California."

Ward says he's only marginally satisfied with his experiences with the Veterans Health Administration: "On a scale of one to 10? I would rate it as a six."

"The reason I say that is that the doctor-patient relationship is kind of lacking," he says. A civilian family practitioner will help you get in touch with your chiropractor, your personal trainer. With the VA, it seems like you go there, you get your number, you sit down, you wait until your doctor sees you, and he says, 'Come back in six months and go wait in line for your medicine.'"

Ward recognizes that the sheer number of returning service members are a big reason why that's so. "It's an assembly line," he says. "I can understand that. There are so many veterans out there getting healthcare. But it just seems like there can be a better way."

Anytown, USA

With the Iraq War officially over and Afghanistan scheduled to draw down by 2014, and with scores of service members now returning home, an array of innovative public- and private-sector health IT initiatives – EHRs and PHRs, telerehabilitation and telepsychiatry, mobile health and wellness apps, even virtual reality and video games – are at work trying to make that "better way" happen, seeking to improve quality and, especially, access to care.

Nearly 2 million service members have deployed to Afghanistan or Iraq (or both) since 2001. Approximately 20 percent of those who return home will suffer from post-traumatic stress disorder (PTSD) or depression, and some 320,000 of them have sustained a traumatic brain injury (TBI), according to the RAND Corporation.

According to the Department of Veterans Affairs, nearly 90 percent of seriously wounded military service members are surviving. Fifty-four percent of Afghanistan and Iraq veterans are getting care from VA – compared to just 40 percent after World War II.
The demographics of this generation of warriors are striking. Compared to, say, Vietnam, where the draft was in place, the all-volunteer military has led to some skewed numbers with regard to income and geography.

Nearly 45 percent of U.S. military recruits come from rural areas – compared with fewer than 15 percent from major cities. Those who live in "the most sparsely populated ZIP codes are 22 percent more likely to join the Army," according to The Washington Post.

Now scores of these returning service members are coming home to these same remote small towns, where they might not have access to (or even be aware of) the specialty care they need.

Casualties of war

"As the tide of war recedes, we have the opportunity and the responsibility to anticipate the needs of returning veterans," Secretary of Veterans Affairs Eric K. Shinseki has said.

The numbers are sobering. More than 48,000 people have been wounded in action since 2001. About 18 veterans commit suicide each day. The grievous physical wounds and deep psychological scars would be a challenge even in ideal circumstances. But for veterans who might be living in remote towns in Mississippi or Montana, the problem is acute.

"One of the biggest challenges to the current health system is to meet the needs of warriors who may be facing polytraumatic injuries," says Maggie Haynes La Rocca, director of combat stress recovery at the Wounded Warrior Project.

Under Shinseki's leadership, the VA has made big strides to modernize and expand its operations to better serve this massive influx of patients with such a wide array of medical and mental health needs.

The VA Innovation Initiative (VAi2) seeks to transform it into "a 21st-century organization that is people-centric, results-driven, and forward-looking, laying the foundation for "safe, secure, and authentic health record interoperability."

VA's advances with VistA open-source EHR, Virtual Lifetime Electronic Record (VLER) and Blue Button initiatives have been well documented. Its joint iEHR with the Department of Defense (DoD) holds even more promise.

Recently VA has also made some news with its telemedicine initiatives as it works to bring care to veterans in far-flung corners of the country. On July 12, it announced the rollout of the Specialty Care Access Network-Extension for Community Healthcare Outcomes (SCAN-ECHO), which will deploy video conferencing equipment to rural and underserved locations. (See Kate Spies' story, page TK.)

Fortuitously, also in July, a bipartisan group of more than a dozen members of the House of Representatives introduced the Veterans E-Health & Telemedicine Support (VETS) Act of 2012, which aims to allow VA care providers to deliver telemedicine services across state lines. The law would circumvent "overly cumbersome location requirements" that "make it difficult for veterans – especially those struggling with mental health issues – to get the help they need and deserve," wrote the bill's co-sponsor, Democratic New York Rep. Charles Rangel.