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Improvements in Brain Injury Data Collection

A Veteran with TBI working with a therapist

VA Advancing Technology in Health Care.

By Hans Peterson
Tuesday, March 8, 2016

Improvements in Brain Injury Data Collection

VA Advancing Technology in Health Care.

March is Brain Injury Awareness Month. The Veterans Health Administration has a Polytrauma System of Care to treat and care for Veterans with Traumatic Brain Injury (TBI) and you can learn more about TBI here.

Depending on their health care needs, Veterans with TBI can receive treatment at one of the specialized rehabilitation programs in the Polytrauma System of Care, or they can seek treatment through their local VA Medical Center or community healthcare providers.

Leading-edge Software Tracks Veterans with TBI

VA maintains a “Traumatic Brain Injury Registry” to monitor Veterans, who may have sustained a brain injury, in order to provide early medical intervention and to prevent long term health problems.

“The Traumatic Brain Injury (TBI) Registry software application collects data on Veterans who participated in Operation Enduring Freedom and Operation Iraqi Freedom,” according to Joel Scholten, Director, VA Physical Medicine and Rehabilitation. “These individuals need to be seen within 30 days of a positive TBI screening result for a comprehensive evaluation and development of a plan of care, as indicated.”

The “TBI Instruments” are a set of comprehensive evaluation questionnaires and templates designed to let rehabilitation professionals assess patients and collect standardized patient information. The information collected from these instruments is electronically transferred and stored as a medical progress note in the patient’s electronic record and can be retrieved through the Computerized Patient Record System.

“Highly trained clinicians develop an individualized care plan for each Veteran to best meet their needs.”


A Veteran with TBI working with a therapist on the computer

Leading-edge Software Tracks Veterans with TBI

Prior to release of the Comprehensive TBI Evaluation (CTBIE) template, evaluations were documented through traditional text notes and local templates. The CTBIE was developed by clinical and research subject matter experts, and established a consistent format and content for VA TBI evaluations. The online evaluation template was originally released in October 2007 with periodic updates to improve data collection and accuracy of TBI diagnosis.

Dr. Micaela Cornis-Pop adds that, “The availability of a national template ensures that patients and family members are evaluated using the same approach across VA medical centers. The use of electronic templates ensures that VA provides a standardized approach to diagnosis while still allowing our highly trained clinicians to develop an individualized care plan for each Veteran to best meet their needs.” Cornis-Pop is a VA Speech Pathologist and program manager of the Polytrauma System of Care.

A younger disabled Veteran with TBI in his wheel chair, visiting the community and surrounded by children.

More Progress in Treating Veterans with TBI

VHA has now screened over one million Veterans for TBI. Screening Veterans for TBI and helping them to deal with the condition is one of the central programs of the Polytrauma System of Care.

VA’s Concussion Coach Mobile Application is enabling Veterans to assess symptoms and also provides coping strategies. The app was developed to meet the needs of Veterans and others who have suffered mild to moderate concussion associated with TBI.

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