Telemedicine techniques, which include remote assessment, are showing promise as means for increasing services to underserved populations and reducing health care costs. Telemedicine techniques such as videoconferencing and telephone consulting and diagnosis have been shown to enhance care for persons with psychiatric conditions [1-4] and for persons with disability related to a variety of central nervous system (CNS) diseases and insults [5-7] . Feasibility, acceptance, and reliability of telemedicine techniques have been documented, with evidence that such techniques are not only cost-effective but improve quality of life [8-10] . Telemedicine-based medication monitoring has been implemented in several general medical populations, including diabetes, heart disease, and HIV [11-15] . These studies have demonstrated not only feasibility but improved compliance with medical regimens [12, 16-18] and reduction of adverse health events [11] . To date, there are no studies of telemedicine-based medication monitoring in rehabilitation or neurological populations.
The objective of the current study is to develop and evaluate a system for remote assessment of cognitive and neurobehavioral status to be used for monitoring of psychotropic medication effectiveness. Tele-based cognitive assessment has been conducted successfully over the telephone [19-21] and via video-conferencing [7, 22] . Studies comparing cognitive assessment using face-to-face, faxing, videophone, and videoconferencing methods have generally found them to be comparable [23-25] . Furthermore, telemedicine-based assessment and diagnosis of psychiatric symptoms and emotional functioning has been found to be feasible and reliable [3, 4, 26-29] . While studies to date have used telemedicine for diagnostic screening, cognitive assessment, psychoeducation, and supportive psychotherapy [6, 7, 30] , these studies have not remotely assessed change in neurobehavioral status related to medical interventions.
Computerized cognitive measures suitable for telemedicine applications already exist. The Automated Neuropsychological Assessment Metrics (ANAM) [31] has a long history of successfully detecting and monitoring cognitive functioning. ANAM was originally developed by the U.S. Office of Military Performance Assessment Technology (OMPAT) to assess the cognitive side-effects of chemical warfare antidotes and pretreatment agents. Over the past 15 years, NRH investigators have been adapting this technology for use with rehabilitation and other clinical populations. ANAM was designed to measure cognitive efficiency and information processing speed and has been shown in factor analytic studies to measure the same underlying constructs as many traditional paper and pencil neuropsychological tests [32, 33] . In addition, because ANAM is computerized it has several advantages over traditional neuropsychological tests, including cost- and time-effectiveness and the ability to be repeated over multiple sessions with minimal practice effects.
ANAM has been used in many settings to assess change in cognitive functioning secondary to pharmaceuticals or other agents. In military samples, ANAM has shown sensitivity to cognitive change resulting from the introduction of various pharmaceutical agents including: terfenedine [34] , diphenhydramine [34, 35] , psychostimulants [35] , and pyridostigmine [36] . In studies of migraine headache, ANAM has been used to identify cognitive impairment related to headache and the resolution of cognitive impairment with various medications [37, 38] . ANAM has also been utilized in studies comparing the effects of diphenhydramine and loratadine on sedation, cognition, mood, and psychomotor performance [39] . In a rehabilitation setting, ANAM has shown sensitivity to both cognitive enhancing and impairing effects of medication in traumatic brain injury (TBI) [40] .
In addition to cognitive assessment, assessment of emotional and behavioral functioning is critical to determining the effect of medical intervention or environmental stress on overall neurobehavioral status. Measures such as the Beck Depression Inventory (BDI) and the Beck Anxiety Inventory (BAI) have been used widely to determine change in levels of depression and anxiety secondary to pharmaceutical intervention [41-43] . The Frontal Systems Behavior Scale (FrSBe) [44, 45] is a commonly used measure to track disturbance in emotional regulation, including disinhibition, apathy, and dysexecutive problems commonly seen secondary to mild traumatic brain injury and other neurologic insults. Finally, the Symptom Checklist (SCL-90) is a standard measure for tracking general psychiatric symptoms and has been frequently used in trials to track medication effectiveness [46-48] . These measures in addition to measures of fatigue and acute stress disorder will be integrated with the current ANAM battery and will be Internet enabled with provisions for multiple data inputs (i.e., keystroke, video, microphone) in order to create a multidimensional assessment tool that can be administered across multiple settings.
This computerized assessment system has direct implications for clinical service at NRH. Specifically, pharmacologic treatment of neurobehavioral disturbance following traumatic brain injury (TBI) and cerebrovascular accident (CVA) is showing great promise for reducing disability. To date, a wide range of medications have been examined for treatment of cognitive and emotional disturbance following TBI and CVA [50, 52-55] . Because TBI and CVA inherently produce heterogeneous behavioral and emotional profiles, the effectiveness of pharmacotherapy for these individuals are subject to a great amount of individual variability [49, 50] . Therefore these individuals need to be closely monitored on a patient-by-patient basis to determine that they are receiving the appropriate medication and dosage to treat their individual symptoms. Traditionally, such monitoring requires tracking multiple factors (cognition, mood, side effects, functional status) over regular intervals within a traditional clinic setting [49] . However, many individuals, particularly those in rural areas or with inadequate access to transportation, have difficulty accessing these services, and as a result may not be prescribed these medications or may remain on an ineffective medication for too long. This project would develop an efficient, remote-based, and cost-effective system for tracking subtle change in cognitive and behavioral functioning. Such a system could be used in the traditional clinic setting, in satellite clinics, and ultimately within the patient's home.