Strengthening the intellectual foundation for our profession of arms.

Idea Pitch – Deployable Health and the Internet-of-Things: Ground Up Recommendations for the ADF’s Deployable e-Health Management Systems

December 6th, 2016 by Nick Alexander

Introduction

‘…compassion and technology aren’t necessarily incompatible, they can be mutually beneficial… machine oddly enough may be medicine’s best friend’

Dr. Atul Gawande – Complications1

I am first and foremost a clinician (a physiotherapist to be exact) and as such, above all else, my commitment to the ADF is the provision of the highest quality healthcare I can provide to soldiers. I am also a huge science fiction geek, a Whovian to be exact, and this year I have been on a journey of discovery that has brought my two passions together. I have discovered that technology I thought belonged on the screen alongside ‘the Doctor’ and his companions, is in fact readily available (or not too far away) and has the potential to radically alter the way that the Army and ADF provide healthcare in the deployed environment.

Fig 1. Controlled chaos in Resus – 2nd General Health Battalion (2GHB) Ex Giant Viper 2016

The Importance of Digital Health Knowledge Management Systems in the ADF

Working in austere environments makes the delivery of military medicine a unique challenge in healthcare. To address this challenge, adequate administrative and procedural supports must be implemented in order to ensure efficient and effective care is delivered to wounded soldiers.

Military health teams often work in isolation from tertiary health care facilities, caring for seriously injured patients with complex poly-trauma and potentially managing specific tactical or strategic considerations whilst doing this. Furthermore if a vehicle rollover occurred between Brisbane and the Gold Coast, the patient would likely be retrieved by State Ambulance Services, transferred to the nearest major hospital and receive end to end care in that facility. In the military medicine environment a patient with similar injuries involved in a vehicle rollover would likely pass through at least 3-4 health facilities, be transferred in airframes or road evacuation platforms manned by differing units, services or nations and end up in a care facility in another country to that in which they were injured.

This complex process of patient management can be referred to as a Land Based Trauma System (LBTS). The complexity of the LBTS increases the risks of delay to definitive care and also the chance for human error – two factors known as key contributors to increased morbidity and mortality in military trauma.2,3

As a means of controlling the additional complexity of military medicine, a large amount of time is spent on implementing and maintaining administrative processes that consolidate the clinical and medical logistic support provided within an AO. Health assets maintain detailed patient records, communication of bed states and critical material levels, regulation of evacuation capabilities and notifications of patient status (as just some examples). The combination of these administrative inputs and outputs can be thought of as a Health Knowledge Management System (HKMS).

Ultimately HKMSs could be considered ‘unsung heroes’ of successful care of battle casualties. These systems need to be intuitive and adaptive IOT reduce the cognitive load on commanders, staff and clinicians alike. In an ideal world they should enable intelligence augmentation, and free-up the human elements of the LBTS to focus on patient care. Ultimately an effective HKMS is possibly health’s greatest weapon in the fight against time and human error and as such, saving soldiers’ lives.

An Experiment in e-HKMS

This year the 2nd General Health Battalion (2GHB) had an opportunity to explore what a digital HKMS could offer to our deployed facility. We were set the challenge of exercising a Role 2 Enhanced (Large) facility for simulated casualties on Ex HAMEL 2016.

To minimise interference in real patient care within our facility, it was decided that a digital simulation should be conducted. To facilitate this, a Microsoft Excel® workbook was developed. This workbook has affectionately become known as the ‘Virtual Hospital’ and it has acted as the Battalion’s first step towards transitioning from a HKMS that revolved predominately around paper, whiteboards and runners but will now hopefully move to smart boards, automated patient tracking and computer based learning.

Fig 2. The Home Screen of the 2GHB ‘Virtual Hospital’

Fig 2. The Home Screen of the 2GHB ‘Virtual Hospital’

The ‘Virtual Hospital’ provides a platform that tracks:

  • Bed States.
  • Critical materiel tracking (blood, oxygen and operating theatre trays).
  • Hospital usage rates and staff fatigue.
  • A database for NOTICAS and MEDICAS.
  • Mass Casualty (MASCAS) tracking.
  • Patient throughput data.

All wrapped in a visual schematic of the facility on the ground.

Though simplistic and still far more ‘mandrolic’ than technologies I’ll discuss later, this tantalising glimpse into the world of digital HKMS’s reaped immediate dividends for our team including;

  • Increased situational awareness (both within our facility and up to higher headquarters) of meaningful hospital state as it related to beds, critical materiel and staff fatigue.
  • Enhanced warning of critical materiel shortfalls such as blood, oxygen and theatre supplies.
  • Real time data capture to inform AAR’s and post incident investigations or training.
  • Simplification of multiple administrative processes into the one platform, improving hospital management efficiency.

Beyond these tangible benefits, trialling the ‘Virtual Hospital’ highlighted significant potential of what a e-HKMS could achieve with regards to big data and computer learning.  If designed and implemented correctly there is great potential for the utilisation of predictive modelling processes to better inform casualty calculation, equipment, manning and patient requirements – all based on recent historical data and the integration of people, things and an advanced ICT network ala the Internet-of-Things.4

Fig 3. Trialling the ‘Virtual Hospital’ Ex HAMEL 2016

Fig 3. Trialling the ‘Virtual Hospital’ Ex HAMEL 2016

So is this Really New and Innovative?

New? No, Innovative? Yes. Within both our coalition military partners, and the civilian health sector, there are many examples of e-HKMS’s and the benefits that they have on patient outcomes. However over the past 5 years it appears that the proliferation of these systems has driven an exponential growth in their power and utility.

A recent article produced by the renowned Cleveland Clinic highlighted a HKMS called ‘Fast Healthcare Interoperability Resources (FHIR)’ in their ‘Top 10 Medical Innovations Most Likely to be Game Changers’.5 This platform is designed to act as interpreter between two or more electronic health care systems. This has the effect of linking clinicians and staff from disparate health facilities, and creates a common operating picture with regards to patient’s medical records, diagnostic results, billing and insurance processes (amongst other factors).  Importantly, it will provide a ‘Decision Support Tool’ for clinicians which is proven to improve patient outcomes and reduce clinical error.

A similar system exists in the US military and is called the Medical Communications for Combat Casualty Care or MC4.6 MC4 is a ‘system of systems’, comprised of joint military, government and commercial health software applications pushed out to US Armed Forces medical facilities and personnel on operations around the world. The applications are augmented by a semi-ruggedized hardware suite and offers US medical personnel with the below capabilities:

  • Access to personnel e-medical records across the battlespace from the integral medic right back to tertiary military hospitals in the US such as Walter Reed.
  • Patient and material tracking throughout the AO.
  • A semi-automated class 8 resupply tool.
  • Patient accessed questionnaires for post deployment health screening.
  • Clinical reference database.
  • Health intelligence collection and report generation tools.
  • Casualty regulation systems.
  • Hospital management systems.

This system has been used successfully on operations in the Middle East, and due to its ‘system of systems’ construction is able to adapt to emerging software and evolve as required.  Furthermore a bi-product of its enhanced interoperability between clinicians, commanders and health planners has been a significant improvement in the orchestration of health resources to missions.

Could there be Moore?

Whilst FHIR and MC4 sound amazing, the most magnificent thing about adopting a technological solution to deployed HKMSs is Moore’s Law. In laymen’s terms Moore’s law states that the processing power of computers doubles every two years.7 For technology like an e-HKMS this means that almost everyday industry is finding more ways to harness the power of computers to make human’s lives easier and in health, potentially give us greater accuracy and competence in care. It also means that any e-HKMS we adopt in the ADF needs to be adaptive to some of the developing technological advancements that could add to our foundation system.

Some of the future considerations for the ADF’s e-HKMS could be:

  • The use of machine learning, linked into a big data source like the US DoD Trauma Registry8 giving clinicians a decision support tool with regard to expected number of blood products, or length and type of surgical procedure required for a patient injured on the battlefield, utilising only the inputs from a ‘9Liner’.
  • RFID tracking of materiel, patients and even staff within deployed heath facilities via barcodes in their patient wrist bands or on products.9 This provides completely automated patient tracking systems, and immediate digital input of resources used on individual patients to feed the ‘big data’ that drives the system (creating even greater accuracy).
  • Live feeds of basic troop measures of health such as temperature, heart rate, blood pressure, respiratory rate, and activity levels via integration of advanced health wearables as thin as a strand of hair.
  • Patient monitors and defibrillators that are linked directly via data, radio and video link across a network of health facilities allowing the person with the right skill set, to provide the right care advice, at the right time no matter where the patient is in the AO.10

Once again these capabilities are being explored and implemented both inside and outside of health right now. All we need is the framework, the software, the hardware and the vision of what the ADF health services needs to develop a truly revolutionary deployed e-HKMS.

Fig 4. Waiting and Ready – 2GHB Ex Hamel 2016

Fig 4. Waiting and Ready – 2GHB Ex Hamel 2016

Why are we Waiting?

e-HKMSs are on the radar of the Australian Defence Force Joint Health Command. In fact it is one of the major projects in motion as part of JP2060 Phase 4. The rub however is that it is unlikely to be rolled out until 2020/2021. This brings me to my pitch for DEFx. An advanced e-HKMS is too important in ensuring best care to our soldiers for us to wait 5 years before interoperability of the LBTS is achieved.

As such I am going to pitch the need for an accelerated acquisition of a ‘proof of concept’ version of elements of the ADF’s e-HKMS. It is my belief that early testing in lockstep with the ADF’s health units has the potential to shorten the R&D loop and hopefully reduce the overall time to end stage product, thereby improving clinical outcomes for soldiers through reducing time to essential care and reducing human error.

So what do I need from you?

  • Do you have examples of large scale projects that have used a ground up approach to R&D with good success?
  • Are you aware of any other ICT that has the potential to positively impact deployed health care delivery if integrated into an Internet-of-Things network?
  • What concerns would you have about having a completely digitised health care system in the deployed environment?

About the author:

Nick Alexander is a Royal Australian Army Medical Corps officer who holds a Bachelor of Physiotherapy with post-graduate qualifications in Complex Pain Management (which he puts to good use to ease the pain inflicted by spreadsheets). He is currently posted as Officer in Charge (OiC) Rehabilitation to the 2nd General Health Battalion in Brisbane.


Disclaimer:

Grounded Curiosity is a platform to spark debate, focused on junior commanders. The views expressed do not reflect any official position or that of any of the author’s employers – see more here.


Notes:

  1. Gawande, Atul. (2002). Complications : a surgeon’s notes on an imperfect science. New York :Picador
  2. Parker, P. J. (2007). Casualty evacuation timelines: an evidence-based review. Journal of the Royal Army Medical Corps153(4), 274-277.
  3. Bleetman, A., Sanusi, S., Dale, T., & Brace, S. (2012). Human factors and error prevention in emergency medicine. Emergency Medicine Journal29(5), 389-393.
  4. Internet of things. (n.d.). Retrieved November 10, 2016, from https://en.wikipedia.org/wiki/Internet_of_things
  5. News Releases. (2016, October 26). Cleveland Clinic Unveils Top 10 Medical Innovations Most Likley To Be Game Changers – Cleveland Clinic Newsroom. Retrieved November 28, 2016, from https://newsroom.clevelandclinic.org/2016/10/26/cleveland-clinic-unveils-top-10-medical-innovations-likley-game-changers/
  6. About MC4. (2016, April 14). Retrieved November 10, 2016, from http://www.mc4.army.mil/default.aspx
  7. Bell, L. (2016, August 28). What is Moore’s Law? WIRED explains the theory that defined the tech industry. Retrieved November 28, 2016, from http://www.wired.co.uk/article/wired-explains-moores-law
  8. Welch, S. (2014, August 04). Joint trauma system vital link to saving lives. Retrieved November 28, 2016, from http://www.af.mil/News/ArticleDisplay/tabid/223/Article/490635/joint-trauma-system-vital-link-to-saving-lives.aspx
  9. Solutions for Government, Defense and Enterprises. (n.d.). Retrieved November 28, 2016, from https://www.globeranger.com/industry-solutions/solutions-for-government-defense-and-enterprises/
  10. Tempus Pro. (n.d.). Retrieved November 10, 2016, from http://www.rdtltd.com/military-sector/

Microsoft Excel is either registered trademark or trademark of Microsoft Corporation in the United States and/or other countries.

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3 Comments on "Idea Pitch – Deployable Health and the Internet-of-Things: Ground Up Recommendations for the ADF’s Deployable e-Health Management Systems"

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I don’t think that it’s reasonable to assume that it is feasible to implement a HKMS architecture that is capable of covering the LBTS end-to-end. Such a system would rely too greatly on data connectivity that either doesn’t exist or the architecture currently employed wouldn’t support it. That being said a service made available at perhaps a collection center and above might be feasible. The problem faced in this environment though is the need to ensure interoperability with the existing ICT environment, this I think would be the primary reason for the lengthy implementation timeline for JP2060.

Nick great article. I have worked in the health informatics industry for over 15 years and commend you and the team on this concept. However it is worth noting that recently Moore’s law has been widely rejected as plausible with the current boolean processors used in computers. That sort of exponential computing power growth is only plausible through quantum computing; systems far too bulky for your needs. In fact Moore himself and his company (Intel) estimate that the law will be defunct within the next 3 years. Having had some peripheral exposure to the ADF health technology development, there are… Read more »
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