Strengthening the intellectual foundation for our profession of arms.
December 6th, 2016 by Nick Alexander
‘…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.
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.
The ‘Virtual Hospital’ provides a platform that tracks:
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;
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
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:
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:
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.
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?
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.
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.
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