Team 3

This week we completed our last round of scheduled beneficiary interviews, effectively signaling that our coursework is in its penultimate stage. One major takeaway from this last week, however, is that the potential for our product extends beyond the Demo Day of April 18th, and we are excited to chase that.

We spoke with student developers and technology consultants, Green Beret captains and communication sergeants, and even a Telehealth nurse. While included at the end of this blog, the summation of these conversations is a validation that the work of this semester has the potential to be successful from three main directions: first and foremost, there is strong runway in the special forces community. Second, that commercial niches are worth pursuing after successful deployment in the military. Finally, that we as a team are heading down the right path from a mobile product development perspective.

As we look ahead, though, we also spent time this week reflecting on where we started. As we will show in our in-class presentation this week, the three versions of our demonstration app reflect the stages of this product development cycle centered around beneficiary discovery. Our group understanding of the military telemedicine landscape was near-zero when we first talked with Cpt. Hinnant in January, and now he is complimenting us on our “fluency with the problem lingo” and is grateful for the progress we’ve made in this relatively short time. In our presentation we will highlight some of the major stages (as well as the notable high’s and low’s) of this experience.

To summarize here, however, it’s safe to say that this project has been nothing like an ordinary “course”. It has been an experiment of our own entrepreneurial, creative, and relationship-making abilities that has doubled as an opportunity to benefit the safety and experience of highly professional men and women in the United States Military. We cannot imagine any greater reward from a short-term, real-world scholastic experience. For that, we are immensely grateful to all of those who make it possible.

______________________________________________________________

Interview Summaries:

(3) Cpt. AJ, SFC AK, LT MC — SF Communications (18E)

• • “The App must have toggle switch for low/high bandwidth”
  • “All traffic outside the version 1 app will be encrypted by the network that already exist, so you don’t need to lose time programming that into your first version”
  • “For photos, you’ll need to incorporate way to scrape any metadata in the app (like geolocating) — this will be important for the security considerations”

(2) Cpt. Drew Hinnant and Cpt. Phil Cotter — SF Team Leaders (18A)

• • “I really see applicability across the whole SOF enterprise”
  • Priority now is getting into a training program (mountain path, SOFACC, or even one of the larger SOCOM rotations). Then look to JCet trainings before full time deployment
  • Action item: schedule demo presentation for day other than 4/18 to show 4th battalion command

(1) Eileen H. — (Maine) Stroke Center Coordinator (specific to Telehealth/Tele-stroke)

• • Test: That EMS teams in rural areas would benefit from our product
  • Result: “Not really…” These types of teams already have well established procedures and channels with the hospitals they serve to do the best they can.

(1) Paul Ford — CEO of Postlight (mobile service and product studio, NY)

• • “Your version current plan is accurate. The app is completely decentralized — it doesn’t require central authority — that’s a great model. This is essentially just smarter digital paper”
  • “As you get bigger, you’ll want to engage with shops like us and we’ll be happy to keep in touch with you. You’ll also want to consider relationship managers (like Salesforce) as you go into version two.”
  • “For your business model, you will surely want to consider (for both version one and two) how you organize, and potentially sell, the injury, treatment, and outcome data.

• (1) Rob Versaw — Product Manager at Wayfair

• • “With user experience, keep in mind the Cognitive Churn — you need continuity of actions with each interface you present”
  • “You get in trouble when you try to bite off too much too soon — its best to address your niche and grow… don’t come out saying you want to take all of it. Showing how you plan to scale is important

(2) Yash and Luke, co-leaders of Duke BlueTech

• • (This conversation was essentially a cost exploration for initial development of our product by vetted student developers)
  • “Over the summer, it may be hard to get consistent buy-in. The app would need to be developed by at least four developers on part-time schedules since everyone on our pre-vetted team has internships they’d have to work around.”
  • Total cost would be low, though, between “$2000 and $5000”

 

 

 

Andddddddd…..

We’re back. Just like that, Spring Break has come and gone. Team 3 is returning to action with renewed vigor, suboptimal tan lines, and a new iteration of TUPAC.

Chief among our work over the last two weeks was thinning out an MVP based on feedback from our marathon day with SF operators during their Mountain Path training exercise. While medics were going through unpredictable prolonged field care exercises, we watched and reaffirmed that a primary need was time-efficiency. One untrained teammate who wasn’t a medic, for example, took nearly 15 minutes to execute a teleconference that should have taken a third of that time for two reasons: they didn’t have the right information in front of them and the support physician on the other end didn’t have their patient’s information readily available either. This is the situation our app will live in, but we also learned during Mountain Path that in order to do so, we had to be more user-friendly than it had previously been.

So, before conducting any beneficiary interviews over break, we set out to create TUPAC “V3”, the latest iteration of the telemedicine app with a central focus on building a “PACket” of information that will be compressible, comprehensive, and easy to create.

After building a new App, we ran a few key A/B tests around 1) messaging, 2) scroll capabilities, and 3) home screen layouts. The results of the latter two are not as consequential as the most former, so we’ll get right to it: We learned from multiple beneficiaries that our MVP is better off to first be deployed as a file-creator, where users can send concise scripts of patient information using a method of their choice, and not as an all-in-one app messenger like our previous versions had envisioned. This does not mean that we do not see that capability in the future, but along our theme of “thinning out” and gaining adoptability, we have decided to focus the experience around creating files that will be easily sendable through already mature communication habits like email.

We look forward to sharing more of our findings and work during the presentation, but also stay tuned for a new team name out of this group on the horizon – its time to make a business!

– Team 3

---

Roger Dail: Former 18D;  CEO & Founder – Ragged Edge Solutions
– Determine a metric that demonstrates time saving between using TUPAC and “hand jamming” the information.
– “The enemy of good is perfect; anything better than what the guys use now is a win.”
– Ensure the PACket, once delivered to a physician, looks like telemedicine script they are used to using/ seeing.

Drew Hinnant: 18A; S3A, 3SFG
– Mountain Path AAR.
– Coordination for potential TUPAC demonstration for command-level leadership.
– Standardize “Medications” such that options reflect current issued drug and dosages.
– Scroll capability is nice; user preferences dictate; Build in flexibility for user.

RC (name withheld): 18D
– Add an ability to share profiles in the setting menu.
– Current debate on colloids and potential for the future; importance of ensuring app is up-to-date with current best practices in medicine.
– In Part 1 of app, merge fluids and bloods together; most medics consider them one and of the same.

Alex Wilson: Former 18D; current Fuqua student
– Importance of reflecting accurate resources available.
– Preferences for scrolling over page view.

Russell Dallas: 18D
– Relevant and up-to-date information on resources slide.
– Indicated preference for sliders and scrolling.
– Supported using other native apps (WhatsApp, Signal, etc.) as a means for sending PACket; in-app messenger not a necessity.

Sean Keenan: Former SF Battalion, Group, and Theater Surgeon;  pre-hospital care SME
– Importance of differentiating between “rank” and “position.”
– Importance of accurately recording certain vitals (i.e. blood pressure); get rid of sliders, or if kept, ensure they have a high level of sensitivity.
– Use the industry standard ADVISOR transcript as the framework for app, not the PFC workflow sheet; importance of ensuring the output mirrors what the ADVISOR docs are used to seeing.

Rich Salve: Former 18D; RN, DUHS;  Ragged Edge Solutions cadre
– PACket compression options.
– For patient history section, use S.A.M.P.L.E. format (industry standard).
– Drop-down option for medications would be easier and more efficient.

CM (name withheld): 18D
– Indicated preference for scrolling.
– Very receptive to using other native apps (WhatsApp, Signal, Wicker) to send PACket over.
– Z-out option is nice to have, not a necessity.

Beck Mitchell: TangoTango
– Discussion of PTToC options integrated w/ existing communication networks;
– Expansion of 5G LTE and high-level assessment of where TUPAC fits in.
– Potential resource for future development.

Mark Schultz: Orion Labs
– AI integration with existing PTToC, and use of bots to automate workflows like TUPAC.
– potential resource for future development.

 

This week, we got to experience the SF telemedicine use case first hand – by observing a live training exercise taking place across North Carolina known as “Mountain Path”.

Huddled in a dark wing of a fifth floor office renovation in Raleigh, we exchanged discussion points and collected key insight that will be shaping the next phase of our product development.

Of the major takeaways from this week, this “out-of-the-office” experience allowed us to realize, and then discuss, a point of iteration for our mobile telemedicine platform. In brief, we need to get deeper into the actual telemedicine needs and shift our focus around providing an all-out clinical care app. This epiphany is not yet considered a “pivot”, as our base ideas are still intact. However, we are walking away from this week of customer discovery with a sharpened problem scope and new design considerations for smoother SF telemedicine in remote conditions.

Below, we share some key takeaways from the people we met:

---

Interviews conducted at 3SFG “Mountain Path” Exercise:

Ryan Maves: SOCOM instructor; Associate Professor USUHS
– Telemedicine best deployed after team has stabilized the patient, after 2nd survey.
– Sometimes it is best for physician to follow patient’s vitals to stay ahead of the complications even when the team hasn’t called the physician.
– Small complications in routine procedures can complicate the treatment, and having a physician to guide the team through would be great.

Doug Powell: Former 4BN 3SFG Surgeon; current Staff Intensivist, First Health Physicians Group
– App ideally can be downloaded in the US that can then be uploaded onto a burner phone bought locally.
– Need a way for physician to monitor each action that the team has performed.
– Simplicity and usability is key.

Jeremy Pamplin: Deputy Director, U.S. Army’s Telemedicine and Advanced Technology Research Center
– BATDOK will inevitably be successful; all other (working solutions) are a waste of time and resources.
– Focused on the “big Army,” enterprise level development, adoption, and integration of technologies.

William Vasios: Former command physician assistant, Special Operations Command – Africa
– Discussed his role in advancing the field of pre-hospital care/ critical care research.
– Discussed trends he has seen in previous PFC exercises, and areas of the exercise where our team might derive the most value.

Roger Dail: Former 18D;  CEO & Founder – Ragged Edge Solutions
– Teams usually have the phone attached to their chest in landscape that they can then flip down to type and read.
– Current methods of paper and pen are inefficient because paper gets torn, ink gets washed off.
– BATDOK works great when used by the techs demonstrating its usability, but few people can use it after they leave.

Rich Salve: Former 18D; RN, DUHS;  Ragged Edge Solutions cadre
-BATDOK is improving usability and can select different capabilities in settings to limit the amount of phone capacity needed for usage.
– Very few deltas receive the training that we observed at Mountain Path
– Fewer use it as a refresher course.

DW (name withheld): Former 18D; Ragged Edge Solutions cadre
– Batdok usually fails after a few clicks and often freeze when all options are selected in settings, especially voice recording and voice recognition
– It is necessary to remember the specific steps needed to get to a specific function.
– Ideal would be to have redundancy in the buttons so that there are more than one intuitive paths to reach the same function.

PL (name withheld): 18D; SOMA PFC Working Group member
– History behind the drive to standardize PFC training, protocols, and resources (ADVISOR Line).

CK (name witheld): 4-3SFG Signals Detachment
– Any solution must meet minimum requirements that ultimately protect a units digital/ electronic signature.

Brad Hayes: Founder & CEO, Aerial Inspection & Mapping Images, LLC
– Provided insight into current efforts to leverage drone technologies during PFC scenarios; talked through strategies his company has taken to overcome the limited communication environment.

David VanWyck: 4BN 3SFG Surgeon; “Mountain Path” OIC
– Need to have a Batdok-like app that works
– Physicians provide advise at around hour 4-5 after injury
– Batdok wanted to test out usability with the deployments, but haven’t been as responsive

JW (name withheld): 18D; “Mountain Path” NCOIC
– Provided candid discussion on why SOCOM and Army Special Forces has stumbled when working to adopt different technological solutions.

Stacey Shackelford: Director, Joint Trauma System (Defense Health Agency)
– Discussed JTS’s role in navigating Title 10 and establishing joint requirements for medical training.
– Discussed JTS’s current efforts to standardize PFC scenario training across the different services.

Sean Kennan: Former SF Battalion, Group, and Theater Surgeon;  pre-hospital care SME
– What do these guys (medics) really need? Focus development on that; teams need an easy way to digitize the tele consult transcript.
– Don’t try and replicate BATDOK

“Kat”(name withheld): PA; 4-3SFG “Mountain Path” team leader
– Provided insight into operational considerations, clinical decisions, and personal feelings around her teams first tele consult experience.

JW (name withheld): 18X, 4-3SFG “Mountain Path” assistant team leader
– Provided insight into operational considerations and personal feelings around his teams first PFC exercise/ teleconsult experience.

NP (name withheld): 18X, 4-3SFG “Mountain Path” team leader
– Provided opportunity to observe and listen to actual tele consult between his team and ADVISOR line.

---

Other Interviews:

Michael Jelen: Director, Berkley Research Group; experience in software consulting
– Reviewed team progress on system architecture plan, advising new efficiency plan for communicating system needs during our final pitch

Matt McGuire: Software Architect & Developer, Protectwise, Inc.
– Provided technical advice on different ways of building a back-end system for TUPAC, and some of the current commercial solutions available in the market.

Drew Hinnant: 18A; S3A, 3SFG
– Reviewed high-level plan for remainder of semester, including Mountain Path exercise and how we could grow from it.
– His outsider perspective of the event, but insider knowledge of how training exercises occur was a major part of our preparation plan.
– Discussed next steps for reconnecting with 18E’s as we build our system requirements document.

 

 

Our focus this week has been geared at garnering as much support from our beneficiaries as we can. We wanted them not only to use our MVP, but also to let other people know about it. To do so, we had to become more accustomed with their methods of operation in the fields.

We have arranged to attend/ observe a training exercise with 3rd SFG (“Mountain Path”) next week in Greenville and Raleigh NC. The exercise is conducted in conjunction with Ragged Edge Solutions; in attendance will be several teams from 3rd SFG, multiple SMEs, U.S. Air Force BATDOK developers/ representatives, as well as key leaders from U.S. Army’s TATRC.

While we want to avoid direct competition with BATDOK (or other TATRC programs), we do want to assess gaps where current programs fall short; we hope to provide alternative solutions to existing products, or integrate where possible. As we get to know our beneficiaries and potential collaborators/competitors more closely, we will have a better direction of how to move forward. Until then, we wait in deep anticipation for the future as we further develop our strategy and MVP.

A huge thank you to the folks who have (and continue to) provide feedback, advice, and recommendations on TUPAC–your support is critical in how we shape TUPAC’s future.

Until next week,

Team 3 TUPAC

---

Rich Salve: Former 18D; RN, DUHS;  Ragged Edge Solutions cadre
– Opportunity to attend Mountain Path, a simulation with 3SFG next week.
– BATDOK and Jeremy Pamplin expected to be in attendance.
– Main POC for urban training lane on Wednesday, 3/6/19.

David VanWyck: 4BN 3SFG Surgeon
– Expectations for Mountain Path.
– Training objectives, key players, coordinating instructions for upcoming visit for next week.

Roger Dail: Former 18D;  CEO & Founder – Ragged Edge Solutions
– Introduction to Rich Salve (above).
– Coordinating instructions for training exercise next week.
– Considerations and planning factors utilized to execute Mountain Path exercise.

Kevin Iskra: Former 18D; current SOF PA
– Landing page should sort by severity. Include injury time.
– For vitals graph, add feature where clicking on each point would get you the value.
– Temperature and CO2 as sliding scale may not be intuitive.

Drew Hinnant: 18A; S3A, 3SFG
– Discussed strategies for approaching Mountain Path exercise.
– Coordinating communication, plans, and expectations.

Jeremy Pamplin: Deputy Director, U.S. Army’s Telemedicine and Advanced Technology Research Center
– Try to understand from technical perspective why people make decisions — what are the key drivers?
– Task analysis — what are all of the tasks they are giving?

Matt McGuire: Software Architect & Developer, Protectwise, Inc.
– Introduction to OSI Seven Layer Model.
– Opportunities to move “deeper into the stack,” w/ back-end development; specific risk/ rewards associated with “deep stack” development (Layers 3 and 4).

 

Michael Jelen: Director, Berkeley Research Group; experience in software consulting
– Discussion on Message Broker (RabbitMQ vs PostgressQL) and full relational database management systems (RDBMS).
– Importance of batching/ scheduling processes to run during non-critical times to sync inventory stock and any other background information that must be available on-demand when an incident occurs.

This week has been an extremely busy week (17 total interviews!) for our team- we have continued to refine our MVP by soliciting feedback from multiple end-users. We developed a second version of the product and are continuing to work through the kinks that we have encountered through last week’s interviews. We have worked to refine both functional and non-functional requirements for our product, with emphasis on back-end architecture to support a working app.

We spoke with several app developers about the requirements to bring our prototype to the real world, and we found that there is a lot more work to do, including storage on the cloud, and interactive communication between devices. As we discover more about our product and the work that’s necessary to bring it to life, we are both excited and daunted about the future.

Thank you for all your support. We couldn’t do it without your help!
Team 3

---

TW (name withheld): 18A
– Focus on making TUPAC as intuitive and modular as possible.
– Anyone one on a given team could use this app, not just the 18D or a SOFACC grad. Situation dictates.
– Early adoption hinges on the ability to integrate TUPAC in SOCM and SOFACC training.

CM (name withheld): 18D
– Use standardized triage categories for patients: Urgent, Urgent Surgical, Priority, Routine.
– Add ETCO2, SPO2, MAP (Mean Arterial Pressure) to vitals input/ tracker.

Kevin Iskra: Former 18D; current SOF PA
– TCCC portion of TUPAC is not necessary; “I don’t have time to use an app when I am conducting tactical field care for a patient;” the real value of the app is in the prolonged field care documentation/ communication.
– Drug calculators are very important; incorporate basic calculations.

RC (name withheld): 18D
– Incorporate a threat algorithm into long-run vital trends; this would offer a backstop for the medic when patient conditions deteriorate, and help focus care plan accordingly.
– SOAP note: “the most important part of my conversation with a provider is the P (Plan); TUPAC should help me convey my ‘P’ when talking with a remote provider.”

Alex Wilson: Former 18D; current Fuqua student
– We need to get TUPAC in front of the cadre at SOCM; they would be a huge resource.
– Incorporate a way to upload/ download drugs and Class XIII; helpful when working in new AOs and the inevitable stress involved in ‘handing off.

Russell Dallas: 18D
– As an 18D, toughest aspect(s) of conducting telemedicine are (1) presenting the patient (what I have done with the patient, time now); (2) my forecast for the future (where I think the patient is going health wise); and (3) what resources I have to treat the patient (if limited resources, how long I can manage current state before running out of resources, i.e. drugs, equipment, etc.).
– With an app – sometimes more (features) are better; sometimes more is more.

Sean Keenan: Former SF Battalion, Group, and Theater Surgeon;  pre-hospital care SME
– Discussion  on necessary additional tools for off-line pediatric drug administration; revised input order for primary data recording.

Brian Smedick: (Outgoing) 4BN 3SFG Surgeon
– Add in MAP to automatically calculate from systolic and diastolic blood pressure. ⅓(systolic BP) + ⅔ (diastolic BP) = MAP.
– TCCC card taking a picture. It would be great to be able to add the vitals trend to the SOAP note.
– Two-way communication on the SOAP note.

David VanWyck: (Incoming) 4BN 3SFG Surgeon
– Upload video in addition to photos on the phone would be really helpful to see pt responses, e.g. flexion vs extension in response to pain.
– Tracking “ins” and “outs” would be vital.

Chris Brezina: Navy SARC (MARSOC)
– Demonstrated App V2.
– Each deployment has individual first aid kit in addition to community health aids. The individual first aid kits include: 2 TQ, pack of 2 chest seals, nasopharyngeal airway, combat-delpaks.
– Include SOAP note ability to voice record patient notes.

Roger Dail: Former 18D;  CEO & Founder – Ragged Edge Solutions
– What does our business plan say we are trying to accomplish? In one sentence, explain how our app provides a specific solution.
– Don’t try to re-create the wheel unnecessarily; find a way to integrate TUPAC with BATDOK – which will inevitably be successful and adopted by SOCOM.
– Invitation to visit RES/ 3SFG “Mountain Path” exercise in March (March 4-8); opportunity to field test/ solicit feedback from provider and practitioners alike.

Eric Malawer: Team 3 Advisor; Comcast
– Our app’s value comes from ownership of the end user.
– Start with the Front end and work your way back, the only way to own the customer is by first focusing on their experience and then finding the ways to make it possible.
– The challenge here is 1) creating knowledge and matching it to experience and 2) how we own the consumer/user.

Wicar Akhtar: Former Head of User Experience, Nokia
– Provided foundation needed to communicate with developer
– Need list to achievements needed in excel
– Development in non-native environment would provide the widest amount of leeway for app development in different environments

Nick Setterberg: Associate Director, Kessel Run
– Prioritize requirements; error on the side of having less features – roust features are typically stripped at the end. Our value/ strength is speed to market/ user.
– Generate a giant list of assumptions before “deploying” prototype (MVP) to beneficiaries, then work hard to validate them; design tools/exercises like “Crazy Eights” and “Dot Voting” are helpful in stimulating user feedback.
– Avoid groupthink when soliciting feedback – no leading questions.

Matt McGuire: Software Architect & Developer, Protectwise, Inc.
– Requirements document – functional and non-functional requirements documentation.
– Non-functional requirements: (1) RPC (remote procedure calls) for message passing; (2) Strong message broker (create a loss-less form of communication) ; (3) Elliptic Curve Cryptology for encryption; (4) Everything should live in the cloud (AWS).

Nick LaRovere: Software Product Manager at a large home security company
– When building out the back-end of our system, we need to look at available frameworks for easier coding, potential code hosts, and good COTS solutions.
– .mil uses legacy code: TUPAC will need to integrate with older systems; plan accordingly.

Michael Jelen: Director, Berkley Research Group; experience in software consulting
– gave direction on how to visualize our development process: determine core database (level 1), create your logic framework (level 2), create system for user to interface with entire stack (level 3).

– planned call for next week with new visuals provided.

This week, we spoke to 13 beneficiaries to further improve our MVP prototype. In a short span of time, we received an overwhelming amount of support and willingness to help. We had developed a telemedicine communication prototype app and through our interview this week, we demonstrated to our beneficiaries its usability.

As we walked our beneficiaries through the prototype, each of our beneficiaries recommended different suggestions and potential additions or adjustments that would allow more widespread utilization among the military. We are excited for our next iteration of the app, as we move forward with our MVP.

Thank you to all our beneficiaries’ support. We won’t let you down,

Team 3

---

Alex Wilson: Former 18D; current Fuqua student
– Ability to add pre-sets of missions to make pre-mission data entry easier
– Group drugs by class
– Drugs are carried in a baggie. It may be possible to barcode the baggies for better tracking when using it

Brian Smedick: 4BN 3SFG Surgeon
– References that can be included: Downloadable Medscape, Ranger Medical Book
– Different equipment bags for different missions depending on the 18D, it would be helpful to have frequent bags available
– Past medical history isn’t important, since deployments mandate health. Most important is blood type and allergies

Doug Powell: Former 4BN 3SFG Surgeon; current Staff Intensivist, First Health Physicians Group
– Include blood titers and possible walking blood matches
– If there’s a way to share the equipment lists, so 18D can collaborate
– Videos can be references, don’t need to be really high quality to save on space
– Advisor coordinator can relay to the physicians

JA (name withheld): Former 18D; current anesthesia resident, Duke University Medical Center
– Focus on scenarios to work
– Best way to improve app is to have folks spend time to thumbing through the app

Kevin Iskra: Former 18D; current SOF PA
– Need a home button
– Drugs often have more than one names. It would be important to have all of them available
– Resources: PFC.org, Ventilators Use Instructions, Emergency Medicine Handbook
– Handwriting the TCCC card is faster. An option to upload the physical copy would be great

MF (name withheld): 18D; current SFSC Instructor, SWTG
– Class VIII instead of tools, Stop Gaps for big ticket items
– Main types of problems: dermatologic, infectious, pain killer,  GI, allergies
– Information that would be helpful with drugs: DD Form 2062 (hand receipt in the Army), Location of drugs (like a safe, or in a different truck, ruck, or person carrying)

PL (name withheld): 18D;  SOMA PFC Working Group member
– A scan and “drop into app” function would be nice
– References: SOFMed Handbook, Ranger Medic, Tactical Medical Protocol (buy it through SOMA), Nursing Sanford Guide
Dermatology guide
– Equipment and serial numbers (nightvision, weapons, etc.)

JR (name withheld): 18D
– Auto populate excel forms into app (i.e. weapons, gear, inventory, etc.)
– As you give/ administer your drugs, app should subtract it
– Near field comms/ barcode would be cool to track

Roger Dail: Former 18D;  CEO & Founder – Ragged Edge Solutions
– Have team list in notes area, e.g. battle roster
– Test BATDOK app
– Must track narcotics

Sean Keenan: Former SF Battalion, Group, and Theater Surgeon;  pre-hospital care SME
– Quantity and type of tools–forces folks to take inventory of what they have. It will be tough to keep folks updating it.
– Barcode scanner is being used right now for organizing medications. Try incorporating a scanner on our function.
– Biggest problem we have is accurately recording data, especially accurate resupplies
– Templates: reference PFC card; patient assessment card from; follow the telemedicine format that is on the ADVISOR transcript

Russell Dallas: 18D
– Time-stamp would be ideal
– Automatic transfer of updates to the hospital would be great, especially if it can help doctors keep track of the team
– Doctors need a way to be alerted, and a way to communicate back in a convenient way

Bobby Collins: 18D
– Provided more resources: Class XIII, Drug lists, 9-line, ZMIST , etc
– There is generally a medical packing list and a surgical packing list

Matt McGuire: Software Architect & Developer, Protectwise, Inc.
– App development is difficult and often require minimum 6 month to 1 year of work
– Amazon web services could be a great way to store data for backend usage. They have apps on AWS that can be used in apps. Downside might be that they have to use constant internet connection

 

This week, we faced the mounting competition in the field of military telemedicine. We had realized previously that there were several other developments in the works that were attempting to do the same thing with acute care telemedicine in austere settings, but we didn’t realize the extent of their efforts. What we learn have made us think more about the direction of this project, and whether we should continue down the path of creating an app for collecting data, or pivoting to another communication avenue that connects existing and future programs.

In the meantime, we have begun a mockup and a separate Android app demo to simulate what our app would look like if we continued down our current trajectory. Similarly, we continued to seek advice through interviews, as we debate the direction of our project in the next few weeks.

For next week, we are going to begin to test our mockup of the app, and determine if we will stay on our current track.

Team 3

---

Jeremy Pamplin: Deputy Director, Telemedicine and Advanced Technology Research Center
– There are at least 10 apps in the works that are trying to solve the same problem that we’re solving, e.g. TATRC, JOMIS, OmniCare, mHealth, TempusPRO, etc.
– Automated documentation would be ideal to help facilitate record keeping
– HIPAA compliance is required, but non-HIPAA compliant apps are both being developed and currently used in the military for telemedicine. Whatsapp is not HIPAA compliant. HIPAA problem has not been solved.

Joe Blanton:  AD Army Officer (SOCOM Acquisitions);  Counterterrorism & Public Policy Fellow (Sanford)
– Introduction/ background on .mil acquisitions process, including subjects like funding, RFPs, development/ testing/ product support
– Barriers to entry for competing for .mil/ .gov contracts – specifically w/in the joint environment (SOCOM)
– Strategies for identifying both unit-level advocates & “snakes in the grass” as we iterate our MVP.

Josh Dickson: LifeLight Paramedic
– Current documentation feels laborious and redundant
– Fewer the buttons, the better
– Half the work is in the documentation: documentation and logistics

Amy Holcomb: Accenture healthcare consultant
– Bite-sized training to prevent need for telemed consult in offline case
– What are the numbers? Quantify medics in SF, of ex: 1:20 medic/patient ratio, Quantify error at patient handoff

Dan Buckland: Emergency physician at DUHS, Director of Duke Acute Care Technology
– Blood-given, mental status → important medical info for doc
– Trends are consistent until they aren’t…. Not key metric, relatively speaking
– Value add is small with some of this tracking
– Value is not in patient management, but purely in info sharing

Rod Greco: CMO of Aquila Med
– Provided thought process for how to convince others that our app has value.
– Cost of change/transition to this solution must be less than the gain it creates — I.e, you need to quantify this gain
– Does it come from productivity? Is there a cost incentive?
– “Every time you save time, you save money” → look into doctor/physician time

Mark Palmeri: Associate Professor of Practice at Duke University
– Burner phones create anonymity, while VPNs “bounces” stuff. Require a combination of encrypting and VPN Bouncing, but order of magnitude of slowing down every time you bounce. Reception and retransmission creates overhead
– Previously, sending a picture sends a ton of redundant data. “What are degrees of freedom for a given entry into a card?” Example: stable/unstable = binary (0,1). We need to map card to all data points. “Encryption scheme is your encoding”
– PGP: foundation for public key cryptography
https://medium.freecodecamp.org/how-does-pretty-good-privacy-work-3f5f75ecea97

 

 

 

The highlight of Week 3 was our visit to Fort Bragg, where we experienced on-the-ground scenarios with casualties, had time to speak with numerous military personnel, and even got to ‘test’ the quality of MREs (Meals-Ready-to-Eat).

We then spent Week 4 synthesizing our new insights from Fort Bragg and continued our beneficiary interviews, where we learned more about the workflow of medical personnel during deployment as well as in-depth communication logistics.  A highlight of our week was also meeting with former Chairman of the Joint Chiefs, General(R) Martin Dempsey. His insight was invaluable to the big picture of our problem and is summarized, along with our other interviews, below.

Looking ahead, we will start to build our initial product based on the architecture outlined in our Week 4 presentation, which will allow us to test greater hypotheses with even more upcoming interviews.

Stay tuned, and God Bless.

– Duke Team 3

---

Matt Runyan: Network Consulting Engineer, Cisco Systems
– Whatsapp constantly tries to make connections
– Other apps can have interrupted messages because of unstable connections

Josh Clark: 18E
– Commercial networking shares data faster but is less consistent; army is more consistent but has slower data sharing
– Heavier encryption worsens signal
– Would be ideal to have photos in app stored locally that can then be recalled separately from photos taken in other situations

Mike Thomas: Military Business Development Manager, GoTenna
– GoTenna is built based on line-of-sight, which makes it possible to relay information via drone (up to 52 miles)
– To get more range, need device offered by GoTenna for short distance mesh networking
– Funding of devices from the military operates on Life Cycle Analysis of 10, 20, or 30 year costs

Mike Fiocca: Former 18D
– Resources e.g. ebooks for non-trauma procedures to save time and resources
– Voices assistance that can operate without internet connection would be helpful
– Protocols and algorithms for all trauma procedures

Pat Butler: Former 18E
– Interconnected devices that would allow for smoother transmission of data
– Redundancies can be helpful to prevent loss of information, but lightening the load would be ideal
– MyVPN is helpful to tunnel through local internet

JA: Former 18D, current anesthesia resident, Duke University Medical Center
– Ultrasound is really useful for diagnosing volume loss
– One of the biggest problems is lack of basic knowledge understanding that then impairs communication between 18D and the support physician
– Notability or similar app has been helpful in the past

Martin Dempsey: 18th Chairman of the Joint Chiefs of Staff
– Product has to not only function with on-the-ground personnel, but also with higher ups
– How to potentially quantify success?

Kevin Iskra: Former 18D
– Doctrine of treatment: Medics treat on the ground, then evacuate to physician’s assistant
– Most time intensive tasks: pulse and blood pressure
– Documentation card or critical care card would be really helpful to transfer data to the next level

Zach Pearson: Team Sergeant
– Need to take vitals at regular intervals. Currently vitals are transferred by taking a photo
– SOFACC can be a beneficiary: closest thing to medic that’s not a medic
– Focus on TCCC: Tactical Combat Casualty Care

Phil K Bohan: General Surgery Resident, San Antonio Medical Center
– Organization of trauma care as they move from the field to hospitals in the U.S.
– Ideal would be more live way of transmitting vitals. Physicians use vitals to decide whether to continue to treat or not
– Blood transfusion, esp live blood banks, can knock the person out for several days from combat

James Horne: former 18A, SOFACC grad, current Fuqua student
– Communications should include the most reliable ones and other fancy modes of communication
– Operational Detachment groups usually consist of 3 people; Operational Detachment Alpha consist of 12 people
– Usually there’s only one chance per day to sync your record or get remote assistance
– Medics have autonomy to adopt telemedicine or not

PL: Prolonged Field Care Working Group
– 2 Types of challenging environments: austere env e.g. Africa, or mega cities like in China
– For vital records, prompts would be helpful, and voice dictation would be useful, but might be problematic in noisy environment esp in mega cities
– “Anything we do has to be layers to the overall solution.”

TO: Former 18E
– Mainly use iridium to connect satellite phones, often to connect with physicians
– PACE plan: mission dependent, necessity for high-threat operational environment, non-necessity for low threat via truck radio or satellite
– Data compressors used include NX powerlite (COTS)

Personnel Interviewed during visit to Fort Bragg:

Aaron Jefferson, Signals Officer
Chandler Merrell, 18D
Dr. Paul Tate, Battalion Surgeon
SFC Michael Goggin, 18D instructer, former 18D
MSG Kevin Schwartz, SOFACC Instructor
LTC David Lewis, SOFACC Instructor
Adam Russell, Instructor, Remote Medical Institute
LT Carl Ellison, 18E
SGT Tim Lanning, SIGDET Operations NCO
Alexi Kotchetov, 18E

We entered this week with a major realization already behind us: that telemedicine is not a new problem-of-interest for the Military. However, we verified that many groups are interested in this field and that work has been, and continues to be, driven by legitimate need from the Field.

For us though, we set out to find ‘how’ and ‘where’ our initial MVP of a mobile app would hold up with our beneficiaries. More importantly, we realized where both existing solutions and our hypothesis alike do not meet the prolonged field care needs of 3rd SFG operators working in austere environments.  The following interview highlights show the insights that led us to what we present as a revised MVP in tonight’s class: A simple, easy-to-use app for tracking only patient information and current medical resources with the aim of creating a more efficient conversation between medics and physicians during a telemedicine consultation. No bells, whistles, bluetooth, or bump-to-share. Just a simple tool for easy adoption and standardization.

Looking ahead, we will be bringing an initial schematic of our app to Fort Bragg  for further beneficiary review. There,  we plan to spend the day learning from 3rd Group members in a variety of settings. Among the exciting prospects, we will get direct interaction with our primary beneficiaries, the SF Medical Sergeants (18D) vernacularly referred to as “Deltas”.

Cheers to another week of progress, see you on the other side.

– Team 3

_______________________________________________________________

Drew Hinnant: Assistant Operations Officer
– Need to categorize and list supplies to rely to hospital personnel
– Video not necessary for communication and rarely used
– Need for diagnosis from medical personnel

Doug Powell: Staff Intensivist at First Health Physicians Group
– Room for AI to alert changes in vitals for need to escalate or potential problems, especially during times when there aren’t medical personnel (wakeup criteria)
– Basic vitals: Blood Pressure, Heart Rate, pulse oximetry, temperature, respiratory rate, mental status exam, Glascow coma score
– Developed paper script for better communication
– App > device. 50% iOS/Android. Don’t need any more devices. Apps can integrate easily into iPhone and iPads that’s already on hand

Dan Taylor: Civilian Paramedic, former medical instructor for Special Operations Austere medical courses
– Austere communications have little bandwidth: voice call is great, good quality picture is better
– Ideal scenario for supply documentation: smart phone to take a picture of what supplies have been used, AI in app to assess what was used.
– People are less likely to use it if it add to their work
– There is rarely any standard to materials that are packed on deployments

Chris Turner: COO – Ragged Edge Solutions
– Difficulty with bandwidths often results in inconsistencies in system use: simple is better
– The best way to approach this might be to gather the pieces, because the pieces already exist, instead of reinventing the wheel
– Security is always going to be hard

Roger Dail: CEO –Ragged Edge Solutions, Former 18D
– Ragged Edge Solutions: Identified gap in concepts coming out of Prolonged Field Care and operations with teams, that there were no standards for training of TCCC
– Network security can be difficult to approach, given the size of the problem and security clearance
– During deployment, medics often only use Whatsapp

Sean Keenan: SOMA PFC Working Group¹ / Emergency Physician
– Telemed script + cell phone > asynchronous communication (relay patient data) > synchronous communication (video communication in real time)
– There are a few procedures that would be easy to do via telemedicine, e.g. fasciotomy
– Telemedicine often is low on tech, because that is what is most reliable and efficient

DE (name withheld): Senior 18D
– Trending vitals is an important piece that’s often done via hand, with instructions for a  “wake-up” criteria
– Hand-off to next level (often Germany) via SF-600 form, which populates electronically for injuries, meds, and vitals, often in combination with SOAP notes
– Most often used technologies are on phones, including WhatsApp and iMessage

Alex Wilson: Former 18D, current student at Fuqua
– Self-printed handoff cards are used often during handoffs instead of SF-600, because SF-600 are often used formally for record keeping
– Medics obtain supplies off of a formulary that’s often an excel sheet, up to 8-10 pages long, and have to order supplies one year in advance
– Monitoring vitals often require physical manpower 24/7. There is electronic monitoring, but it is a physically large and often old.

Brandon (Last name withheld): Lieutenant Commander Physician
– Military physicians also use telemedicine for communication with specialists when deployed that often telemedicine results in a written report returned in 24hrs (asynchronous communication)
– It is possible to get a phone call, but often unnecessary

GS (name withheld): Former Army Reserve, FBI Special Agent
– Communications have historically been an issue outside of the US, so working to solve that issue alone is not worth your time

PFC flowsheet:
https://prolongedfieldcare.files.wordpress.com/2018/05/handout-pfc-flowsheet-v21-1-16jan2018.pdf

¹Special Operations Medical Association (SOMA) – Prolonged Field Care (PFC) Working Group