Author: Rob Frazier

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:

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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.

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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

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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

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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

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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