TTMWL: Episode 12 — “Telemedicine Support During Military Operational Medicine Training” with TATRC’s Director Col. Jeremy C. Pamplin

Training the Modern Workforce Live is a weekly show discussing training and talent development solutions and best practices. Hosted by Allogy CEO Colin Forward, each episode features an informative conversation with a prominent guest in the training world.

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About Col. Jeremy C. Pamplin, Director, Telemedicine and Advanced Technology Research Center

Colonel Jeremy Pamplin currently serves as the Director of the Telemedicine and Advanced Technology Research Center, or TATRC. Before stepping into the role of Director, he previously served as the Deputy Director when he joined TATRC in August of 2018. Immediately prior to this assignment, he began the Army’s first Tele-Critical Care service at Madigan Army Medical Center from 2016 to 2018. Prior to that assignment, he was the Chief of Clinical Trials and Burns and Trauma and the Medical Director of the U.S. Army Burn Intensive Care Unit at the U.S. Army Institute of Surgical Research. He has served as medical director of surgical and medical ICUs since completing his Critical Care Medicine fellowship at Walter Reed Army Medical Center.

Episode Transcript

Adam Wagner:
Hello, everyone, and welcome back to Allogy’s podcast, Training the Modern Workforce Live, the weekly show discussing training and talent development solutions and best practices. Each episode, we’ll talk about a different training topic—and make sure to keep an eye out for special guests and interviews from top training professionals.

With me, as always, I have Colin Forward, CEO of Allogy. For the last decade, Colin has provided major U.S. hospitals and federal agencies with distance learning solutions. He studied mobile technology at the University of Central Florida while earning a degree in computer science and his MBA.

And joining Colin this week is Colonel Jeremy C. Pamplin and Dr. David Rogers. And since one of our guests is a high profile and active member of the Department of Defense, we do need to read a quick disclaimer:

The views, opinions, and/or findings contained in this discussion are those of the author and do not necessarily reflect the views of the Department of Defense and should not be construed as an official DoD/Army position, policy, or decision unless so designated by other documentation. No official endorsement should be made. Reference herein to any specific commercial products, process, or service by trade name, trademark, manufacturer, or otherwise, does not necessarily constitute or imply its endorsement, recommendation, or favoring by the U.S. Government.

Colonel Jeremy Pamplin currently serves as the Director of the Telemedicine and Advanced Technology Research Center, or TATRC. Before stepping into the role of Director, he previously served as the Deputy Director when he joined TATRC in August of 2018. Immediately prior to this assignment, he began the Army’s first Tele-Critical Care service at Madigan Army Medical Center from 2016 to 2018. Prior to that assignment, he was the Chief of Clinical Trials and Burns and Trauma and the Medical Director of the U.S. Army Burn Intensive Care Unit at the U.S. Army Institute of Surgical Research. He has served as medical director of surgical and medical ICUs since completing his Critical Care Medicine fellowship at Walter Reed Army Medical Center.

This week, we’re going to be talking about telemedicine support during military operational medicine training. We’ve got some great questions on deck already, but again, feel free to ask any questions that may come up in the chat, and we’ll try to get to as many as we can. Alright, Colin, over to you.

Colin Forward: Great. Thanks, Adam. And thank you, Colonel Pamplin, for joining us today. We really appreciate you taking the time to have this conversation with us. Telemedicine is just an exploding field right now. I mean, my daughter is about a month old. I can tell you that telemedicine came in very handy over the last month. Just making sure that we were able to take care of our first child is a learning experience, and having that kind of support was very helpful for me in a very very civilian setting.

I think having this kind of conversation with someone like yourself is going to be interesting to the audience for a few different reasons. One, I think a lot of people assume that the military is just years ahead of whatever kind of technology that civilians are benefiting from right now. And, I’m sure that in some cases that’s true, and in other cases, you guys are figuring out what works for the rest of us. And so it’s going to be great to understand the kind of challenges that you’re up against, how you’re dealing with them, and how that is going to affect the rest of us that are either just starting to or looking forward to getting the benefit of this emerging industry.

Before I get into any really specific questions, could you give us a little bit of background on your work in telemedicine, in this space?

What Is the State of Telemedicine in the U.S. Military?

Col. Jeremy C. Pamplin: Yeah, sure. Absolutely, Colin, thanks for the question. And thank you to yourself and to Adam to David to Steve Carlson for inviting me onto the podcast today and for the opportunity to talk a little bit about certainly one of my great passions, which is telemedicine. And congratulations on your child. I’m not sure if I heard if it was a girl or a boy, but very exciting to have your first child. You probably saw me drinking from my mug, and it’s got lots of pictures—the kids always have little gifts to give you.

Yeah, you pointed to the fact that telemedicine has kind of had explosive growth as part of the pandemic really as a mitigation strategy for social distancing, a lot of ways. We’re reducing human contact but yet still maintaining kind of the daily workflow, the task accomplishment that we need to do in order to have adequate healthcare or you to do everyday work. Obviously, telework has also exploded in the same venue as has telehealth.

And in the U.S. Military, we’ve similarly experienced a significant increase in the amount of telemedicine encounters that occur. And I think that’s a value, and in many ways, the civilian space and the military space parallel each other with respect to COVID and to everyday healthcare.

The military has some other unique challenges that are above and beyond but certainly have elements that are important to the civilian sector, as they relate to telemedicine. We often call this space operational virtual health, and it’s the ability to deliver expertise to the point of need wherever that need may be. And oftentimes, that’s in very austere locations—under a bush in the middle of Africa, in the back of a helicopter, in the back of a plane evacuating a casualty from a distant land.

And obviously, those challenges are important for the military, but surprisingly, they actually occur not too infrequently in the U.S. healthcare system too, in some of our rural parts of our country where broadband is not ubiquitously available, network connectivity is not always available, access to the right expert at the right time is certainly not readily available. And the way our current healthcare system is structured in the United States, the technology landscape in some of our larger hospital systems and cities is much more robust than the technology landscape is in the U.S. Military. The ability to access health records, the ability to access video-on-demand, the ability to access appointment schedules, things of that nature.

Outpatient services is much more robust in the civilian world than it is in the military. What is unique about the military is some of the ways we think about using telemedicine to support the caregiver who needs help, regardless of who that caregiver is, regardless of where they are. Which is very different than the U.S. healthcare system that has a lot of self-inflicted wounds related to policy, laws, procedures about how one expert clinician can help another clinician or patient in a different location.

We have rules around cross-state licensure. We have rules around credentialing and privileging. We have a lot of financial rules about reimbursement, and in the U.S. healthcare system, some of those—in fact, many of those—were relieved during the COVID pandemic but certainly not been eliminated as part of this COVID journey.

So I think it’s a mixed bag. The military has some advantages over the civilian sector, and the civilian sector has some advantages over the military. And you asked about some of my journey—I’ll isolate it largely to the COVID pandemic—but our experience delivering telehealth support—the expert to the local caregiver, regardless of location of either the expert or the local caregiver—in the military to help that person who needs the experience, we have been trying to translate that to a National Emergency Telecritical Care Network where we are able to similarly deliver expertise to healthcare systems that might need help with increasing the scope of practice for a clinician who’s otherwise unfamiliar with managing a critically ill patient because either a) they haven’t kept a critically ill patient at their hospital for a long time, they usually evacuate that patient, transfer them to a referral center, or if you are in a referral center, as we saw in New York City and L.A. and some other large metropolitan areas, there are clinicians that may be very experienced and very deep in a subspecialty service but otherwise are unfamiliar with managing ventilators and vasopressors and IV pumps, the things that define critical illness. And we took them out of their standard practice and put them into the critical care environment, and they felt out of their domain. One way to help them is with a local caregiver; the other way is that remote expert.

Colin Forward: I’m going to ask what might seem like a kind of stupid question, but you’re alluding to some of the skills and the knowledge that people will need in this telemedicine environment. And for a lot of us, including myself, like I said, that have recently accessed telemedicine, it’s hard to imagine what telemedicine means other than medicine via Zoom. So can you help provide some more context for what it really means to affect— what the skillsets are for effectively delivering telemedicine?

What Are the Skillsets Needed to Deliver Telemedicine?

Col. Jeremy C. Pamplin: Yeah, so that’s a great question, and I think the first part about that is really recognizing that we use telemedicine every single day. And culturally, in the United States, I’ve been doing this for a while and I’ve asked the question at many of my presentations, “How many people are clinicians in the audience?” Fifty to 75 percent of people raise their hand. “How many people use telemedicine on a regular basis?” And then, 50 to 75 percent of those hands tend to go down in the audience. And then I say, “Okay, how many people have used one of these to call somebody during the day or call a patient or call a family member?” And everybody’s hand goes back up, and that’s technically telemedicine.

We use tools to help us communicate and to help us deliver services all the time. But oftentimes, we don’t bend those tools or those capabilities, those technologies, into the telemedicine bin, for whatever reason. Email, text messaging, photographs, phone calls, and video teleconferencing as well as some of the advanced hardware-installed telecritical care capabilities where you can remotely monitor somebody continuously—you have a pan tilt, zoom camera. All of those fit inside the construct of what is telemedicine.

In some ways, there’s very little training that’s required for doing telemedicine because we do it all the time. It’s just another tool in the toolbox. On the flip side, everybody can look at images. Lots of people will look at EKGs. Lots of people can look at CT scans or MRIs. But we train some doctors out there to be specialists in that service. Right? Radiologists, cardiologists, echocardiologists, echocardiographers—these subspecialty trained individuals really are what we would probably call a virtualist in today’s modern vernacular, where we have certain clinicians out there that specialize in the delivery of telemedicine services. And in that context, there are some important skillsets.

Those skillsets, I think largely can be contained in what we would call, historically, a bedside manner but have really become a screen-side manner. Your ability to communicate empathy, your ability to listen, your ability to convey information in simple terms sometimes or at the right level of the receiver and really ensure that what they have heard is what you’ve said is a strong skillset for telemedicine. A lot of what telemedicine—especially in the military or in the disaster setting—is predicated upon is understanding the context of that local caregiver.

In that context of that local caregiver, their skillsets, their knowledge base, their stress levels, the number of patients they have, the resources they have—all those types of nuanced details around the context that they are in becomes really important for that remote expert to provide consultation in context. And I think the last real piece about that virtualist is related to their demeanor and the ability for them to engage in a nonthreatening, very collaborative fashion over a screen. Because there are many people out there that have probably actually participated in some element of telemedicine or tried to engage with a remote expert, and they’ve had a bad experience with that. That remote expert has turned them off in some way, shape, or form.

It’s because they’ve called them stupid. They have not provided the right expertise. They’ve yelled at them over the phone or over the video. They have done things that, frankly, are just not very nice, and that local caregiver’s response to that is, “Click, I’m going to turn that off.” Right? Or they don’t call back. And that’s the last thing that remote expert really wants to have occur, right?

There are going to be mistakes made at that local level, right? They’re not the expert. That’s why they’re calling the expert. So you have to start with that base understanding that they’re calling you for help, and your goal is to ensure that you’ve helped them as best as they need—not as best as you can provide but as best as they need.

And I think that component of this skillset is really important. It’s a little bit different with consultation than it is with direct patient care. Direct patient care is a slightly different context, but it’s very similar in terms of the skillsets and the training required for a remote expert.

Colin Forward: So everything you just mentioned makes really good sense, but it makes me think back to one of the first things that you said in this conversation, which is in military context and even in a lot of rural American context, people don’t have reliable connectivity. So with that in mind, why should someone feel the need to train on telemedicine? Why should they feel the need to develop these screen-side manners, as you described?

Why Should Healthcare Providers Train on Telemedicine?

Col. Jeremy C. Pamplin: Yeah, because Murphy exists, and as soon as you’re thinking you’re stable on your phone call or your video consultation or even your ability to send an email, oftentimes technology does fail you, and you need to have backup plans.

You need to have a PACE plan: primary, alternative, contingent, and emergent plans. What do you do when the technology has a limitation to it? And really this goes into the tool, right? Just like an ultrasound, just like a stethoscope, just like a CT scanner or an MRI, all of these tools that medicine uses, a lab test, all these tools that medicine uses have limitations to them. They have a time and a place. They have a purpose. They have a sensitivity, a specificity. And part of our job as healthcare providers is to understand what the right time is to use the right tool, what the limitations of that tool are, and when to use a different tool.

And there are some things that telemedicine will never be able to do. I can never reach through a screen and do a procedure for someone else. If it’s required for me to physically put hands on a patient, then that person, that patient, needs to be transferred. If I can coach a local person through a procedure or a task, then we have options.

But the fundamental aspect that the network, the connectivity, will fail you at some point in time is real. And if you don’t know that going into a telemedicine encounter, then you won’t be prepared. And oftentimes, for my role when I’m talking about a consultation, that begins with a backup phone number, first thing. “Hi, I’m me. What’s your name? Who are you? Okay. We’ve exchanged the niceties. Okay. What’s your callback number or what’s an alternative mechanism for us to communicate because when this one fails, I want to be able to re-establish communication. If you can’t get back in touch with me, this is what you should do next, right? Here’s my text message. Here’s my email. Here’s an alternative phone number to call.”

Some of those are systematic in nature. Some of those depend on the system you’re using, right? So if you don’t have a formalized system, and it is just a phone call, establishing some of those very early backup plans at the beginning of a call becomes important.

I think the other part, when specifically related to training, is people oftentimes assume that telemedicine is going to function for them. Just like I’m sure you’ve experienced in your time as a host of a podcast, especially a video podcast, your skillset in doing that has improved over time. You have learned the tricks of the trade. Just like you’re able to say, “Hey, Colonel Pamplin. Jeremy, slow down for a second. I’ve got something else to add.” That’s a skillset. You know how to do that and when to do that, and I’m much appreciative by the way.

Similarly, for the local caregiver making a phone call or even a patient trying to call a remote expert—a consultant, a doctor—there’s a skillset in doing that. We’ve recognized that using a script to make that phone call is a best practice because many people haven’t practiced that skill frequently, but if you don’t have a script, just training on it is useful. And it’s similar for the remote expert.

Colin Forward: Yeah, that makes me think that there are probably some cultural challenges to overcome. So, I run a software business, and it’s really important for us to set the expectation for new developers that it’s okay to ask questions, and they need to ask questions because we can’t afford for them to not know what they need to do next. Working around medicine a lot, my impression is that a lot of the times people are even more apprehensive about coming off like they don’t know the answer to something. And the dynamic you’re describing with telemedicine is sort of like an implicit admission that someone needs help. So how do you train to overcome some of that apprehension?

How Do You Train Healthcare Providers to Ask for Help?

Col. Jeremy C. Pamplin: Yeah, that’s a great point. It’s one of the hardest challenges of telemedicine, strictly in the military but really for any trainee healthcare provider. We actually developed a mnemonic for thinking about how to employ telemedicine in what we call prolonged casualty care—but it’s really care in any resource-limited environment or any place you’re uncomfortable—we called it PREP. The first one was PREPARE. That’s the training ahead of time. The R is for recognition, the E is for execute, and the last P is for problem-solving. That recognition component has largely been recognized or identified as the hardest part of telemedicine, and the way that I boil that down to make it most simple is that whenever you feel like you have a question, that’s an opportunity to make a phone call and to ask for help.

Building that into our training pipeline and making it acceptable is hard because the way that we test people right now, or historically, has been to make them an island unto themselves. You will take care of this patient all by your lonesome without assistance.

I think that paradigm is changing over time. We see it across many training environments, probably the most commonly experienced is the ACLS paradigm. When we say advanced cardiac life support, now we do our mega codes as a team. We don’t do mega codes by ourselves. And we’re encouraged to ask other people on the team their opinions, their thoughts, for help.

Obviously, you have to have a basic understanding about what to do, but as long as you can manage the team and be successful in the response, that’s the goal because the only person that benefits, then, is the patient. Similarly, in military training, a lot of our medics now have scenarios when they are intentionally pushed beyond their expected limits, their expected scope of knowledge, and it’s at that point in time, they should recognize that they need help. And the only way to get help in some of those situations, because they might not have a smart book that tells them exactly what to do, is to call for it. And that’s where the telemedicine side comes into play. Great question.

Colin Forward: Yeah, that makes a ton of sense. And we do have David Rogers with us. I’m about to bring him into the conversation. And I know you guys are going to have a good discussion. So before we bring David in, I have sort of a very broad question for you.

I know that you are involved with the military’s efforts to modernize our telecritical care network. You’re involved in the effort to adopt 5G technologies. I alluded to this a little bit at the beginning, but I think there’s probably a sense that you may have a better idea of the kind of technology that we’re going to get to interact with, you know, a year, three years, five years from now. So what do you see coming down the pipeline in telemedicine that we can look forward to?

What Are Some of the Exciting New Technological Advancements in Telemedicine?

Col. Jeremy C. Pamplin: That’s a very broad question. You know, surprisingly, and I think you alluded to this a bit earlier, there are differences between how the military does telemedicine than in the civilian world. The technology component of telemedicine, the military lags the civilian world. So I think on the military side, a lot of the next five years will be catching up to what the civilian side takes for granted. Your ability to pick up a phone, engage with the provider ubiquitously without a whole lot of effort, we will get to that point in the military.

What’s important to both military and civilian telemedicine—and many people may not even know this—is that most of the calls that are being made are actually recorded. And the data that is gathered from those calls and those interactions starts to help us paint the picture of pattern recognition, which fundamentally becomes the foundation for artificial intelligence and for aiding how we’ll use the AI tools that are out there to make better diagnoses more quickly. It probably won’t be AI by itself. It will almost assuredly be AI with the human, so human-computer or human-machine teaming. And that is clearly a capability, a direction, that I would say almost all telemedicine is moving.

That doesn’t specifically address your 5G capability. We actually just had our first hopefully annual telerobotic surgery symposium for the military yesterday. But the ability to use the enhanced features of 5G for moving large amounts of data very quickly obviously opens up opportunities to do more advanced capabilities, more hospital-like capabilities closer to the point of care.

And that will likely be an increase in the ability to do telemedicine or really just healthcare to home-type capabilities. And we’ve seen several examples of that in COVID, where we’ve used both imaging, radiology, laboratory evaluations, oxygen therapy, and fairly, you know, just advance what we would expect to have care performed in a hospital done at home in order to decompress some of the hospital systems.

But I think some of the other procedural-based care will likely be pushed out on the back of 5G, and I think that will probably happen in the military as well. Certainly, the ability to manage more or monitor more people over a wide range, wide geographic area, will come along with the 5G capabilities.

Colin Forward: I think that’s a great time to bring in Dr. Rogers. He’s the kind of guy that spends a lot of time thinking about what’s on the bleeding edge of this type of technology. He’s been on the show before. A lot of folks who listen to the show know that David and I have worked together for a long time.

David is the A-R-M-I, ARMI—a different army—Chief Development Officer at DEKA. He got his doctorate from the Text and Technology program at UCF where he was a research associate at the Institute for Simulation and Training. He has over a decade of experience building software solutions for humanitarian aid and training in austere environments. So you can understand why we thought you two would have a great conversation. David was also a White House Fellow where he worked on workforce data policy. So thanks for being on the show again, David.

Dr. David Rogers: Glad to be here, Colin. Thanks.

Colin Forward: I’m going to turn it over to you two. I know David has some questions for Colonel Pamplin, and I might chime in here and there.

Dr. David Rogers: Sure, thanks, Colin. Yeah, so one of the observations that I’ve had watching part of the pandemic response—and certainly that influences our area of work and research—has to do with the role that medical devices play in facilitating care remotely. Like, Colonel Pamplin, you mentioned how most people think that telemedicine is care delivered over Zoom. But one of the things that we’re seeing increasingly is the ability to provide care that’s mediated through mobile devices and other types of medical devices.

One of the things that was encouraging to me is that even before the pandemic there were a lot of reasons why it made sense to start to move towards more distributed care models. Certainly, I live in a rural state in New Hampshire, and a lot of our population is far from a hospital. And so the ability to get care through telemedicine is a big benefit to a lot of people—saves on travel times, cuts down on expense.

And for hospital systems, the more care that they can push into the home, that saves a lot on costs. Outpatient care is just a great, beneficial thing—just being able to have more resiliency in your care system, being able to avoid increases in infections that would have happened by having people concentrated in facilities.

So we’ve experienced this tremendous benefit from distributed care, but there are also some, I think, some disadvantages or some kind of friction points that we need to figure out a way to overcome. And so one of the big ones is device interoperability. In the environment in the hospital, it’s typical for healthcare systems to spend something on the order of $20,000 a patient-bed per year just on IT expenses to be able to make sure that all the equipment is working together and talking together properly.

And so that’s why I followed with some interest programs like the “Medical Device Interoperability Reference Architecture” that’s being developed over at Johns Hopkins. Programs like that seemed like a good step to move the industry forward. And so, my hope is that we will be able to leverage some of the experience that we’ve learned about interoperability and the need for systems compatibility to start to move some of that forward.

Colonel Pamplin, did you experience anything or have any insights with regards to interoperability issues with telemedicine devices? And I’d love to hear more about your experience with that during the pandemic.

What Is the Status of Interoperability with Telemedicine Devices?

Col. Jeremy C. Pamplin: Sure. You know, you’ve covered a broad swath of topics in that intro, and they’re all fascinating.

We start seeing the entry of non-traditional companies into the healthcare space: Apple, Amazon, Google, IBM—although IBM has a long history in health as well—but there’s other divisions of those companies that are now taking interest in how we can affect health. And I think that’s in many ways what you’re talking about, and the drive towards being able to have industry standards is imperative.

You know, the airline industry, the nuclear industry, the auto industry would never imagine that you would have a different standard for each car’s speed regulator. You know, your accelerometer, your gas consumption, your flow meters, those all have standards around them, right? I think the U.S. public is still blind to the fact that there is no standard behind which we collect heart rate. Right? Heart rate display is still very variable as to what the sample frequency is, what the quality of the signal must be, all those pieces. Just something simple that you would think is ubiquitous is not actually standardized.

And you alluded to the Madeira project; that’s a Joint Program Committee-1 funded activity from MRDC, with TATRC as a collaborator. We have taken that project and expanded that during COVID into what we call a Device Interoperability Autonomy Coordinating Center that is bringing together all of our National Emergency Telecritical Care Network, or NETCCN teams, as well as device vendors together into one environment where we will at least create a small ecosystem for disaster response around an interoperable framework for sharing medical device data, monitors, ventilators, and IV pumps across three different technology platforms, NETCCN platforms, and the ability to control those devices from a distance. And that ecosystem built upon the works that have been done in Madeira will hopefully set the foundation for us to collect data in a consistent manner, learn from that data, and then hopefully project that type of interoperability standard for the DoD, at least, hopefully, the MDMS, and then we’ll see if we can get the rest of the community on board.

Health information exchanges are a part of that. They’re really confined to the electronic health record, which I don’t think is the conversation we’re having with distributed health. Really we’re talking about real-time data, physiologic monitoring, behavior monitoring, and that’s not quite electronic health record data. So I think the interoperability is really in that distributed space as you pointed out.

Dr. David Rogers: A lot of people might not recognize the relevance of interoperability with devices, but one thing that drives it home is if you think about what it’s like to set up the electronics that you have in your home office. I can expect that I can plug in a webcam; I can pick any mouse that I want; I can, for the most part, I can get my printer working on a good day. But that’s what device interoperability means for consumer electronics. I mean, with some of the stuff that you alluded to, do you think that’s ever really possible or achievable with medical devices? Do you think we could get to the point where, in a distributed care environment or digital care environment, you’d be able to achieve that same level of plug-and-play with the devices that you need to distribute care?

Will Telemedicine Devices Ever Be Truly Interoperable?

Col. Jeremy C. Pamplin: I guess I’m an optimist, so the answer to that is yes. I know many pessimists that are out there would give the exact opposite answer and say no. But I, honestly, the reason I would say yes to that is I think that if the healthcare industry doesn’t figure that out, the consumer electronics industry will. And the consumer electronics industry is already on a journey to making consumer devices that are are medical grade. Think about the Apple Watch. It has an FDA clearance for diagnosing an arrhythmia, right? That’s a consumer electronic device that has never been in a hospital, never used doctors to make the evaluation, and yet they’ve patented it; they’ve moved it through the system. So that’s only the beginning. That’s the tip of the iceberg. There’s more coming down that pathway.

And I think the big medical companies see it coming, and they’re willing to start playing in this space. You know, we have part of Madeira is Phillips is Drager is Medtronic. We have those groups, some of these big companies that are interested in being in the space and understanding what that future might look like. I’m not confident that all of those entities yet fully understand what open interfaces and open architectures look like. And I’m also not sure that they’re really fully open towards sharing the data, and obviously one of the challenges with data is privacy. And that’s still a conversation that’s up in the air.

And I think we, as a nation, as a national strategy, as policy forming entities, I don’t think we’ve really wrapped our heads around, had the deep conversation necessary to decide what is ethically right about sharing what elements of our health data are appropriate. And I personally think that it’s a bit more personalized than that. I think some individuals are more likely to be open to sharing their data because it’s going to be better for their health and better for their safety than other individuals are. And we’re going to have to figure out a governance structure that will allow U.S. freedom of maneuver, freedom of choice, to be paramount.

Colin Forward: So I have to ask, then, are there any special technologies that you think are really leading the way when it comes to operational virtual health? Anything that is setting a great example that someone else might want to learn from?

Col. Jeremy C. Pamplin: So let me make sure I bound this the right way. You’re talking in the military operational virtual health setting, or you’re talking about operational virtual health as an operation of virtual health in the civilian setting?

Colin Forward: Well, so anything that you’ve encountered in the course of your work that you think is setting a great example, whether it’s in a military or a civilian setting, as far as interoperability or technology that is doing a good job facilitating the type of outcomes that you’re hoping for.

Col. Jeremy C. Pamplin: Yeah. I need to be cautious about endorsing any specific group because I think that there are certainly leaders in the field. There are people that are moving forward. But in my experience, even the leaders that are out there are not alone.

But by and large, the groups that are most interested in sharing data and recognizing that the data is important, but how you use the data, how you apply the algorithms, how you curate that data and use it to see a problem, understand that problem, and then make a decision that is better than we are currently doing is really the right pathway.

The other component of that—and I feel pretty confident in this—the groups that are trying to incorporate the human with the machine, as opposed to excluding the human from the process, I think tend to be more successful than the ones that are trying to do it purely from an engineering standpoint and exclude the humans. Medicine remains very complex, and there are few right answers because we don’t understand the human body, by and large. There are some aspects we do, but we still have a very hard time understanding what the right choice is for individual patients.

So including the human in those decision trees, I think, is probably the better pathway, at least in the next five to probably 15 years. Maybe in the 15-20-plus-year period, we’ll start having some more fully autonomous systems that outperform the human. But I think we’re not quite there yet.

Why Is it Important for Humans to be Involved in Technological Developments in Training?

Dr. David Rogers: I think that’s a great point and one worth noting is this idea of including the human because that’s sometimes something that we forget about. I mean, this isn’t the first time that the field of medicine has really wrestled with the question of data interoperability. The first big era of that was with electronic health records.

And I think maybe if we’re looking back for those that were involved in that revolution, one of the things that maybe we didn’t do as good a job as we could have was remembering the human. And one of the consequences of that is that we ended up turning a large portion of the healthcare system into little data entry machines, which caused a fair bit of difficulty for a lot of providers who wanted to be able to focus on medicine instead of just entering data all day. And so I wonder if in this new iteration of interoperability around medical devices and distributed digital care if we don’t have another bite at the apple, so to speak, and a chance to do device interoperability and data interoperability but really privileging the human experience and trying to figure out a way to design those systems with the end-user in mind from the beginning, from this perspective of usability, of training, of ease of use, and all the other kind of human factors that sometimes get overlooked with a device and engineering-centric approach.

Col. Jeremy C. Pamplin: Yeah, I think you’re spot on. We call that human-centered design. In the military and the Army, we call it soldier-centered design. But absolutely. Including that touch-point, not at some future state but right from the beginning, agile development processes with sprints that allow us to continually evaluate the progress and the success of a specific technology in the right domain of interest.

So one technology may work great in an outpatient clinic, but it may not work one iota in the back of a helicopter, or in an emergency department, or in an operating room or an intensive care unit. So we really have to understand that context, and the humans that are involved in those spaces become vitally important for understanding that context.

Your analogy to healthcare records is also pertinent. We as a medical culture, I think, are still, I don’t know, recovering from our experience in the electronic health record. I don’t think it’s even over yet. And the repercussions of bad design, the repercussions of trying to shift to a technology that was not appropriate for the setting—it was designed to help with a specific problem with billing—that has not resonated well with clinicians, and it’s given the hospital systems—clinicians, in particular—a bad taste toward technology. And the more we promote technologies that are not efficient, effective, active, reliable, and that make the clinician’s job easier, the less likely we are to adopt those technologies in our future. Adoption is by far the hardest thing. It’s easy to make the tech. The tech is not that hard. It’s the workflows, it’s the way it affects the care that’s provided, the way it’s affects the workflow that are much harder.

Honestly, I think that’s part of the training space too. You mentioned training before, I personally think that training and technology development go hand in hand. So one of the elements of training that really needs to be highlighted is the recording of that training, understanding what a human’s baseline is and how you perform a task or how you make a decision within the specific medical context. That type of understanding, then, can be compared to how you do the same task, make the same decisions within a similar care context with new technology. And what we’ve never really done—and the FDA is actually very interested in this—we’ve never compared a tool’s ability to improve patient care compared to humans. So right now, most technology vendors are required to provide a standard that is of some diagnostic quality. This tool gives a sensitivity and specificity of 80% or more or whatever the cutoff value is going to be.

When I run this test, it’s going to give me an accurate and reliable result X percentage of the time across a wide range of a patient population. And those are the requirements that we use in the FDA to define a quality device. We’ve never had that same rigor for a human. How often does a human make that correct diagnosis? And I think as we think about benchmarking to humans—to themselves; I don’t think we have to compare them to others—then, they may have an understanding about how good they are doing a specific task. And then, we can apply a technology that’s called an ultrasound and see if that task achievement is actually improved—or a clinical decision support tool or a new visualization tool or an electronic health record. If we’d applied this rule to electronic health recording, we would have rapidly realized that electronic health records slowed down clinicians in clinic. It made them less likely to make good decisions for a variety of tasks.

And, yes, it made order entry better, and it made it easier to understand those orders, but it didn’t make many of the tasks of medicine more effective, more efficient, or more reliable.

Colin Forward: Yeah, and thank you for bringing it back to that. I think that’s the kind of takeaway that we’re looking for in these conversations? We do have one question that came in from the audience that I think is a good one. Brenda Butler asks:

Do you see broad fielding of telemedicine in operational use, and do you see any challenges with comms to enable telemedicine in prolonged field care?

Col. Jeremy C. Pamplin: Yes and yes. Great question, Brenda. Thank you for asking.

I think we’ve alluded to this a little bit before. Again, for the prolonged casualty care environment or scenario or really any military operational environment and probably for civilian disaster support, you can’t do telemedicine without some form of connectivity or network—just, you can’t do it, right? That’s not an option.

But the ability to be flexible to the options available and the ability to make a decision about capability is what we need to train. If you have slow internet and you can send text messages, asynchronous communications, you can do a lot with asynchronous communications.

We oftentimes refer to routine care. Probably about 80 percent of all care can be managed by asynchronous communication, which requires very low bandwidth. You can have lots of latency; you don’t have to have very much communication. Ultimately some of those challenges may be resolved by AI tools. Because we could record that information, the decisions that need to be made in that space can be aided by a computer. It’s really not until you start getting into some of the more complex tasks, oftentimes procedures, or coaching through a specific physical exam or coaching through a less-than-ideal situation that you need to be able to have some more advanced communication tools.

Radio is oftentimes enough. Even unilateral signal transmission—but it is voice—can provide enough context, enough information exchange to solve a lot of the problems. When you start getting into procedural, like surgical telementoring, that’s when you really need to have a lot of the visual cues in order for their remote expert to be able to help that local caregiver.

But again, I think that as we record telemedicine encounters over time, even some of those assumptions will be challenged, and the computer will be able to start recognizing some of the patterns, particularly of a surgical procedure. “That’s a leg. This is where you need to put your escharotomy line. That’s a swollen compartment. This is where you need to decompress the compartment.” Those types of decisions are already being evaluated in laboratory environments that will allow the computer vision to help with a lot of those decisions. I don’t know if the computer will ever make them on their own, but they will certainly help the local caregiver make some of those decisions. Hopefully, that helped, Brenda.

Colin Forward: Yeah, I think that’s a great response. And thanks again, Brenda, for the question. We are getting towards the end of our time. So, Colonel Pamplin and David, if you could stick around for a few minutes. I’m going to make sure that Adam lets everyone know where they can find this conversation after the fact.

But I appreciate both of you joining us today. I think this has been a really insightful discussion on not just telemedicine but also some of the interoperability and IT challenges that the healthcare industry faces both in civilian and military settings. So really appreciate your taking your time to share your insights, and I hope that everyone has been able to learn something about the space today. So over to you, Adam.

Adam Wagner: Yeah, thanks, everyone. This was Training the Modern Workforce Live, presented by Allogy. If you’d like to explore previous episodes, subscribe to our YouTube channel or like us on LinkedIn and Facebook. And if you’d like to connect with one of our learning specialists to see how Allogy could help improve your training, head to allogy.com and schedule a demo.

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