DHIC’s projects focused from battlefield hospitals to the medical centers and beyond to include reaching patients in between clinical encounters using mobile technologies:
This AAMTI funded project was developed to determine utility and practicality of utilizing the current mobile healthcare application platform to deliver clinical guidelines for limiting progression of PTOA. Military service members are at increased risk for traumatic knee joint injury and those who sustain these injuries are much more likely to develop PTOA during their military career. Using mobile health, this project created a usable virtual knee health clinic that delivers innovative therapeutic care to limit progression to PTOA, and preliminary assessment was conducted in partnership with Keller Army Medical Center at West Point and the University of North Carolina (UNC).
In September of 2019 the favorable outcome from this AAMTI evolved into a full scale randomized controlled trial initiative, as part of a much larger four-year program established to improve rehabilitative care for service members with musculoskeletal injury, ultimately enhancing overall military readiness, thanks to a multi-million dollar grant from the Defense Health Agency awarded to the Uniformed Services University of the Health Sciences (USU). The program, referred to as the Collaboration for Musculoskeletal Injury Rehabilitation Research (CMIRR), was created in support of the estimated 800,000 service members effected by musculoskeletal injury each year. These injuries result in 25 million days of limited duty, and 34% of medical evacuations from the battlefield. The CMIRR is based at USU and the PTOA mobile curriculum created from the AAMTI initiative will serve as the technology platform for patient users and caregivers.
The program will foster interdisciplinary collaborations and partnerships between the services (Army, Navy, Air Force, Marine, and Coast Guard), the Department of Veterans Affairs, the Department of Defense (DoD), and several major civilian academic medical centers. CMIRR scientists will look at general musculoskeletal injury care processes and targeted treatments for back, knee, and shoulder pain.
The program will also study effective methods for returning to running after injury, and returning to duty activities. Results of these studies will lead to evidence-based approaches to guide clinical practice guidelines and enhanced education for our future military providers (e.g. medical, nursing, therapy students) and scientists. The knowledge gained through CMIRR will also be disseminated more broadly to the military, veteran, and civilian communities, ultimately enhancing the care of these injuries across the nation. The CMIRR will be guided by a steering committee composed of members from the Joint Program Committees at the U.S. Army Medical Research and Development Command, military operational leaders, and experts in musculoskeletal medicine from the military and civilian communities to maintain a military mission focus.
In early FY21, West Point cadre members and older patient population users at UNC will be enrolled and will be followed up to six months with the DHIC supported app and provider portal platform; they will be compared to anterior cruciate ligament (ACL) tear patient “controls” without the platform before and after changes in symptoms; behavior; weight; nutrition; overall readiness.
Preserving Continuity of Behavioral Health Clinical Care to Patients Using Mobile Devices.; This JPC-1 funded project aimed to use mobile technology to leverage telehealth services as a means to maximize the continuity-of-care that the military healthcare system (MHS) can provide to Service Members when they are temporarily relocated due to military service requirements, but require and are engaged in behavioral health (BH) services.
The effort was focused on utilization of the patient’s personal mobile device in an approved, secure fashion to maintain the established therapeutic relationships with their BH provider(s) during an outside the continental United States (OCONUS) temporary duty assignment (TDY) using a relational model of care delivery to complete a course of treatment that the patient sought out prior to being reassigned.
This project sought to conduct video teleconferencing care consultations from a military care provider’s desktop to a patient’s personal mobile device without compromising privacy or security in the process. The research team assessed existing IP-based desktop teleconferencing solutions, generically known as a Web Real Time Communications (RTC) system, for establishing a secure connection to a Service Members personal mobile device outside of the DoD network. Of the five existing WebRTC systems evaluated, only the backbone component to the existing Defense Information Systems Agency’s (DISA’s) Global Video Services (GVS) known as Vidyo, was suitable to meet DoD security requirements and still connect with both major OS systems on mobile devices. An existing DoD program of record mobile application, mCare, was integrated with Vidyo desktop technologies to form what the research team called “Mobile Connect”.
Deployment of the Mobile Connect product yielded distinct differences and high levels or variability between the .osd.mil and the army.mil network connections over time. These network differences impacted quality of service (QOS) solution where Mobile Connect couldn’t be used to provide care between the .mil and patient's personal mobile devices from a osd.mil domain connection. By September of 2019 the research team members were able to conclude that it is technically feasible to provide desktop VTC capabilities from a .mil computer to a personal mobile device without compromising DoD security and information assurance requirements using future WebRTC systems. Approved ports, protocols and system settings must be configured to accept both inbound and outbound, encrypted traffic to/from personal mobile devices is required to maintain consistent quality of service (QOS) with all DoD networks. Of the current DoD WebRTC options, working with the DISA GVS Program Manger (PM) to expand services to support commercial mobile devices has the highest probability of future success. As of September 2019 these conclusions were finalized and continued site testing was taking place to accumulate as much additional data regarding bandwidth. The final report for this effort was completed at the end of FY20. A publication of findings may be found at: Little, J., Schmeltz, A., Cooper, M., Waldrop, T., Yarvis, J., Pruitt, L., Dondanville, K. (2021). Preserving Continuity of Behavioral Health Clinical Care to Patients Using Mobile Devices, Military Medicine, Volume 186, Issue Supplement_1, January-February 2021, Pages 137–141, https://doi.org/10.1093/milmed/usaa281.
This AAMTI funded project seeks to bridge the gap of perioperative surgery communications about appointment reminders, surgical preparation and post-operative care. In partnership with the Trauma and surgery department at Madigan Army Medical Center, DHIC developed a mobile solution affording patients the opportunity to leverage their personal mobile device to maintain an established therapeutic relationship with their surgical provider, the existing MHCE system technologies were be leveraged for this project. Text messages go out to each patient at their pre-op (or diagnostic) visit, timed a few days prior to their surgery (medical prep instructions as well as directions and appointment reminders), the morning of surgery (continued fasting etc) and upon discharge, as well as for the follow up appointments. Recruitment concluded March of 2020 and final reporting was sent to AAMTI. Abstract and poster presented at AMUS Methods: 200 patients at single military hospital undergoing elective surgery received educational materials, peri-operative instructions, and text reminders of time-sensitive peri-operative events from mCare to their smartphones. Post-operatively, a survey was administered via the application to evaluate usability and patient satisfaction utilizing the System Usability Scale (SUS), a standardized measure of computer system usability. Results: 200 patients were enrolled of which 180 underwent surgery. Of these patients, 19% were >60 years old and 49% were female. The survey response rate was 49%. The app scored 84 on the SUS, correlating with >90th percentile usability. 86% of patients responded that mCare improved their overall surgical experience, and 90% responded that mCare clarified information provided by the surgical team in the pre-operative visit. Conclusions:The mCare mobile application provides a usable method of delivering patient education that augments traditional peri-operative communication and improves satisfaction within the military surgical experience. Additional studies are needed to determine the effect of mobile applications on patient compliance and operative outcomes.
Further, the service was widely received at other MAMC clinics. An unfunded use case of the just-in-time reminder messaging was provided to Steven J. Bernick, MD, FACP, Staff Gastroenterologist
Gastroenterology/Endoscopy Service, Madigan Army Medical Center and deployed just prior to Covid shutdowns across the United States. The project to date hasn’t been taken back up as routine / elective endoscopies remain back logged but Dr. Bernick anticipates reactivating in the spring of 2021.
The Army National Guard has partnered with the TATRC DHIC team to demonstrate a means to connect with their assigned service members during their non-drill status to assess readiness levels through the service member’s personal mobile devices in a secure, HIPAA compliant fashion. In this first phase of this demonstration the TATRC DHIC team will be delivering the part one of the periodic health assessment or PHA questionnaire to a select number of pilot users and established a data exchange with two enterprise data centers, MEDCHART and MODS.
This AAMTI funded effort was focused on patients with low back pain (LBP) who experience persistent or fluctuating levels of pain, resulting in ongoing disability. While the current management strategies for LBP are moderately effective, the delivery of care is inconsistent with our current understanding of LBP. Most conservative treatment approaches for patients with LBP are delivered over a relatively short period of time in conjunction with an episode of increased pain. The purpose of this project is to assess the feasibility of an innovative virtual health interface accessible via the patient’s personal mobile device to facilitate an ongoing delivery of care for patients with chronic LBP. This interface will help by providing push notifications to patients encouraging exercise adherence, log activity levels, allow clinicians and patients to track progress toward goals and provide valuable ongoing education about the nature and progression of chronic LBP and empower the patient toward continued self-management. For this project the current Mobile Health Care Environment (MHCE) system’s secure provider portal platform and its accompanying mobile application, mCare, will be modified to be a “one stop show” for low back pain patients so their providers can cherry pick to highlight and tailor content to the patient/ mobile user. Physical Therapy (PT) exercise information links, video demos, and physical wellness inventories will be customized as well as a general repository of links and data for wellness behaviors and pain relief tips. The feasibility of this technology solution will be tested on 30 patients at Brooke Army Medical Center (BAMC). Questionnaires will be implemented through this mCare app for assessment.
In collaboration with the TATRC MEDRAS Team, the TATRC DHIC team is providing a supporting role to the JMEDIC effort to provide a virtual health solution to US SOCOM in the operational environment. The specific aims and tasks of this project are as follows:
Develop a global capability targeting temporary fixed facilities for deployed Special Operations Medics that enable them to establish a remote tele-consultation link with a clinician in a CONUS Military Hospital and share near real-time information consisting of medical telemetry, patient condition, and treatment provided, still images, audio, and video.
Develop a global hand-held mobile capability targeting deployed Special Operations Medics that enable them to establish a remote tele-consultation link with a clinician in a CONUS Military Hospital and share near real-time information consisting of medical telemetry, casualty condition and treatment provided, along with still images, audio, and video.
In May of 2019 DHIC researchers kicked off an initiative the team coined the MAST “Research Roadmap” to address the need for a capability outlining, quantifying and establishing Virtual Health Foundational Concepts in a Future Multi Domain Battle concept (MDBC) via Systematic Analysis. The ultimate goal of this analysis is to determine the research areas in need of the most support allocation with regards to the future Multi Domain Battle warfighters medical requirements. In late August of 2019 the team set forth on a keyword and textual analysis path, including subject matter expert input and established scientists, which as of this reporting period has culminated in a refined keyword list of medical and virtual terms for increased textual analysis in peer reviewed journals and related relevant publications.
The US Army Medical Research and Materiel Command (USAMRMC) Telemedicine and Advanced Technology Research Center (TATRC) partnered with the US Air Force 59th Medical Wing to develop a secure mobile application to treat ocular trauma in remote deployed locations. The primary purpose of this research project was to develop and test an operationally secure, HIPAA compliant application to treat combat-related trauma injuries involving the eye. With the growth of teleophthalmology and advancements in technology there is an opportunity to improve the capabilities of teleophthalmology in a remote location.
FOXTROT has been tested on CONUS military treatment facilities including Malcolm Grow Medical Clinics and Surgery Center (MGMCSC) at Joint Base Andrews, San Antonio Military Medical Center (SAMMC), and Wilford Hall Ambulatory Surgical Center (WHASC). FOXTROT was subsequently deployed at selected forward operating bases (FOBs) in Afghanistan. Features of FOXTROT that have been developed during this overview include triage surveys, image capture, chat, reports, remote health monitoring, and user management.
As part of the Joint Health Risk Management (JHRM) Enhanced Capability Demonstration, Blast Overpressure Exposure Operator Monitoring Demonstration. Using the MHCE Web Portal, “Project Boom” will make information visible at different echelons to support Situational Awareness (SA) and decision making by matching blast data collected from blast gauges to weapons firing data, and criteria collected from operators and observers during firing range training exercises. This weapons firing log data will be collected via a capability built within the mCare app, and after aggregated and parsed, will address the following gaps:
Using the existing MHCE/mCare capability, Project Impulse is a mobile and web-based COVID-19 diagnostic test result logging, tracking and reporting tool, built to support non-traditional point of care testing sites and locations. The website and app are built to allow for the test results of multiple types and brands to be entered through either a PC or a mobile device. The website also enables the user to maintain an inventory, shipping, and tracking database for test kits as they are distributed to units or other groups. From the MHCE website, the test result data and other relevant content can be queried, reported or even transferred through an API to another health system of record.
NETCCN is an evolving COVID-19 clinical surge support capability that is currently composed of 4 clinical-technical teams each of whom have completed a six-month, three phase, competitive down-selection process to develop and deploy effective tele-critical care solutions for use at scale and able to rapidly deploy during a disaster. Clinical support is provided by a combination of commercial tele-critical care vendors and vetted volunteers helping to support hospitals in need during a declared emergency. All volunteers are vetted through an established process and are reviewed for performance according to protocol. Provision of clinical support to a healthcare system/hospital/facility/location is prioritized according to need and contingent upon current funding levels of the National Emergency Tele-Critical Care Network. Duration of support is dependent upon local conditions, available funding, and national requirements. Support services will be provided according to published clinical guidelines and best possible care given available local resources.
The objective for this research is to overcome the inability to obtain highly complex Role 1 clinical decision support data with the current technologies in the multi-domain battlefield space through the harnessing of multiple cell phone processors into a clustered network. CluNet partitions and distributes complex problems across devices in the network and combines the results to present it to the user. CluNet adopts a modular and highly agile architecture to manage nodes, resources, and tasks to optimize and maximize the use of available mobile devices such as phones and tablets.
V-CRAMMIT is capable of delivering video compression transmission speed-up capability to ensure fast and effective diagnosis and treatment across myriad, unforeseeable force projection conditions. Being a purely-software solution, V-CRAMMIT requires no special hardware or accessories, and integrates easily into medical image processing or viewing systems of any kind (hand-held, laptop, or others). It compresses huge medical image or video files while automatically maintaining the necessary image quality for their purpose, such as diagnostic or consultative quality. A unique feature is that the V-CRAMMIT techniques supplement existing and proven video or image compression techniques and make them more effective.
MHS requires a persistent, durable non-paper patient transportable tactical combat casualty care documentation capability for transport and transfer of medical care information in the absence of a reliable communications link. With the introduction of new bio-compatible inks, higher density barcodes, reductions in printing component costs, and increased battery life, there exists the potential to replace the use of paper with a device which could employ temporary tattoo technology. Development of a QR Code tattoo that can be generated by the Medic’s Nett Warrior End User Device (EUD) as a result of them filling in the electronic information using an electronic TC3 card facsimile and transferred to a handheld tattoo printer which can print a QR code barcode onto the skin of the warfighter. This will eliminate the need for a paper TC3 card and the potential for any loss of information along the continuum of care.