The new NMMAST Program Office is advancing Navy medical simulation through collaboration with the Air Force. Chuck Weirauch explains.

The US Military Health System's (MHS) Defense Health Agency (DHA) is a joint, integrated Combat Support Agency supporting the Service’s medical services in their roles. The DHA, stood up in 2013, has the general goal of enabling the delivery of integrated, affordable, and high quality health services to MHS beneficiaries and is responsible for driving greater integration of clinical and business processes across the MHS. With this in mind, there is a considerable interest in employing medical modeling and simulation technologies for medical training and education. An example - through the partnered Defense Medical Research and Development Program (DMRDP) Joint Program Committee-1 (JPC-1) Medical Simulation and Information Sciences Research Program (MSIS) - is the Joint En Route Care Training Initiative that would include simulation-based continuum-of-care training system to address the challenges of medical complications associated with improper hand-offs and transfers of patients from one medical treatment care level to another. It is estimated that 80 percent of serious medical errors involve some sort of miscommunication between healthcare personnel, particularly during the transfer of care from one provider to the next.

Allied with DHA and JPC-1, and the overall body of joint and partnered DoD medical M&S organizations are the medical modeling and simulation program divisions of each service's medical education and training commands. The newest such organization is NMMAST, the Navy Medical Modeling and Simulation Training (NMMAST) Program Office.

NMMAST

The NMMAST Program Office, which stood up in July 2014, is the execution agent for Navy medical M&S, and participates as a voting member in the Federal Medical Simulation and Training Consortium. The NMMAST is an element of the Navy Medicine and Education Training Command (NMETC).

NMETC manages and coordinates education and training services within Navy Medicine. It has the Navy Medicine Professional Development Center (NMPDC), the Navy Medicine Operational Training Center (NMOTC), and the Navy Medicine Training Support Center (NMTSC) under its command, as well as management of the Healthcare Inter-service Training Office.

During the current fiscal year, 2015, the NMETC is going through a transformation as it consolidates its resources and moves to Joint Base San Antonio (JBSA), Texas along with the NMMAST office. The move is to be completed by the end of the FY in September. One of the key elements of the NMETC transformation is to deploy a standardized and centralized learning management system (LMS) throughout Navy Medicine Commands. During this process, the NMETC has been continuing to implement a standardized process of curriculum development and review throughout its learning centers and Navy Medicine programs at the Joint Service Medical Education Training Campus (METC) at San Antonio.

Shared Resources

Another reason for the move is so that NMMAST personnel can share the resources of the Air Force’s Medical Modeling and Simulation Training (AFMMAST) Program Office already in place in San Antonio. The AFMMAST office is that service’s counterpart to the Navy’s NMMAST.

According to the NMETC FY 2015 Business Plan, the AFMMAST office “is more mature in their development of medical modeling and simulation, allowing the Navy Medicine program management office to leverage the Air Force’s progress for the Navy.” The NMMAST office “will move toward integrating simulation modality into the curriculum development and review process; instituting a life cycle management process for equipment; and implementing a workforce development program to ensure simulation capability at each tier of the organization.”

Established in 2008 at the Air Education and Training Command (AETC) located at the joint San Antonio base, AFMMAST “is responsible for the development and assessment of the medical modeling and simulation processes to facilitate training the Air Force enterprise,” according to Air Force Col. Melatios Fotinos, AFMMAST Medical Modernization Chief. One of AFMMAST’s recent projects was to develop an internet-based IT Portal that connects all of that service’s medical simulation centers in order to share best practices and medical training procedures. Another AFMMAST endeavor is the Virtual Medical Center, where the on-line avatars of medical professionals provide medical information real-time to service medical staff and patients via the Internet. AFMMAST is also currently developing mobile medical apps for distribution to the services.

“One of the things that we enjoy being juxtaposed with AFMMAST is the ability to examine some of the clinical needs with clinical SMEs and grading them as the vendors might present their adjunct medical training equipment,” said NMETC Operations Chief Pat Craddock. “SMEs can identify the best utilization of those medical simulation adjuncts that we might want to invest in, and AFMMAST has done a lot of work in this area. And then we take that to the Central Simulation Committee and adjust our equipment list as we go forward. Another thing that we have is an impending kind of force upon us in the future. That’s because the Defense Health Agency is paying quite a bit of attention to modeling and simulation, and has identified the Army’s Program Executive Office for Simulation, Training and Instrumentation (PEO STRI) as its primary acquisition arm.”

NMMAST Responsibilities

Commander Typhanie Kinder, director NMMAST, explained, “A primary function is that NMMAST is an advisory body regarding medical modeling and simulation. We are linked together with JPC-1, the simulation working groups, and obviously medical modeling and simulation academia. We don’t do research and development, nor do we do acquisition. We are facilitators. We bring the best that the Navy has together through the Central Simulation Committee and then we manage it. Being co-located with AFMMAST has brought us forward light years from where we would be if we had to do this de novo.”

The NMMAST program was actually conceived back in 2012, but was physically stood up this past July, Kinder said. Being co-located with AFMMAST has afforded the NMMAST office the opportunity to share in its infrastructure and more quickly become a more full-fledged entity. One of the NMMAST roles is to utilize a tiered approach to facilitate medical modeling and simulation efforts through the Navy Central Simulation Committee.

“The tiered approach also allows us opportunities to collaborate to evaluate (training and education) gaps, to jointly investigate capabilities and leverage the shared Service opportunities against the greater environment of the Medical Modeling and Simulation Working Group, JPC-1 and its research and development efforts to support medical M&S,” she added. “We can work through the Services, as well as under the directives of the DHA, to improve standardization and leverage cost-savings opportunities. So to that effect, our office uses the tiered approach to introduce standardized equipment inventory to support specified requirements and capabilities. We also working to project resource requirements for entire Navy programs as we touch them, centralized procurement for both equipment and to support that training equipment evolution through the Logistics Command support.”

M&S Focus Areas

One of the areas where the NMMAST organization sees medical modeling and simulation-based learning tools providing a means to help fill training gaps is in the field of obstetrics, particularly for mobile obstetric emergency systems, Kinder reported. Another is the improvement of current airway training devices, which have been described as not as realistic as needed for training for more complex procedures performed by medical personnel.

“We are looking at opportunities to develop synthetic neo-natal airways that would take us away from live tissue potentially when that is ready for prime time, as well as a joint airway project,” Kinder said. “This is probably the one with the greatest impact throughout the services, but is the least glamorous. In other words, what are the airway requirements that military medicine needs as we move through the different type of learners, from a combat medic all the way up to the highly specialized physician. So this is an example of how we work collaboratively as the Navy’s representative for military medicine and modeling and simulation in a joint forum - focusing not only on Navy specific concerns but also military medicine as they touch military modeling and simulation.”

However, there are many other opportunities where the military medical community can pursue the development of medical modeling and simulation to address medical training and education gaps. Kinder postulated. One of these areas is learning how to successfully manage and treat very rare and very high-risk, high-mortality conditions, such as vericeal bleeding, she pointed out.

“So instead of waiting for that patient to present with such a rare and high-risk condition, and perhaps not having done the procedure ever, except in a textbook, modeling and simulation allows the physician to practice it until they are comfortable and develop muscle memory,” Kinder said. “Then when he sees the real event in a patient, it isn’t as threatening. Likewise we are looking at resiliency and hardening through medical modeling and simulation for team training aspects. So how can we make small, mobile teams and bring them together perhaps virtually so that they are ready so when they see each other in person for the first time – that’s an area we are moving into and trying to define the boundaries of.”

Ending “Train on the Patient”

While progress is incrementally being made to provide medical modeling and simulation teaching tools for certain procedures and treatments, the end goal for both military and civilian medical educators is to eliminate the traditional practice of ‘see one, do one, teach one’. Kinder said this training gap is being addressed as medical credentialing programs for physicians, as well as their graduate medical education programs, are moving towards a high reliance on modeling and simulation to replace the “train on the patient” concept.

“The goal is so that no longer do we practice on the patient,” she summed up. “We want to do our pre-rehearsals if you are an established physician in a modeling and simulation laboratory of some sort before that individual comes to the operating or treatment room. And likewise, residents, interns, fellows, and physicians in training are no longer handicapped or limited by the type of cases that are presented in the patient demographics, but have the opportunity to rehearse them using modeling and simulation. And medical programs are almost 50 percent now with some requirement for modeling and simulation. So there is a gap that medicine is facing in the United States - and probably the world - that we can fill.”