medical simulation industry overview (technet 2012)
DESCRIPTION
This presentation is intended to provide an introduction and overview of the medical simulation market domain for defense modeling, simulation, and training audiences interested in applying their capabilities, expertise and products to medical and healthcare training and education needs.TRANSCRIPT
Bob Heinlein Medical Simulation Associates
20 Jan 2012 TechNet
Speaker Background Education
BS Engineering (Mechanical) Masters Business Administration Master Science (Acquisition) Logistics Management Doctoral Work at UCF, Industrial Engineering (M&S), ABD
Military USAF (Ret O-5) Experience in Flight Ops, Acquisition, OT&E,
Simulation Last USAF Liaison in Orlando prior to AFAMS standup
Industry Experience in Immersive VR, Simulation, Logistics, IT, Program
Management and Business Development Independent consulting since 2008
MedSim total focus since 2010 No Clinical Background
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About Medical Simulation Associates Specializing in connecting the medical simulation
industry with the defense simulation industry to rapidly advance the state of the art and the use of simulation technology in healthcare.
Business Development & Marketing Support Medical & Technical SME Support Proposal & Program Development Support Related Services
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Disclosures
Recent MedSim Clients General Dynamics Information Technologies,
Health Solutions Division, Frederick MD
Hudson Simulation Services, Delmar NY CHI Systems, HapMed R&D, Ft Washington PA
National Center for Simulation, Orlando FL
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Presentation Context
Defense simulation & training solution provider with interest in Medical Simulation
FAQ Where do I start? Where are the customers? Who are the players? Where is the $$? Where can I play?
MedSim Business Development for dummies Based in my experience and perceptions as a newbie to
medical simulation
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What is Medical Simulation? (Some Definitions)
…a training and feedback method in which learners practice tasks and processes in lifelike circumstances.
…a cross-disciplinary effort that brings together providers, including nurses, physicians, and allied health professionals across a variety of disciplines with computer scientists, researchers, educators, and human factors engineers.
…an interactive way to further educate and train medical or health professionals.
...an all-purpose term covering everything from using a block of resin or wood for would-be surgeons to get the feel of handling a drill to a surgical simulation so sophisticated that it reproduces an individual patient's anatomy perfectly
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Many Application Areas Schoolhouse, Refresher, Skills Maintenance, Re-qualification,
Certification, Assessment, Training, Education, Practice, Warm-up, Rehearsal
New Equipment, Product Procedure, Process FDA Approval, Research and Development, Training
Architecture and Design of Facilities, People Orientation, HR Medical IT applications, Medical Records, Telemedicine Medical Scenarios and Simulated Illness Team Training and Group Exercises Develop & Practice Interview Skills, Cultural Training, Empathy
Training Doctor-Patient Interaction Skills Triage/Trauma/Disaster Response Rehabilitation/Therapy Patient Education & Patient Actor Training
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Many Users & Domains
Anesthesia, Radiology, Neurology, Cardiology, Audiology, Opthamology, Orthopedics, Urology, Obstetrics and Gynecology, Oncology, Proctology…..+++
Surgeons, Physicians, Nursing, Dental, Pharmacy, Allied Health… Emergency Medicine, First Responders, Veterinarians…. Therapy, Rehabilitation, Psychology, Psychiatry, Mental Health Medical Teams & Patient Actors Medical Equipment Vendors Substance Abuse Education & Rehab Special Needs Children/Families General Public, Patient, Care Providers, Patient Educators Office Staff, Human Resources, Utilization Reviewers, Insurers
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Multiple Customer Groups 151 Medical Schools plus many more education programs 90 Professional Societies 400 Teaching Hospitals
98 Health Systems (National, Regional, Local) 68 VA Medical Centers, 173 Military Medical Facilities
Individual Hospitals (hundreds) Military Units (medics, combat life savers, etc.) – (thousands) First Responder Units – Fire, Police, EMS – (millions) Clinicians & Specialists – (millions) Commercial Training Providers – (tens) Medical Equipment Vendors (hundreds) Patients/Consumers – (hundreds of millions)
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Medical Simulation Clusters
CAMLS – Tampa Mayo, UF CoM - Jacksonville Gordon Center (UM), Ryder Trauma, ATTC- Miami NCSA, VA SimLearn, UCF – Orlando Nemours, PEO STRI - Orlando
Phoenix AZTEC (Uof AZ) Banner Health Mayo
Stanford CISL Goodman Sim Center Palo Alto VA Sim Group CAPE USC
San Franisco UC Davis, Travis AFB Sutter Health
Seattle U Wash ISIS, Simulab, Red Llama, Mimic, Swedish MC, Madigan AMC
Texas MITIE (Methodist) Childrens Texas A&M HSC
Ohio Cleveland Clinic, Simbionix, Surgical Theater, Case Western
Minnesota CREST (U Minn) Mayo City Health Partners IME
Boston CIMIT Harvard Mass Gen Brigham Womens Beth Isreal, MIT Boston Medical, Draper et.al.
Pittsburg WISER (U Pitt.) SimMedical
Va EVMS ODU NH Portsmouth
NC Duke ARA Therasim RTI
DC Area SiTEL, USUHS, Johns Hopkins
Apologies to anyone that didn’t make the slide!
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Multiple Solutions and Technologies
Human Patient Actors (standardized patients)
Virtual Patient Avatars Human Cadavers (whole
to individual parts/organs) Live Animals/Animal
Cadavers (organs) Human Patients Virtual Patients Part task trainers Mannequins Human Patient Simulators Surgical Simulators
Virtual Worlds Immersive Virtual Reality Haptic-enabled Devices Interactive Courseware Web Based Training Mobile Devices Serious Games Video Recording Video
Training,Teletraining, Telementoring, Live broadcasts, etc.
Learning Management Systems
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Multiple Solutions and Technologies Synthetic Cadavers/Tissue Synthetic Tissue Virtual Tissue Moulage Wearable Cut Suits Bleed Simulations Environmental / Special
Effects Imaging Video/Data Recording
Systems Performance Assessment
Applications After Action Review/Debrief
Systems
Projection and Display Systems
Wearable Displays and Devices
Scenario and Simulation Control Systems
Curriculum Development Tools Courseware/ISD Development
Tools Electronic Classrooms Interactive 3D Instructor Control Systems Simulation Centers Transportable/Mobile Units
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Broad Base of Solution Providers Human Patient Actors (standardized patients) -- Usually
contracted directly with individuals Virtual Patient Avatars - Universities (UCF, USC/ICT, UF, etc.)
Industry - VCom3D, ECS, Breakaway LTD, ARA, Kognito, etc. Human Cadavers – Science Care or direct donation to academic
or research organizations “Living” Cadavers - Connecting Cadavers to fluid pumps to
simulate a living human or animal Live Animals/Animal Cadavers – Limited use in medical
education now, except for combat medics and vets Human Patients – Yikes, me and you! Virtual Patients - Therasim, Innovation in Learning,
Healthstream, Decision Simulation, Medbiquitous.org
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Broad Base of Solution Providers Part task trainers - Limbs & Things, Simquest, Simulab, Nasco, CHI
Systems, CAE, etc. Specialty trainers - IngMar Medical (respiratory), Ventrioloscope
(cardiac), MedSim (Ultrasound), CAE (Ultrasound), HAL (UM/Laerdal) (cardiac), etc., etc.
Mannequins - Simulaids, Gaumard, Laerdal, KGS, etc. Surgical Trainers - Simbionix, Mentice, Medical Simulation Corp,
Surgical Science, CAE, Red Llama, Simulated Surgicals, Mimic Human Pt. Simulators - CAE/METI, Laerdal, Guamard, Simulaids, Virtual Worlds - ECS, VCom3D, Breakaway, ARA, Innovation in
Learning, SAIC, MYMIC, Kognito Immersive Virtual Reality - UCF/IST, Siemens, USUHS Haptic-enabled Devices - CHI Systems, Touch of Life, Simbionix,
Mentis, CAE, Immersion, Medical Simulation Corp, Simulab
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Broad Base of Solution Providers Interactive Courseware/Web Based training – Healthstream, Medical
Curriculum Technologies, Medical Simulation Corp, Interact Medical, Websurg
Mobile Devices & Apps - VCom3D, ECS, Interact Medical, Websurg… + 4700 apps on iTunes!
Serious Games - ECS, VCom3D, Breakaway, ARA, Innovation in Learning, SAIC, MYMIC, 360Ed
Video/Data Recording/AAR- Education Management Solutions, B-Line Medical, KbPort, CAE, IVIR
Video Training, Teletraining, Telementoring, Live broadcasts, etc. – Websurg, NCSA (FL Hosp), Universities & Hospital Systems, Websurg, iTunes (Yale Health and Medicine, UC Davis Medical School (UCTV), Univ of Arizona, Stanford)
Learning Management Systems – Syberworks, Interact Medical, Medical Research Management Healthstream
Performance/Assessment Applications - IVIR, Design Interactive, Kronos
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Broad Base of Solution Providers Synthetic Cadavers/Tissue - Syndaver Labs, Operative Experience,
ASTEC (Univ of AZ), CIRS (imaging) Virtual Cadavers/Tissue - U Minn (CREST), Red Llama, Touch of Life,
Cyber Anatomy, Elsevier, BioDigital Moulage – Skedco, Enasco, Military Moulage, Moulage Sciences… Wearable Cut Suits – Strategic Operations Bleed Simulations – Skedco (wearable), embedded in other products Simulated Blood – HPS vendors, multiple sources and varying fidelity Environmental / Special Effects – Strategic Ops, KBZfx, Military Wraps…. Imaging – Digital Art Forms, GE Healthcare, Able Software, Simbionix &
Surgical Theater (pt. specific), Siemens, Phillips, MedicVision Display Systems - Barco, Intevac, VDC, RGB, DP, Panasonic Scenario, Instructor and Simulation Control Systems – METI, CAE, B-Line
Medical, EMS, GDIT, Laerdal Curriculum Development – SimMedical, Medical Sim Corp, MCT…
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How do I get smarter?
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Multiple Conferences Int’l Meeting on Simulation in Healthcare (IMSH) – 27 Jan 12 San Diego (ORL 2013) Military Health System Conference (MHS) – 30 Jan 2012 Washington DC Medicine Meets Virtual Reality (MMVR) – 9 Feb 2012 Newport Beach CA Healthcare Information & Mgmt Systems (HIMSS) – 20 Feb 2012 Las Vegas CAE/METI Human Patient Simulation Network (HSPN) – 28 Feb 2012 Tampa FL Accreditation Council Graduate Med Education Conference – 1 Mar 2012 Orlando Laerdal Simulation User Network (SUN) – 10 April 2012 Mashantucket, CT Medical Technology, Training & Treatment (MT3) – 9 May 2012 Orlando Patient Safety Conference – 23 May 2012 Washington DC AUSA Medical Symposium – July 2012 San Antonio TX Adv. Tech. Applications for Combat Casualty Care (ATACCC) – 13 Aug St Pete Bch American College of Surgeons Annual Clinical Congress – 30 Sept Chicago MODSIM (Healthcare Track) – 11 Oct 2012 Virginia Beach EMS World – 29 Oct 2012 New Orleans IITSEC 2012 – 3 Dec 2012 Orlando Other Professional Society Conferences – Too many to list
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Various “How To” CoursesFrom the Ground Up: Simulation Center Building BlocksCreating a Simulation Center
Course Description:The purpose of this course is to provide the opportunity for participants to gain knowledge and skill in planning and designing.
Course Topics:
Intended Audience:
Course Directors:William Dunn, MDGreg Coltvet, MBA, MHSM
Course Faculty:Jacqueline Arnold, MSN, RNThomas Belda, BA, RRTBrian Brost, MDDonny Dreyer, MBA, BBA, CPMRoger Nelson, BArch, AIA, LEED, APMatt Morgen, BA
Course dates and registration deadlines are listed on the Web site at:Log on to:
http://www.mayo.edu/simulationcenter/
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Mayo Clinic# Harvard Center for Medical Simulation#
WISER Center#(U Pitt)
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Useful References
Documents VA SimLEARN compendium AAMC Survey of Medical Simulation in Medical Education MedSim Magazine SSiH Journal Professional Society Journals
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Association of American Medical Colleges
Learn
Serve
Lead
Medical Simulation in Medical Education: Results of an AAMC Survey
September 2011
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Useful References
On the Web ACS Education Division Medical Modeling and Simulation Database (EVMS/
ACS) Harvard Center for Medical Simulation (1048 papers) Bristol Medical Sim Center (UK) Vendor White Papers & webinars (e.g., ems-works.com)
Websurg iTunes!!
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Business Opportunities
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Joint Program Committee
JPC-1 Chair: COL Karl Friedl, PhD Tri-Service Programmatic Committee TATRC is primary execution agent (tatrc.org)
JPC-1a Medical Simulation & Training Grew from Orlando/NCS supported JMST-IPT Efforts spawned AFSIM
JPC-1b Health Information Technology JPC-1c Decision Support Tools & Modeling JPC-8 Clinical and Rehabilitative Medicine
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JPC-1a Voting Members
US Army – PEOSTRI US Air Force - Air Education Training Command US Army - Central Simulation Committee USUHS – Nat’l Capital Area Medical Simulation Center AMEDD C&S - Directorate, Combat Medic Training AMEDD C&S - US Army EMS Office US Navy - Office of Naval Research US Air Force - Air Education Training Command US Army - RDECOM / STTC DARPA Medical Education and Training Campus (METC) Office of Naval Research
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UNCLASSIFIED
JPC-1a Structure
Combat Casualty Training Initiative
Medical Practice Initiative
Developer Tools for Medical Education
Patient Focused Initiative
AFSIM
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FY 10 Combat Casualty Training Initiative
Live tissue / sim - metrics research - $370K BCT-3 live tissue / sim study - $250K Multiple Amputee Trauma Trainer - $756K Rapid trauma skills - $498K COMETS improved capabilities - $450K Maxillofacial & Ophthalmology Trauma Trainer -
$3.1M
Award TOTAL:~$ 5,550,000
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FY 11 Combat Casualty Training Initiative
Awardees: Univ of Minnesota (PI: Rob Sweet, MD) -
$11.0M Univ of Missouri (PI: Stephen Barnes, MD) -
$5.3M Critical Research Areas ○ Trauma Airway ○ Hemorrhage ○ Emergency Medical Skills (Nerve Agent Casualty)
Goals ○ Live Animal/Simulator Comparative Research ○ Curriculum Development ○ Simulator System Gap Analysis
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UNCLASSIFIED
Medical Practice Initiative Strategic Building Blocks (MPI)
Advanced Doctor
Education System
(COMRADE)
JPC-1b EHR
Education &
Reference Integration
Virtual Human
Standardized Patients
JPC-1c Decision Support
Integration
Loss of Skills.
Retraining &
Competence
Serious Games for Training
Common Curricula & Metrics
(Tri Service Consortium
)
Military Medical Lifecycle
Counselor (DKO)
Military Medical
Simulation Masters
Development of medical training systems & competency assessment for sustained military medical readiness.
Continuous Observation of Medical Records for Advanced Doctor Education (COMRADE)
Real-time specialty specific evaluation for loss of skills & knowledge
Real world benefits:-Reduced cost for training-Reduced liability-Cost savings by replacing expensive standardized live patient teaching cases with reusable virtual human patients-Improved Tri-Service medical interoperability-Leverages Electronic Health Record system as training portal
-Can use AHLTA or another EHR
PFIDTME
CCTI
EducationalContent
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FY10 Medical Practice Initiative Projects
Medical Training Evaluation and Review (MeTER) -$515K
Training Outcomes Research Metrics - $450K Hospital disaster simulator – CBRNE Based – $2.6M Redeployment skills evaluation -$800K Tri Service Medical Simulation Training Consortium -
$2.5M Anesthesia and Anaphylaxis for Physicians $1.9M Virtual Sick Call - $773K
Total: $9.6M
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FY 11 Medical Practice Initiative Projects Navy Redeployment Skills Degradation Multiple Amputee Trainer (MATT) final year Olfaction training device & study Medical Simulation Training Consortium Years 2-3 Simulation for Futuristic Surgery (VR Urology) CBRNE Hospital Incident Management Radiological
Scenarios Ocular Craniofacial Manikin Advanced Development Medical Simulation Master’s Degree Program Student Innovations in Medical Simulation (Skunk Works) Unfunded request for large web portal hosted by Air Force Total ~$13.5 Million
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FY 12 Medical Practice Initiative Program Announcements Breadth of Medical Practice & Disease Frequency Exposure
(MPI-BMP) W81XWH-12-JPC1-MPI-BMP - $8.0M Cognitive Skill Focused
Procedural Skill Decay and Maintenance (MPI-PSD) W81XWH-12-JPC1-MPI-PSD - $4.0M Psychomotor and Procedural Skill Focused
Scope 1) Identify when and why degradation of cognitive/psychomotor and
procedural clinical skills occurs. 2)Create validated analytical tools that can predict the probable onset of
skills degradation and determine, with specificity, when skills have degraded or will be likely to degrade
3)Propose methods and tools which will enable physicians or surgeons to preemptively refresh the expected psychomotor/procedural competencies for their specialty or to preemptively refresh knowledge and maintain familiarity and fluency across the expected competencies for their specialty.
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UNCLASSIFIED
Patient Focused Initiative Strategic Building Blocks (PFI)
Advanced Virtual Reality & Augmented
Reality Training
Technology
Mobile Technology
Integration for Health & Training
Virtual Human Patients & Coaches
Physical & Neurocognitiv
e Therapy Applications
DARPA –Healing Heroes
NIH – Virtual Reality for Obesity & Diabetes
Game Industry
Technology
JPC-8 Rehabilitation, Physical and Neurocognitiv
e Rehabilitation
ICT simCoach& Emotionally
Expressive Characters
Advanced user interface and interactive technologies for healthy living, medical practice , patient rehabilitation & training
Advanced technology for training applications leveraging investments of DoD and Government Partners
Adapts therapeutic technology targeting warfighter readiness and mental health
Real world benefits:-High impact development at reduced costs, especially for VR-based training-Technology highly adaptable to training-Direct injured warfighter benefit
-Traumatic Brain Injury-Psychological Health (PTSD, Suicide)-Physical Therapy
-Adaptation of mobile and tele-health technology
MPICCTI
PARTNERSHIPS
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FY10 Patient Focused Initiatives
Vitalize Game Based Wellbeing (Kinect-based Physical Therapy Coach) $4.3M
Refining medical outcomes deployment $500K
TBI Rehabilitation Surface -$1.4M Olfaction & Resilience Research - $4.0M
TOTAL:$10.2M
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FY11/12 Patient Focused Initiatives
FY11 Natural Language Processing for Virtual Humans 3D motion tracking for rehabilitation DARPA: Healing Heroes TOTAL: ~$5.0M
FY 12 Possibilities (stay tuned) Virtual Humans for Coaching Assessment of off the shelf and easily hacked
technology for the rehabilitation, assessment and therapy environments
Mobile Technology ○ Constantly proposing SBIR topics in this area
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UNCLASSIFIED
Developer Tools for Medical Education Strategic Building Blocks (DTME)
Affordable Training Content Creation
Surgical VR Training System
Standards
Character AI
Advanced Displays & Interfaces
OS Natural Language Processing
OS Practical Physiology
Engine
OS VR Anatomy &
Haptic Platform
OS Speech & Motion
Recognition
OS Medical Asset Library
Transformational open source advanced developer tools to reduce development costs and democratize access to technology.
Based on the need to greatly reduce the burden to develop interactive medical & surgical training content.
Open Source (OS) promotes low cost and innovation
Real world benefits:-Greatly reduced development costs-Saves development time-Facilitates content creation
-Greatest need as program matures-Opens development to a more diverse and wider community-Reduced system procurement costs-Reduces redundant development
CCTI
MPICCTI
OnlinePortal
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Developer Tools for Medical Education
FY 10 Dynamic Holographic Displays & 3D in medical
education - $2.0M Tri-Service Open Platform for Simulation $3.0M
FY 11 Advanced VR Eyewear Display - $4 Million
FY 12 Public Physiology Research Platform (DTME-PRP)
W81XWH-12-JPC1-DTME-PRP - $7.0M ○ Creation of publicly accessible, free, open-license,
and/or open-source physiology platform
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Army and VHA Opportunities
Medical Simulation Training Centers TC3 MedCenters
VA SimLEARN Program Support
www.SimLearn.va.govww.simlearn.va.gov/index.asp
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Navy Opportunities
U.S. Navy is developing an R&D Agenda and Roadmap for Medical Modeling Simulation and Training The approach included a series of facilitated
workshops and a literature review completed in 2011
Findings to be briefed to senior leadership over next couple months
Stay tuned for resulting initiatives ICF supported initiative; similar to previous
USAF efforts
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Air Force Opportunities
Virtual Medical Center Request For Information (RFI) (Aug 11) Solicitation #:
N65236_SNOTE_00025EBE Agency: SPAWAR
AF Medical Modeling and Simulation Training Portal
Other VW Efforts Uses an IDIQ w/Dept of Ag.
POC is LtCol Dominquez ○ [email protected] ○ 407-208-5663
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Other MedSim Opportunities
SBIRs – Write a topic and pursue it!# BAAs#
USAF AFRL BAA 11-01-HPW ○ Aerospace Medicine, Clinical Research, Human
Performance Research, and Expeditionary Medicine USA, ARL W91CRB-08-R-0073, Amdt 5, Topic 6B ○ A--Virtual Patient technology with Virtual Worlds
technology Sources Sought - $1.6M # Commercialization of SBIR developments#
Many good solutions donʼt transition for lack of a solid business approach and investment#
Buying the IP may be a good market entry strategy….
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Simulation Market Drivers
Sim Center access mandatory requirementfor program accreditation and physician certification# http://mountsinai.academia.edu/EthanBryson/Papers/1289874/
Role_of_Simulation_in_US_Physician_Licensure_and_Certification#
Rapid expansion in simulation centers# Growing need for simulation center services# Sim Center sustainability business models#
HR 855/S616????? Proposal to allocate $50M/yr for medical simulation
assets #
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Simulation Research Opportunities
Overarching Architecture and Systems Engineering Approach
Standards and Interoperability (vs. Open Source??)
Modular Design Concepts (enabling a market for sub components)
VV&A Concepts Common Definitions and
Enumerations
Graphic Presented by Dr Roger Smith at MT3 June 2011 http://www.modelbenders.com/papers/RSmith_MT3_Interop_Panel.pdf
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Simulation R&D Opportunities
Smart Integration between Simulation, Electronic Health Records & Telemedicine
Integration of Virtual Worlds/Games with other systems
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Collaboration Opportunities
EDGE Innovation Network Sponsored (facilitated vs. controlled) by GDC4S
Not a profit center for GD Members collaborate amongst themselves at will
Open, Virtual, Collaborative Network of Industry & Academia Many GD competitors are members; over 200 members $0 full mbrship for academia/non-profits/$0 limited industry Not a funding source, no contracts or obligation with government
EDGE has multiple domain foci Currently establishing a Healthcare domain focus and recruiting
members (~50 to date) Kickoff meeting coming soon
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EDGE Innovation Network
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EDGE® Innovation NetworkKnowledge Management System
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Network MembersIndustryAcademiaNon-ProfitsBusiness Services
Vast Network of Technology Providers
End Users & CustomersGapsRequirementsNeedsFeedback
Identifying Needs & Providing Feedback on Innovations
EDGE® Innovation Centers (EIC)
Reception and Gathering AreasVisioneering & Collaboration FacilitiesPrototyping & Integration LabsDemonstration Areas & Tech Shelves
Worldwide Network of Innovation Centers to Facilitate Collaboration
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The EDGE process happens off-program, ahead of the deliberate acquisition process to integrate and demonstrate innovations. This enables rapid adoption & fielding.
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Summary Significant medical and healthcare simulation, training and education
industry exists (~200 US entities), plus foreign# Lots of applications, customers, needs to be filled#
We have a lot of existing capability to focus on the market# Many diverse and disconnected players#
Many small mom & pops (or Drʼs and Engineers)# Lots of academic players (grant vs. mentality)# Some academic business spinoffs# No medical simulation industry coordination/organization#
Simulation is by and large an accepted method for medical education, but…#
Diverse customer base with multiple constituents and drivers# Fragmented market makes business pursuits challenging# No civilian Government regulating agency (no FAA equivalent) driving
the requirements#
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Summary Simulation in Healthcare/Medicine where DoD simulation was 25
years ago# Point solutions & stovepipes# Lack of integration, limited to no interoperability# No standardization in design concepts# Limited standardized curriculum#
Lots of opportunity to apply DoD M&S lessons learned to medical# If theyʼll listen and let us!# We must learn to speak and understand the language of the customer!# Realize medical IS different! (although much is the same!!)
Orlando is a late bloomer in medical simulation# But we can make a HUGE difference in moving the timeline to the left!#
1/19/12 48 Medical Simulation Associates
Questions?
Bob Heinlein
Medical Simulation Associates [email protected]
407-719-6212 http://www.linkedin.com/company/medical-simulation-
associates
1/19/12 49 Medical Simulation Associates