Care Without Walls
How military medicine, distributed diagnostics and emerging technology could redefine remote healthcare in Canada
By Trina Diner
The hospital without walls
For decades, we have tried to solve remote healthcare by bringing remote patients into a healthcare system designed around hospitals.
Sometimes that means flying a patient out. Sometimes it means a visiting specialist. Increasingly, it means video, sometimes with limited peripheral equipment.
Video is important. But video alone has a limit.
A physician can see the patient, talk to the patient and direct a nurse through an examination. But there is a point where the physician needs information that a camera cannot provide: a laboratory result, an ECG, an ultrasound, an X-ray, a medication, or a blood product.
That is where I think the next generation of remote healthcare begins.
Remote Canada is not simply underserved—it is differently designed
For this discussion, I use a practical definition of remote: communities more than three hours from a town of 100,000 people.
That definition is not a clinical or governmental standard. It is a way of describing a systems problem: at some point, distance becomes sufficiently large that the normal assumptions of urban healthcare stop working.
In Northwestern Ontario, this is not an abstract problem. The region is enormous, communities are dispersed, and many Indigenous communities rely on local nursing capacity and visiting or virtual clinicians.
The foundation for video already exists. The question is what comes next.
The next step is Distributed Medicine
I think it is tempting to describe the next generation as 'better telemedicine.' I don't think that is quite right.
The next generation is distributed medicine.
The clinician can be somewhere else. The laboratory can be somewhere else. The specialist can be somewhere else. The pharmacy can be somewhere else.
But the diagnostic and treatment capability has to be available where the patient is.
That means turning a remote clinic into something more like a small, connected clinical node.
The remote examination room
The room contains connected diagnostic tools: ECG, digital stethoscope, otoscope, dermatoscope, pulse oximeter, blood pressure, temperature, retinal imaging and point-of-care laboratory equipment.
The remote physician can request tests, watch it being performed, see the result and incorporate it into the clinical decision.
This is fundamentally different from a video visit. The video is only the communication channel. The real system is the combination of people, devices, information, workflow and clinical expertise.
Ultrasound shows what this could become
Ultrasound is particularly interesting because the equipment is portable and the barrier has often been the availability of someone trained to perform and interpret it.
Researchers in Canada demonstrated a mixed-reality tele-ultrasound system between Skidegate, British Columbia and experts at the University of British Columbia in Vancouver, 754 kilometres away. Novice operators performed scans under remote expert guidance. The study reported that human teleoperation was feasible at that distance.
Instead of asking, 'How do we get an ultrasound specialist to the community?' we can ask, 'How do we allow an appropriately trained person in the community to perform an examination under remote guidance?' That is a much more scalable question.
Diagnostic Imaging is the harder problem—and therefore the interesting one
Diagnostic Imaging illustrates why this isn't simply a technology shopping exercise.
A portable system may be physically small, but safe operation involves radiation protection, training, positioning, image quality, quality assurance, interpretation, maintenance and regulation.
The answer cannot simply be to put a machine in every nursing station. But that doesn't mean remote radiology is impossible.
It means the system needs to separate the functions: trained local acquisition, remote interpretation, quality assurance and appropriate governance.
That is exactly the sort of decomposition that modern military medicine has repeatedly been forced to make: what has to be at the point of care, what can be remote, and what can be automated?
AI as a force multiplier—not a replacement
Modern military medical research is increasingly concerned with meaningful capability when highly trained specialists are not physically present. The Department of Defense's Prolonged Care portfolio explicitly includes far-forward diagnostics and treatment in austere, remote and resource-limited environments.
AI could become an important force multiplier. It might help assess image quality, flag an abnormal ECG, help identify findings on an X-ray or ultrasound, or prioritize cases for specialist review.
But I would resist the seductive idea that the solution is 'AI replaces the specialist.' The more powerful model is: AI increases what the local clinician can know. Remote specialists increase what the local clinician can do. The technology connects the two.
Laboratory medicine may be the quiet revolution
One of the biggest barriers in remote healthcare is physical. The patient may be in the community, but the laboratory is somewhere else.
A sample has to be collected, packaged, transported, received, processed and reported.
Point-of-care testing changes that equation. Some tests can increasingly be performed where the patient is, producing information quickly enough to influence the encounter rather than merely document it afterward.
Other samples will still need centralized laboratories. That is where logistics technology becomes part of clinical care.
The drone is not the healthcare system
We are asking the wrong question when we ask whether drones can deliver medical supplies.
Of course they can.
The more important question is whether we can build a healthcare logistics network that determines how a specimen, medication, vaccine, blood product or piece of equipment should move.
Sometimes the answer will be a drone. Sometimes an aircraft. Sometimes a truck. Sometimes a boat. Sometimes a person.
The drone is simply another transportation mode in a distributed system.
Canadian research has demonstrated the feasibility of using drones for diagnostic kits, medical supplies and remote ultrasound delivery to remote communities.
Prolonged care changes the design
Military medicine is increasingly preparing for situations in which evacuation may be delayed. Its Prolonged Care portfolio focuses on the ability to provide more definitive care farther forward when access to higher levels of care is constrained.
Remote locations in Canada have a civilian version of this problem. The reason may be weather rather than enemy action. A flight may be cancelled. A road may be closed. A patient may be too unstable to move immediately. A specialist may not be available.
The system still has to care for the patient.
That suggests a different design goal for remote healthcare: don't design only for rapid evacuation. Design for the period before evacuation as well.
The remote clinic as a resilient clinical node
Imagine a community clinic that can operate in several modes.
Normal mode: video consultation, connected diagnostics, point-of-care testing and routine medication supply.
Limited-connectivity mode: store-and-forward images and results, asynchronous specialist consultation and locally cached clinical information.
Transportation disruption: local medications and supplies, with alternative logistics routes.
Extended disruption: enough diagnostic capability, medications, communications and clinical decision support to manage patients safely while the regional system responds.
That is not a military clinic. It is a resilient civilian healthcare node. But the thinking comes from the same problem military medicine has been forced to solve: how do you maintain meaningful care when the next level of the system is far away?
The opportunity is bigger than healthcare
A resilient remote healthcare network could share infrastructure with emergency management, search and rescue, education, community services and other essential systems.
Connectivity supports healthcare, but also emergency response. A drone network supports healthcare logistics, but can also move other essential supplies. A regional diagnostic hub supports remote clinics, but also improves coordination of conventional hospitals.
The same infrastructure that makes a remote community healthier can make it more resilient to wildfires, severe weather, transportation disruption, pandemics or other emergencies.
The ethical question matters
Remote healthcare technology cannot become an excuse to provide remote communities with a permanently second-class version of healthcare.
The goal should not be 'they can have telemedicine instead of specialists.' The goal should be that a person in a remote community can receive the appropriate level of clinical assessment and treatment without being forced to travel simply because the healthcare system was designed around urban geography.
Technology should reduce the burden of distance, not institutionalize it.
What I think the future looks like
I don't think the future is a hospital in every community. I also don't think the future is every patient being transported to a hospital.
I think it is something in between.
A network of small, capable clinical nodes connected to regional centres and tertiary expertise. Local clinicians with better diagnostic tools. Remote specialists with better information. AI assisting both. Laboratory capability distributed according to what makes clinical and economic sense. Medications and samples moving through an intelligent logistics network. Conventional hospitals reserved for the things that genuinely require a hospital.
The hospital without walls
That is what I mean by a hospital without walls.
The hospital doesn't disappear. Its capabilities become distributed.
The specialist can be somewhere else. The radiologist can be somewhere else. The laboratory can be somewhere else. The pharmacy can be somewhere else.
But the patient doesn't have to be.
I think that may be the next major evolution of remote healthcare.
And it is why I find the lessons coming from military medicine so useful—not because civilian healthcare should become military healthcare, but because military medicine has repeatedly been forced to ask a brutally simple question:
What do you need to make good care possible when the hospital is too far away?
Remote Canada has been asking essentially the same question for decades.
Perhaps we finally have enough technology to answer it differently.
Sources and Further Reading
Evolution of Military Medical Technology — U.S. Military Health System — Military medical technology timeline including MEDEVAC, diagnostics, computing and telemedicine.
https://www.health.mil/About-MHS/Military-Medical-History/Historical-Timelines/Evolution-of-Military-Medical-Technology
Prolonged Care Portfolio — U.S. Army Combat Casualty Care Research Program — Current military research emphasizing far-forward diagnostics and treatment in austere, remote and resource-limited environments.
https://cccrp.health.mil/portfolios/prolonged-care/
Telehealth — First Nations Health Authority — Current description of telehealth for remote and rural First Nations communities, including specialist access.
https://fnha.ca/services-and-support/access-and-support/health-and-virtual-services/telehealth/
NORTH Network — Ontario government archive — Ontario history of remote telemedicine using video, digital stethoscopes, examination cameras and diagnostic imaging.
https://news.ontario.ca/en/backgrounder/6418/mcguinty-government-expands-healthcare-access-in-far-north-communities
Mixed Reality Tele-ultrasound over 750 km: A Clinical Study — Canadian demonstration of remote expert guidance of novice ultrasound operators in Skidegate, BC.
https://arxiv.org/abs/2409.13058
The use of drones for delivery of diagnostic test kits and medical supplies to remote First Nations communities during Covid-19 — Canadian study examining drones for diagnostic kits, supplies and remote ultrasound delivery.
https://pmc.ncbi.nlm.nih.gov/articles/PMC9329072/
New DI central intake implemented in Northwestern Ontario — Example of regional coordination of diagnostic imaging referrals across Northwestern Ontario.
https://www.canhealth.com/2024/08/21/new-di-central-intake-implemented-in-northwestern-ontario/