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Toward Live Virtual Constructive Simulations in Healthcare Learning
Jose J. Padilla, PhD;
Saikou Y. Diallo, PhD;
Robert K. Armstrong, MS
Abstract:This article explores the combination of live, virtual, and constructive (LVC) sim-
ulations in healthcare. Live, virtual, and constructive simulations have long existed in the
military, but their consideration (and deployment) in medical and healthcare domains is
relatively new. We conducted a review on LVC its current application in the military
domain and highlight anapproach,challenges, and present suggestions for its implemen-
tation in healthcare learning. Furthermore, based on the state of the art in simulation in
healthcare, we suggest that a combination of two simulation types (LV, VC, LC) at the time
may be a simpler approach to the community at large.
(Sim Healthcare 00:00–00, 2018)
Key Words: Live simulation, virtual simulation, constructive simulation, LVC simulation, LVC
in healthcare.
The US Department of Defense (DoD) for decades has lever-
aged modeling and simulation (M&S) to provide effective and
realistic training to warfighters. Within this context, there are
three major types of simulation typically used to deliver
warfighter training: live, virtual, and constructive (LVC). A
training simulation is considered live or a live simulation if
all the roles are played by human beings in a real environment
with real systems. A training simulation is considered virtual if
some roles, systems, and/or the environment are represented
via a computer program, mathematically and/or graphically.
A training simulation event is considered constructive if all
the roles, the systems, and the environment are represented
via a computer program.
The decision to use a live, virtual, or constructive training
event is driven by time, level of effort, available resources
(trainers, computers, money, etc), and the desired learning
outcomes. As the complexity of DoD training requirements
increases and the need to use and reuse M&S assets grows,
we are reaching the limits of a single paradigm, tool, or ap-
proach. Consequently, the idea of generating mixed LVC sim-
ulations to account for the increased complexity of training
and education needs has begun to take hold.
1
Several LVC ar-
chitectures and frameworks have been proposed by the DoD
2,3
and cyber domains.
4
Typically, LVC solutions focus on simultaneously training
a large group of individuals that would not be able to physi-
cally train together (geographically dispersed), playing distinct
roles at different levels of responsibility, and at lower compar-
ative costs (logistics, equipment, manpower) to develop coordi-
nation and communication skills in large-scale challenging
scenarios. Technologically, to achieve these goals, LVC training
systems have (1) large heterogeneous components at multiple
levels of resolution and aggregation, (2) some components
that execute in parallel (run simultaneously to save time) over
a common network using a set of interoperability protocols
such as the distributed interactive simulation standard or the
high-level architecture standard, and (3) components that
are distributed geographically connected via networks. These
complex LVC training solutions are not without challenges,
including the following: data engineering issues such as the ad-
ministration, management, mapping, and transformation of
data between simulations; technical issues such as network se-
curity, data latency, and data consistency; and conceptual is-
sues such as the alignment of assumptions, the underlying
models, and their implementations. Resolving these challenges
is time-consuming, expensive, and error-prone, which is per-
haps why LVC simulations are not the norm even in the DoD
domain. Given the level of complexity and challenge faced by
the well-resourced and centralized DoD when employing LVC
training, should (or can) elements of the complex healthcare
domain adopt LVC?
The answer is potentially. There are scenarios where using
LVC to establish a parallel, distributed, interoperable set of
simulations and simulators applies to the healthcare domain.
One LVC use case includes creating a “digital human.”In this
case, LVC provides the framework and architecture to inte-
grate different models of human physiological systems that,
when combined, create a digital human. Another LVC use case
involves training for a mass casualty response. In this case, an
LVC training simulation can incorporate multiple types of train-
ing simulations that, together, can provide integrated training
solutions for everyone from first responders, dispatchers,
emergency department personnel, surgical teams, and hospital
clinical staff. This type of LVC simulation can include the op-
portunity to manage a myriad of issues, such as disaster site
management, transport, routing, triage, staging, and supply
management. The LVC event might also include other local,
state, and federal disaster management teams training from
their own facilities.
These use cases demonstrate that LVC simulations have
the potential to allow us to explore complex training scenarios
From the Old Dominion University (J.J.P., S.Y.D.); and Sentara Center for Simulation and
Immersive Learning, Eastern Virginia Medical School (R.K.A.), Norfolk, VA.
Reprints: Jose J. Padilla, PhD, 1030 University Blvd, Suffolk, VA 23435
(e‐mail: jpadilla@odu.edu).
The authors declare no conflict of interest.
Copyright © 2018 Society for Simulation in Healthcare
DOI: 10.1097/SIH. 0000000000000317
IMSH Research Summit Article
Vol. 00, Number 00, Month 2018 1
Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
that involve healthcare situations alongside other factors,
teams, systems, and roles. In this article, we explore the appli-
cability of LVC simulation in the healthcare domain. The arti-
cle is organized thusly: Section 1 briefly describes LVC in the
context of DoD and consideration for transition out of DoD.
Section 2 provides an approach and potential challenges to im-
plement LVC simulations in healthcare domain. Sections 1
and 2 inform Section 3 looking at how LVC simulations are
seeing in healthcare. Section 4 provides examples of LVC in
the context of healthcare, and Section 5 provides a discussion
on LVC in healthcare followed by the conclusion.
TRANSITIONING LVC SIMULATIONS OUT OF THE
MILITARY DOMAIN
Regardless of the resources available, publicly funded organi-
zations are often asked to deliver services more efficiently
and cheaply, but without compromising quality and value.
This exact problem existed in the US Army between 1991
and 2000. During that decade, live warfighter training budgets
were dramatically cut. In response, the Army used virtual and
constructive simulation as an effective and affordable means to
keep the force trained. During this period, deployments in-
creased 400 percent, yet the Army remained trained to a very
high level.
More recently, a mix of LVC simulations have been suc-
cessfully used reduce the cost to train senior warfighting staffs.
Instead of using actual warfighting assets (ships, units, planes,
tanks, etc.), DoD has employed constructive simulations.
These simulations enable distributed training worldwide. Ex-
amples of this form of LVC simulations include the following:
(1) the Ulchi-Freedom Guardian, an annual yearly US and
South Korea event focused on defense of the Korean penin-
sula; (2) the NATO Pathfinder program, which integrates var-
ious NATO country simulations; and (3) the Swedish-initiated
VIKING Computer-Assisted Exercise (CAX), which prepares
civilians, police, and military for crisis management and disas-
ter response.
The healthcare domain is ripe for adopting aspects of the
LVC paradigm. This is due to several factors: (1) the need to
foster collaboration and trust under stressful medical situa-
tions, (2) the need for repeatable training scenarios, which
may be challenging in live conditions, and (3) the need to
make training available to more people and at more locations,
simultaneously. According to Paige and Chauvin,
5
operating
rooms are highly dynamic environments in which effective
teamwork is crucial for patient safety, yet it is common to find
poor communication and disruptive behavior within these en-
vironments. A well-deployed LVC simulation can provide a
realistic training event that helps complex and distributed
teams to overcome significant performance challenges.
Although LVC is used mostly in support of training in the
military, the concept can be extended to the nonmilitary
world. Table 1 provides a parallel between the military world,
where LVC simulations are currently used, and the nonmili-
tary world, where LVC solutions are lacking.
Table 1 summarizes some characteristics that military and
medical and healthcare organizations share:
•Size: Both types of organization are divided into echelons
overlaid with a leadership structure at each level;
•Leadership: Both types of organizations are often controlled
with a top-down approach where orders/directives emanate
from the top and are propagated and executed downward
with built-in independent decision-making;
•Governance: Both types of organizations have a well-defined
mission and vision and follow a unified set of codified pro-
cedures not only at the organizational level but also within
each echelon;
•Context: Both types of organizations deal with other similar
types organizations and often operate in more than one
country. In addition, both types of organizations are made
up of branches and divisions that play a specific and some-
times independent role in the organization;
•Aspect: Both types of organizations require multiple aspects
of their activities to function in unison to be effective.
Based on these shared attributes, we can loosely state that
LVC simulations are useful in the context of a System of Sys-
tems (SoS). In theory, SoS approaches such as soft-system
methodology
6
are supposed to be considered better alternatives
to the traditional system engineering approach to LVC because
they provide a holistic view and therefore gives developers more
opportunities to detect potential problems. However, these ap-
proaches are extremely difficult to implement in nontrivial
cases, because they are usually more time-consuming and cost-
lier. In addition, this approach is not always feasible because of
its inherent complexity to build a model. We use M&S concepts
to model and study the SoS. Modeling and simulation can be
used to represent and study organizational challenges using live
simulations such as focus groups, surveys, and role-playing. It is
alsopossibletohavelivemembersoftheorganizationinteract
with a virtual computer simulation of the technical components
of the system. We focus on the M&S approach to building LVC
simulations in the next section.
APPROACH AND CHALLENGES of LVC
To the authors' knowledge, there is not an approach for devel-
oping LVC solutions. As such, because LVC is at its core a fed-
erated approach to M&S, we depart from the Distributed
Simulation Engineering and Execution Process
7
to identify
overarching steps to obtain a generic LVC. Figure 1 shows
the suggested approach. It is noted that the development of
TABLE 1. Shared Characteristics, Conducive to LVC Initiatives, Between Military and Civilian Organizations
Characteristics Military Organization Nonmilitary Organization
Size Unit, company, brigade Department, unit, division, subsidiaries
Leadership Operational, strategic, tactical Senior management, midlevel management, team leaders
Governance Doctrine, tactics, techniques, procedures Strategic plans, individual goals, manuals
Context Joint, coalition, service Multinational, divisions, branches
Aspect Human, social, cultural, behavioral, kinetic Leadership, management, organizational, technical, social
2Towards LVC Simulations in Healthcare Learning Simulation in Healthcare
Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
this approach was informed by a low-cost in-house prototype
developed by the researchers.
Healthcare domain experts need to be at the center of an
LVC effort for these steps to take place. They are the ones that
provide the training scenarios and generate the requirements
for those scenarios to be successful. Domain experts will cut
across the different areas that require training. For instance,
if training for a disaster, individuals with expertise on proce-
dures conducted by paramedics, emergency department per-
sonnel, and hospital administrators must be present to
design scenarios and means for evaluating whether training
of such procedures is taking place.
The design phase is centered on the identification and
specification of a reference model
8
that captures the problem
or situation that we intend to study. This model includes all
relevant actors, activities, behaviors, and interactions. At a high
level, we associate activities that involve only human actors,
behaviors, and interactions with the live component. Similarly,
we associate activities that involve only machine actors, behav-
iors, and interactions with the constructive component and ac-
tivities that involve a mix of both with the virtual component.
During the data phase, we apply model-based data engi-
neering.
9
This data phase extends the reference model speci-
fied in the design phase by adding relationships between
activities and actors, further specifying attributes, data types,
and value domains. At the end of this phase, we have a well-
defined data model specification that encapsulates the data ex-
change needs and capabilities, with the appropriate resolution
and scope. The implementation phase focuses on establishing
simulation development and/or integration of LVC simula-
tions across computers in separate locations. The manage-
ment phase ensures that the LVC project accomplishes its
goals and meets its requirements. The verification and vali-
dation (V&V) phase consist of developing a V&V plan for
the LVC simulation. Rather than being isolated, the V&V
phase is done in close connection with all other phases from
design to implementation.
It is important to note that this process requires a team of
experts, namely domain knowledge expert (healthcare), sys-
tems engineers, M&S professionals, data engineers, distributed
simulation professionals, federation managers, and V&V
professionals. Such variation in expertise and activities re-
quired generate a myriad of challenges.
An LVC federation, a combination of simulation systems
exchanging data via a platform, common language or tem-
plate, presents challenges not found in live, virtual, or con-
structive federations individually. In general, the challenges
are related to the design and specification phase and in the ex-
ecution phase. In the design phase, it is often very difficult to
identify and represent entities and their interactions along with
their existential dependencies and their transformational de-
pendencies. In the implementation phase, synchronization, data
distribution management, multiresolution, and multiscope is-
sues are sources of increase in time, number of errors, and cost.
Although these challenges need to be addressed separately and
holistically, they only cover the technical aspects of the problem.
On the other hand, and considering Table 1, there needs to be
healthcare professionals with knowledge of procedures that
require training across the mentioned characteristics. For in-
stance, deciding what, and how, to train large groups of indi-
viduals across departments and organizations that requires
the simultaneous involvement of different levels of leadership
is a complex task.
LIVE, VIRTUAL, AND CONSTRUCTIVE IN
HEALTHCARE LEARNING
The healthcare domain uses virtual and live training simula-
tions extensively. According to Scerbo,
10
“many in our health-
care simulation community are familiar with live and virtual
forms of simulations that incorporate mannequins, part-task
trainers, virtual reality (VR) systems, and standardized patients.”
However, and based on the same article, Scerbo
10
highlights the
following: (1) the scarce presence of constructive simulations,
(2) the consideration of adopting LVC simulations from the
military, and (3) the embracement of simulation beyond training.
On activities beyond training, Scerbo
10
posits that simulation for
testing in healthcare is gaining acceptance as “simulation centers
work with medical device manufacturers to provide context-
based user evaluations of equipment before seeking US Food
and Drug Administration approval.”This is consistent with
the military M&S literature as LVC is applied to activities such
as testing
11,12
and analysis.
12
On constructive simulations,
FIGURE 1. Adapted DSEEP into an LVC Methodology.
Vol. 00, Number 00, Month 2018 © 2018 Society for Simulation in Healthcare 3
Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
Scerbo
10
presents that “there is a great potential for these types
of systems. They can be used for modeling the delivery of
healthcare services, inform providers and administrators
about potential impact of policies, and incorporated into live
and virtual scenarios to enhance the environmental and oper-
ational context.”While works by Diaz et al
13
provide insight
into how constructive simulation can be applied to healthcare,
more cases can indeed be found in traditional M&S outlets,
such as Society For Simulation International and Association
for Computing Machinery conferences and journals such as
Simulation: Transactions of the Society for Modeling and Simu-
lation International and Journal of Simulation, among others.
Works by Brailsford et al,
14
Gunal and Pidd,
15
and Duguay
and Chetouane
16
to mention a few showcase the positive ap-
plication of constructive simulations in healthcare.
However, LVC does not seem to be on the radar of health-
care researchers or educators. Searching in the Simulation in
Healthcare journal (as the main simulation in healthcare outlet),
there is only one return referring to the live virtual constructive
entry: Scerbo.
10
The work of Phrampus et al
17
provides a de-
scription of a detailed setting that could implement LVC for
training (Ebola readiness) and there seems to be a simulation
implementation, but the authors could not assess whether the
implementation was LVC.
Looking at the Society for Simulation in Healthcare (SSH)
Simulation Dictionary,
18
the authors assessed keywords in the
context of M&S (as in the M&S community at large) and
simulation in healthcare (as in the M&S community that
specializes in healthcare or the healthcare community that
relies on simulation products and services) as it relates to
LVC. The assessment seeks to identify the most likely use of
the keyword on both communities. It is noted that the assess-
ment was conducted by the authors lending potential bias to
the result. Table 2 shows a sample of the keywords assessed.
Table 2 shows the assessment of terms, live (L), virtual
(V), constructive (C), LVC (live virtual constructive), lv (live
or virtual), and lvc (live or virtual or constructive). Lower case
“lv,”“vc,”and “lvc”are used to convey that terms are used in
either domain but not necessarily combined. Terms such
as immersion, modality, and realism are used in M&S as
either live or virtual or constructive and in LVC but are
not unique terms to LVC like distributed simulations or
system integration.
Table 2 shows red, yellow, and green rows highlighting
the level of matching or overlapping of terms on both contexts.
Red rows show where the term does not reconcile or does not
exist in either context. For instance, the terms incognito stan-
dard patient or distributed simulation seem specific to each do-
main (healthcare and M&S respectively). However, terms such
as advocacy and inquiry may be conducted under a different
name in M&S. A term close in meaning is that of accreditation,
which is not found in the dictionary. Yellow rows show terms
that are overlapping. Terms such as computer-based simulation
andsimulatoroverlaponbothM&Sandsimulationinhealth-
care because they both refer to virtual simulations. However,
computer-based simulation and simulator are also used in
the M&S community as a form of constructive simulation.
Lastly, green rows show where the terms on both context
match. Terms such as virtual reality, discrete-event simulation,
and embedded participant are used consistently on both communi-
ties to refer to virtual, constructive, and live simulations respectively.
Finally, Table 2 provides two insights as we move LVC to
the medical/healthcare domain: (1) reliance on combination
of two forms of simulation (LV, LC, VC) to implement more
complex training/testing scenarios. Table 2 shows that the lv
combination is already widely used in the simulation in health-
care community and (2) moving toward LVC simulations may
rely on considering the inclusion to these lv cases of constructive
solutions. For instance, discrete-event simulations could pro-
vide the consideration of a large number of patients to an emer-
gency department, while training using haptic and embedded
patient is taking place. This provides training to different indi-
viduals at different levels within an organization ranging from
higher-level management to people in emergency departments.
LIVE, VIRTUAL, AND CONSTRUCTIVE
HEALTHCARE-RELATED TRAINING EXAMPLES
Documented cases of LVC exercises that include healthcare
training are scarce. As mentioned, perhaps the best-known
case is the Viking CAX.
19,20
The Viking CAX series are distrib-
uted computer-assisted exercises that provides joint training to
military, police and civilian units from different countries.
Training focuses on cooperation in peace operations and crisis
situations. According to the Swedish Armed Forces Web site,
21
Viking CAX 18 will take place in April 2018 with 2500 partici-
pants from 50 countries and 35 organizations participating from
sites in Sweden, Brazil, Bulgaria, Finland, Ireland, and Serbia. The
TABLE 2. Context Comparison Using Sample Keywords From SSH Simulation Dictionary
Context
Keyword M&S Healthcare
Avatar V V
Advocacy and inquiry* Not used LV
Briefing lvc lv
Computer-based simulation vc V
Discrete-event simulation C C
Distributed simulation LVC Not used
Embedded participant L L
Fidelity lvc lv
Guided reflection lvc lv
Haptic V V
Immersion lvc lv
Incognito standardized patient Not used L
Just-in-time simulation C lv
Low fidelity C lv
Modality lv lv
Multiple modality** lvc lv
Nontechnical skills* lvc lv
Objective Structure Clinical Examination* Not used lv
Prebrief lvc lv
Process-oriented simulation lvc lv
Realism lvc lv
Scenario lvc lv
Serious games vc lv
Simulated person lvc lv
Simulator vc v
Systems integration LVC lvc
Task trainer lvc lv
Virtual reality V V
4Towards LVC Simulations in Healthcare Learning Simulation in Healthcare
Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
exercise is coordinated by the Swedish Armed Forces and the
Folke Bernadotte Academy (Swedish government agency for
peace, security, and development). The Viking CAX exercise
has taken place seven times since 1999.
Bolcar and Collins
20
highlight other exercises that involve
LVC. The SEESIM (South Eastern Simulation Network) CAX
in 2002 worked out of an earthquake scenario with damages
through the Southeastern Europe forcing nations “to determine
what outside assistance is required, make the request for assis-
tance, and coordinate external support.”The Joint Theater Level
Simulation, a multisided simulation system focusing on opera-
tional level of war, was distributed from Athens, Greece, to nine
sites in Southeast Europe (Greece, Turkey, Bulgaria, Romania,
Former Yugoslav Republic of Macedonia, Croatia, Slovenia,
Albania, and Italy). The lessons learned from this exercise
identified the following needs
20
:“standardization of message
formats and response procedures, development of a regional
training program on standard procedures, establishment of a
reliable means of national communications, and a relevant,
challenging, and realistic scenario to meet training objectives.”
Smaller-scale exercises occur across municipalities in the
United States. However, we found no evidence that the few
documented cases are LVC. They are either live or virtual with
few combining live and virtual. Figure 2 shows a small demon-
stration of an LV exercise taking place at MODSIM World
2010 in the City of Hampton, Virginia. The exercise focused on
police forces (live) neutralizing a shooter (live), securing the site
and aiding a victim (virtual) until paramedics (live) arrived. Para-
medics then proceeded to stabilize the victim and wheeling out
in their ambulance. The exercise provided training to first re-
sponders across organizations (police and paramedics).
Lai et al
22
provide an LV simulation-based training sce-
nario for emergency medical first responders. Training focuses
on communication, decision-making, allocation of resources,
adaptation, and hazard protection. Scenarios are built around
a mannequin and people: the mannequin (virtual) acts as vic-
tim 1, motionless after being exposed to a chemical agent, and
a person (live) acts as victim 2, tending to the motionless indi-
vidual. Trainees need to assess the danger while protecting
themselves and complete a protocol that may include other in-
dividuals (live).
Cases that consist of a combination of two simulation
types require role coordination without necessarily encumber-
ing into interoperation efforts.
The crisis response community, police, paramedics, nurses,
etc do have options for conducting realistic training without
LVC. Disaster City (Texas A&M), for instance, provides a large
site where emergency responders can train for rescuing and
tending individuals among rubble of metal and glass. However,
this training takes place in one location leaving out parties that
could benefit from such a training at different levels of decision-
making that are not field personnel.
DISCUSSION AND CONCLUSION
Purpose drives all simulation efforts. The challenge is identify-
ing whether live or virtual or constructive or a combination
thereof is required to satisfy the training objectives under cost
and other constraints. In terms of LVC simulations training
frequency, training at different levels of leadership across
departments/organizations and training for different skills
among others drive implementation decisions.
The following are some guiding questions when consider-
ing the implementation of an LVC initiative:
•What is the purpose of the training exercise?
•Would live, virtual or constructive simulations serve the ex-
ercise purpose?
•Would combination of LV or LC or VC serve the exercise
purpose?
•Does the LVC exercise event provide multilevel (from coor-
dinators to operators) training/planning capability?
•What is the number of personnel and equipment?
•Does the event support inter-department/interorganization
training/planning capability?
•Do the personnel need to train simultaneously?
•How do we assess that the LVC exercise was successful?
•What is the frequency of these exercises?
•Would we rely on existing simulations that require
interoperation support?
It is important to note that the healthcare domain has a
comparative disadvantage to DoD to implement LVC initia-
tives: DoD is a large customer with a large budget. While
spending in healthcare is increasing as an aggregate, advance-
ment is driven by industry products to satisfy training but
not at large scales. This is where agencies such as FEMA (Federal
Emergency Management Agency) could play a leading role into
developing not only LVC initiatives for crisis response but also
low-cost LVC initiatives that can be used frequently across the
country. Ultimately, these exercises provide lessons learned
that advances not only the development of new and relevant
scenarios and the readiness of organizations/agencies but also
FIGURE 2. Live Virtual Demonstration at MODSIM World 2010.
Vol. 00, Number 00, Month 2018 © 2018 Society for Simulation in Healthcare 5
Copyright © 2018 by the Society for Simulation in Healthcare. Unauthorized reproduction of this article is prohibited.
the technical infrastructure required to conduct those exer-
cises, as was the case in SEESIM CAX 02.
In the meantime and considering that virtual simulations
are widely used in the medical/healthcare domain, we must
consider how to combine it with live and/or constructive op-
tions. A combination of two forms of simulation may be easier
to implement and more cost-effective for a domain that still
needs to decide whether LVC is a viable option. Considering
LV, VC, or LC combinations may result in advances in
training/education at lower costs with readily accessible tech-
nology. For instance, the simplest one to consider is the LV
combination. Live simulations could involve role-play to de-
velop communication and coordination skills, whereas man-
nequins provide the virtual simulations support for varied
training objectives. Both exercises are available without tech-
nological or interoperation limitations. The requirement is
then to develop the use case/scenario where such exercise pro-
vides the desired learning objectives. Similarly, the LC combi-
nation has low technological and interoperation challenges.
This combination could be used for emergency response at
a hospital. Hospital decision-makers could use the concept
of a digital table top exercise where they train for an emer-
gency with the input from a constructive simulation. Live
simulation would support communication and coordination
training. The constructive simulation would support analysis
and experimentation.
On the other hand, the VC combination runs into all the
challenges mentioned previously. Ultimately, the M&S com-
munity needs from the medical and healthcare communities
use cases where these combinations can be tested, and their
effectiveness evaluated. As such, collaboration of these com-
munities and the M&S community is key.
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