5

Applying Technology to
Real-Life Problems

In this session of the workshop, there were seven quick presentations about innovative technologies and systems that are being used to train and educate health professionals and students. Each innovator gave basic information about the technology and how it worked, and then workshop participants were invited to walk around the room to ask the presenters questions and try out the technologies that they brought. Afterward, participants and presenters engaged in an open-ended discussion about issues that arose.

RAPID FIRE POSTER SESSION

Digital Clinical Experiences

Rob Kade and Benjamin Lok of Shadow Health Inc., talked about their program that simulates a clinical experience in order to allow students to learn communication skills and clinical reasoning. Lok said that health professions students are leaving school without the skills they need to communicate with patients and to think through complex patient situations. This lack of skills results in negative patient outcomes and poor communication with patients as well as other team members, he said. To remedy this situation, Shadow Health built a curriculum of virtual simulation experiences using virtual patients that are “realistic people and have a story behind them” (Shadow Health Inc., 2018). These patients have belief systems and personalities, and “challenge students to get the whole story.” For example, “Rachel” is a teenager who wrecked her parents’ car, and “Eric” is an adult who thinks he may be hav-

ing a heart attack. Using the technology, students act as health providers and interact with these patients; they can ask questions, do physical exams, and observe the patient. The system documents each action the student takes, and provides feedback. One patient the workshop participants interacted with was “Tina,” who was having difficulty breathing (see Figure 5-1). Lok explained that as students interact with Tina, the program records everything that is said and flags places where the provider could have done something differently. The program also scores the student on both process (the questions that were asked) and outcome (whether the conclusion was correct). During the course of the interaction, Tina told the provider that her father recently died. The program flags this as a potential time for connection and empathy. Lok said he believed this program would help tackle issues such as cultural competency and patient-centered care in a safe and accessible digital world.

vSim for Nursing

vSim for Nursing is a computer simulation that focuses on clinical reasoning, critical thinking, competence, and building the confidence of nurses in training, said Jeanie Staton and Robin McCune. vSim allows students to interact with patients in a safe, realistic environment through various online nursing scenarios, and it allows learners to “make mistakes here in

the virtual world instead of the real world.” The simulation requires the user to click through the correct path of treatment, and each decision is recorded and measured against a validated algorithm that generates a user proficiency score. The user may go through one scenario multiple times, either to increase their proficiency score or to maintain competency in a skill set. There are currently 72 virtual nursing scenarios, said McCune, ranging from mental health to maternity. The program also includes instructor tools to assist with monitoring progress and assessing comprehension.

vSim can be used by nursing schools as well as in health care practice settings and has helped address some of the challenges in nursing education and training (Laerdal, 2018). For example, Midlands Tech in South Carolina has 400 nursing students per year, and was struggling to find clinical placements for all of their students, with some students traveling long distances to reach their designated locations. The college replaced a portion of their clinical experience with the vSim program, saving time and money while still allowing students to learn in a realistic clinical setting. Another user of the program, University of North Carolina Women’s Hospital, was looking for a way that nurses could maintain their competency in high-risk, low-frequency obstetrics events. The hospital did conduct regular team training using traditional patient simulation, but these trainings were spaced out; using vSim in between these sessions allowed nurses to maintain their competency in a cost-effective and efficient way. McCune said they have seen high levels of engagement and enthusiasm from users of the technology. Students are motivated by the scoring system that demonstrates proficiency and creates a friendly competition among fellow students that drives them to continue using the program.

ReelDx

ReelDx is “focused on bringing the real patient experience to learners in their classrooms or online,” said Bill Kelly. Rather than using virtual patients, ReelDx uses videos of real patient experiences in clinical and preclinical settings, primary and acute care (e.g., paramedic interactions, emergency rooms, or physician practice). There are more than 700 video cases of patients, all of which are made with strict conformance to the Health Insurance Portability and Accountability Act (HIPAA) and with fully informed patient consent (ReelDx, 2018). Kelly said that these patient cases are designed to “plug into any curriculum as case study material or to anchor problem-based learning.” Professors can select cases and assign them to students in conjunction with classroom teaching. Each video comes with patient vitals and demographics, differential diagnosis, actual outcomes, and peer-reviewed standards of care. Many cases also include diagnostic elements such as ultrasound clips, X-rays, EKG, or lab results. Educators can not only choose what cases but what case details to reveal to students,

providing an opportunity for both synchronous and asynchronous learning activities. These video-based real patient cases can be used for a wide variety of purposes, said Kelly, from elucidating classroom discussion to full integration in simulation labs. The videos are “learning objects that can be leveraged in the course of whatever instructional model you are using,” he added.

Filament Games

Filament Games is a design and development studio that “focuses exclusively on learning games and games for positive impact,” said Dan Norton. The studio has developed more than 100 game-based training projects over the past 11 years, but the move into health training is fairly new (Filament Games, 2018). One recently designed health project is a game called Saving Lives that trains users to do cardiopulmonary resuscitation (CPR). Norton said that in the course of developing Saving Lives, they grappled with several challenges that affect many game-based health trainings. One specific challenge was ensuring the right balance between simulation fidelity and an effective learning experience. Norton said that in order for a game to simulate the reality of CPR, some patients should die in the simulation no matter how well the user performs the intervention. However, from a games perspective, the game should have feedback that rewards performance metrics—that is, if a user does everything right, he or she should be rewarded with the patient not dying. Getting the balance right is essential to making a game that is useful for participants but also keeps them engaged, Norton concluded.

Knowledge Acquisition and Testing System

Andrea Parodi said the Knowledge Acquisition and Testing System (KATS) was requested by the U.S. Department of Defense (DoD) and stemmed from a concern about how DoD could assess whether health professionals were ready for deployment. This included understanding trauma care while demonstrating an ability to perform adeptly during emergency situations. To accomplish this, Parodi described developing an educational, game-based program that would not be an administrative burden to the trainer who is frequently faced with inadequate staffing. The process uses computer automation and begins with a stand-alone module for learners to gain knowledge and speed for mastering a skill. As soon as the learner demonstrates competency, his or her results are automatically transferred to a storage cloud for future reference. With automation, instructors are not burdened with large amounts of time-consuming administrative duties.

The next stage of training requires the learner to become the teacher in what Parodi termed a skill rodeo. He or she must be able to teach the instructor before moving into the next phase of the instruction where the

individual learner becomes part of a team. This is a critical phase of the training where learners are graded on their ability to incorporate components of teamwork and safety into their skill sets.

PeriopSim

Angela Robert told workshop participants about her application that trains operating room nurses in hospitals. Today, said Robert, operating room nurses are trained on the job; this application allows them to train and practice in a virtual world before getting “scrubbed in” to surgery. The training program includes an iPad app as well as a virtual reality application that has many game-like attributes (PeriopSim, 2018). This program stemmed from discussions with surgeons who said that the best operating room nurses are the ones that “hand us something before we ask for it.” When a nurse is tuned into what is happening in the surgery and anticipates the surgeon’s needs, it allows the surgeon to focus on the patient and enables a shorter procedure, said Robert. PeriopSim was developed by talking to more than 1,000 nurses, identifying the problems that needed to be solved, and then building the app around these needs. Users of PeriopSim don a virtual reality headset that shows an operating room (see Figure 5-2); users can train on the app to learn about various instruments and to practice procedures step by step. Robert said that nurses learning with PeriopSim show the same outcomes as nurses learning in real life, but PeriopSim is more time efficient and uses fewer resources.

Simulation-Based Education

Geoff Miller told workshop participants about his experience with incorporating expertise into the simulation lab at Eastern Virginia Medical School (EVMS). Miller said that several years ago, they identified a problem at the simulation lab at the medical school: students had unequal access to expertise owing to the availability of clinical faculty. Miller and his colleagues decided to try to leverage technology to improve access to expertise. They worked with engineers and other industry partners to develop a way to capture the performance of experts in 3-D time-space models. For the first iteration of the project, they chose to focus on endotracheal intubation via direct laryngoscopy because it has a highly refined, very concrete procedure. Hundreds of different experts were captured intubating, and all of the data were combined to create an expert model. Students could play against this model expert using a game-based platform, and they could receive immediate synchronous feedback about their performance. Students could play this game “any time they want—3 in the morning or 3 in the afternoon,” said Miller. The simulation lab at EVMS continues to refine and advance this type of application, and it is exploring the potential of augmented reality.

DISCUSSION

Referencing Jeffries’s opening talk at the workshop, Mary Beth Mancini, a forum member with the Society for Simulation in Healthcare, brought up several big challenges in health professions education, and asked the innovators if and how their technologies might help address these problems.

Faculty Shortage

Kade said that one of the main drivers behind the Shadow Health digital clinical experiences is to reduce the burden on faculty. Shadow Health provides users with a transcript of the entire interaction, and they can compare their performance with that of an expert practitioner. This immediate access to feedback and expertise is one way to address the faculty shortage, he said.

Individualized Learning

Technology is a great enabler of individualized learning, said Miller. It can facilitate assessment of a student’s knowledge, attitudes, behaviors, and skills in order to develop a “portfolio of performance.” Using technol-

ogy to identify the needs of the students will better prepare each student for work in the clinical setting. McCune gave an example of this with the vSim for Nursing tool. vSim allows instructors to monitor student progress and focus attention on the critical skills and steps that the student is not performing well, she said.

Mastery

Miller stated that health professions education needs to “promote and push this concept of mastery learning as the model.” In the early stages of learning, mastery may not be an appropriate model, but by the time a student is set to enter clinical practice, he or she needs to have mastered the needed skills. To make his point, Miller said, “Eighty percent proficiency on a skill like endotracheal intubation is great if killing 2 out of 10 is okay.” To adopt a mastery model, health professions need to understand what expertise looks like, and how to measure it on a granular level. Assessment needs to be done rigorously and methodologically, he said, and technologies may provide a way to achieve this. Mastery requires a set of specific knowledge, the ability to do specific tasks, and self-identification as a master, said Norton. While some trainings are focused only on knowledge or tasks, Norton said that a robust game-based simulation could develop mastery “at a bunch of different angles.” Kelly added that mastery requires repetition—ReelDx allows students to view and engage with a diverse set of patient scenarios “as many times as they want.” Robert agreed that repetition is an essential part of mastery, and told a story about a nurse who was struggling with performance in the operating room. She was given an iPad with the simulation and told to practice over the weekend. When she returned for surgery the next week, she showed remarkable improvement. Their research, said Robert, shows that it “takes seven iterations on a procedure” to achieve a level of mastery, so the simulation is designed to help nurses practice over and over.

Cost

Miller said that while the cost of implementing technology can be high, the cost drops significantly as the technology becomes more widespread. For example, providing technology for the first student costs a lot, but adding the same technology for the second and third student adds little to the price. Kelly said they worked with early customers to find price points and structures that made sense. The current pricing for ReelDx is about $200 per faculty member, with discounts for volume. For students, it is approximately the price of a textbook, he said.

Other Factors to Consider

Cox said that empathy and trust are two key elements of the provider–patient relationship. While skills- and knowledge-based trainings are obviously essential, he implored innovators to consider how they could incorporate assessing and teaching empathy and trust into the technologies. In addition, Cox said that a key part of clinical education is learning how to manage uncertainty. “Decisions are often not binary: there is not a right answer or a yes/no answer,” he said. These technological innovations would have even more value if they could explore and model ways to manage uncertainty, he said.

LEVERAGING TECHNOLOGY FOR SOLVING PROBLEMS

With the innovators’ work in mind, workshop participants were asked to talk with others at their tables to identify a problem or challenge in health professional education, and to think of a way that technology could help overcome the problem or challenge. Below are the main areas of discussion as raised by individual participants.

Patient Education

Norton said that his table spent much of their time identifying the problem because “if you do not have a well-identified problem, your solution is worthless.” The problem Norton said they settled on was that patients often do not have the skills necessary to be an active partner in their own care. The table discussed creating a free mobile game in which there would be multiple scenarios with different types of health care providers. While they did not have time to hammer out the details, said Norton, they agreed the game should focus in part on developing the patient’s identity as a partner in care. Eric Bauman added that patient education is extremely important to the success of health care, but that current methods (e.g., pamphlets) are inadequate and do not focus on the needs of the patient. Compared to the number of health providers, there are a huge number of patients or potential patients, said Bauman. Well-designed technology that meets the needs of patients could make an enormous difference in health care.

Data

The next focus was on the challenge of managing and using the large amounts of data produced by new technologies such as digital health tools and wearables, said Hinton Walker. Hector Garcia from the Virginia Modeling, Analysis & Simulation Center at Old Dominion University followed by

saying that while these data convey important information, they must be connected and analyzed in order to be useful. Big data analytics can help “paint a picture of each individual over time” by using the data to create a model. This model, which includes the uncertainties inherent in medical practice, can be used to help students learn. Cox interjected that Garcia was really talking about probabilistic algorithms. Garcia agreed, adding that probabilistic models evolve over time as more data are added into the system. It allows the developer to fine-tune the model making it increasingly relevant to the user.

Another of the table conversations also focused on the issue of data. Miller framed his discussion by saying there are so many sources of data about individual health, but “there is no curation process for those data.” He added, “I don’t want big data, I want big, good data.” He further stated that in order to develop a tool or a technology to deal with these data, we must first find out what the public wants to do with these data. When the public entrusts us with their health care data, he said, we, as developers, have a responsibility to consider the users’ needs and wants, and to apply the data in ways that incentivize the public to want to share their data with no fears of it being mishandled.

Provider Role Change

As technology improves and resources such as clinical decision support tools become more widespread, providers may resist incorporating these technologies into practice, said Hinton Walker. How will health professionals use their knowledge differently when, for example, a machine determines the diagnosis or the treatment? How must health professions education change in order to prepare providers for this world?

Soft Skills

Kelly’s table discussed how to use technology to teach softer skills such as empathy, listening, and teamwork. The table suggested using technology to capture patient interactions (e.g., video-recording clinical rounds), and then having students evaluate and discuss the opportunities that arose for empathy or connection, and how they are progressing on these skills. Kelly noted, however, that it can be challenging to assess these types of skills, and that an “automated empathy assessment” game may be difficult to build.

Suicide Prevention

Wendi Schweiger, representing the National Board for Certified Counselors International, talked about using technology to make suicide assessment and prevention more accessible to the general population. She

suggested that lay people in the community could be trained as first-level assessors who could then help get people to professionals when needed. Miller pointed to some interesting evidence coming out of the military about using technology for suicide prevention—specifically, using automated processes to monitor speech and physical behavior to detect a soldier’s risk of suicide. Robert followed Miller’s comment with information about emerging tools to track a person’s online behavior or text messages to detect patterns that suggest a risk of suicide. Miller responded that there is another effort under way to use virtual providers for counseling. Evidence suggests, he said, that people are willing to talk to virtual providers over face-to-face encounters. Evans added that a game-based application might be quite useful for suicide prevention, especially among boys, who may be unable or unwilling to talk to their parents or other authority figures about their problems.

REFERENCES