(10:00 am, Friday)

Rodger Marion, Ph.D.
University of Texas Medical Branch

Bruce R. Niebuhr, Ph.D.
University of Texas Medical Branch

Teaching Collaborative Patient Management Using Computer-based Simulations of a Future Health Care Environment

ABSTRACT

The Health Information System Simulation (HISS) Project has developed, evaluated, and validated an approach to teaching allied health students to use the most up-to-date methods of computerized patient assessment and management in the delivery of health care services. This approach focuses on simulated patient cases presented in a computerized patient record. In this environment they learn to collaborate with colleagues in other disciplines while mastering skills in diagnosis and treatment planning. This paper focuses on the philosophy underlying the use of computer-based simulations to teach patient management and collaborative skills, and our experiences during three years of student software usage.

PAPER

For three years the Health Information System Simulation (HISS) Project has led a major effort in health care informatics. We have developed, evaluated, and validated an approach to teaching allied health students to use the most uptodate methods of computerized patient assessment and management in the delivery of health care services. This approach focuses on simulated patient cases presented in a computerized patient record. Students interact with their simulated patients, other students, and faculty through networked computers using Windowsbased computer applications developed by the HISS Project. In this environment they learn to collaborate with colleagues in other disciplines while mastering skills in diagnosis and treatment planning. This paper focuses on the philosophy underlying the overall concept of the HISS Project, and our experiences with student usage of the software.

Health care today and in the future depends on accurate diagnosis and coordinated treatment. In today's high tech health care environment, there are critical requirements for health care providers to be able to communicate with each other and to integrate the many sources of patient information available. Two technologies, the computerized medical record and telemedicine, can be combined to create the health care workstation of the future. Health information systems, and specifically the computerized medical record, have been seen as solutions to many problems regarding the availability of patient information and reduction of duplication by making diverse sources available at the workstation.

Telemedicine is the process of establishing two way communication between providers using computer based video and audio. The National Information Infrastructure (NII) initiatives, among many others, call for expanded technology development in telemedicine (National Telecommunications and Information Administration, 1993). The NII plan calls for the development of networks which will link hospitals, clinics, and provider offices. The effectiveness of the communication process is never more critical than when a patient is referred to another care provider. Studies have pointed to the conclusion that professional conversations are dominated by fact gathering and opinion giving interactions, with very little opportunity for the form of interaction that leads to true problem solving behaviors (MacKinnon, 1984, Rintala, et al, 1986). To effectively use technology it is important that health care providers are comfortable with high tech solutions. We felt that students could be prepared for this future environment, both mechanically and effectively, by using a training environment that simulates it.

Research on the effectiveness of simulations to change attitudes in a positive have found inconsistent results (VanSickle, 1986), however participants in simulations overwhelmingly report that they are worthwhile (Byrnes & Kiger, 1992). These results are encouraging, because they show simulations can affect attitude change. What separates a simulation that can cause change from one that cannot? Fisch (1993) states that a simulation's user interface must be clear, responsive, flexible and engaging. Also, simulations cannot be used in a vacuum, but must be integrated into the content of the course and into the expectations of the students and faculty. We have incorporated all of these suggestions into the HISS software.

Table 1
Frequency of Replies to Question About How Realistic
and Involving Were the Cases

Response
%(N)		 1 2 3 4 5
1993 1.4(1) 8.6(6) 37.1(26) 50.0(35) 2.9(2)
1994 3.5(3) 5.8(5) 34.9(30) 51.2(44) 4.7(4)
Total 2.6(4) 7.0(11) 35.9(56) 50.6(79) 3.9(6)

Scale anchors are: 1 (awkward, boring, dumb) and 5 (elegant, fascinating, challenging)

The central HISS application, the Electronic Patient Record (EPR), accesses and displays a complete simulated patient record. It includes histories and physicals, laboratory results, photographs, and graphical representations of diagnostic tests such as X-rays, ECGs, and CT scans. Four simulated patient cases have been developed for the EPR: geriatric stroke, pediatric leukemia, cardiac-hip fracture, and HIV. These patient cases, along with other applications that support their integration into curricula, are currently available for use as the Phase I Release (PIR) software.

Four new patient scenarios are being developed including: lung cancer with work rehabilitation problems, tuberculosis and alcohol abuse with chronic back pain, systemic lupus erythematosus, and premature birth with spina bifida. The EPR will expand to include on screen video and sound of patient evaluations, an on line community resource directory, records of home assessments, 2D and 3D diagnostic images, interactive patient interviews, and other data from various sources. We are using the method described by Cooper & Owens (1994) to create the simulated patient interviews. This allows us to use simulated teleconferences for consultations and referrals, giving students experience with how new technology encourages better communication and interaction between different health care professionals. With these advances, the EPR transforms from a computer based, electronic patient record into a virtual patient record able to reach all the resources available when treating a patient. These expansions will be available as the Phase II Release (PIIR) software in late 1996.

Other HISS applications, MainBooks, run simultaneously with the EPR and provide the computerized links between students, faculty, and the simulated patients. MainBooks track student usage and record findings for assignments. Here, faculty members record their assessments of student performance which students can view later. One MainBook, Patient Consultation and Referral (PCR), allows students to consult with colleagues in other fields while developing care plans for their simulated patients. Other MainBook applications include an online HelpBook, a tutorial called HISSRules, and a NoteBook.

In the fall of 1993, 70 Physicians Assistant (PA) and Occupational Therapy (OT) students conducted a collaborative learning activity in care planning for an elderly patient. During the Fall of 1994, 86 PA and OT students also participated in the same activity. The scenario was as follows. A PA student and an OT student worked as a team to assess a simulated patient using the Electronic Patient Record (EPR) and Patient Consultation and Referral (PCR) applications. The patient, a 72 year old female, hospitalized after suffering a stroke, develops a complication in her rehabilitation process. Specifically, she was planning to return to her home and be assisted by her daughter. Her daughter however is moving out-of-state. The PA student acted as the attending provider and reviewed the patient's history using the EPR application, and wrote a referral using the PCR application. The PA was seeking alternatives for the patient's rehabilitation. Functioning as consultant, the OT student provided several community based alternatives to the PA student by writing a reply with the PCR application. The PA student replied with an assessment of the alternatives. This learning activity allowed students to practice making and answering referrals, while showing how the computer eases communication between providers and consultants.

Table 2
Frequency of Replies to Question About Attitudes Toward
Computer Use

Response
%(N)		 1 2 3 4
1993 67.9(44) 7.7(5) 18.5(12) 6.2(4)
1994 68.7(59) 4.6(4) 19.8(17) 7.0(6)
Total 68.2(103) 6.0(9) 19.2(29) 6.6(10)

The scale is:

1. I was enthused about computers in clinical practice at the beginning of the semester and I am enthused now.

2. I was enthused about computers in clinical practice at the beginning of the semester and I am not enthused now.

3. I was not enthused about computers in clinical practice at the beginning of the semester and I am enthused now.

4. I was not enthused about computers in clinical practice at the beginning of the semester and I am not enthused now.

Evaluation data in the tables are from 70 students who used HISS software during the Fall of 1993 and 86 students during the Fall of 1994. Table 1 summarizes the students' opinion of how realistic and involving were the cases. As 90% of the students gave ratings of 3 or better, we concluded that the simulation met requirement that it engage the students' interest.

The general conclusion we draw from Table 2 is that students are positive towards the use of computers (68.2% chose response #1). A choice of responses #2 and #4 may reflect that the students can be frustrated, particularly with software under development. An encouraging result is the number of students who became more positive about computers after the experience (Response #3).

The HISS Project is based at the University of Texas Medical Branch (UTMB) School of Allied Health Sciences (SAHS), and has established cooperating test sites at the Medical College of Georgia and the College of Health Sciences, Community Hospital of Roanoke Valley, Virginia. Colleagues at UTMB involved in the HISS Project are: Karen Babola, Lynda Baldwin, Richard Muma, Suzanne Peloquin, John Bernstein, Winifred Fraser, Chris Renten, Kim Suggs, Charles Costello, Belinda Escamilla, Art Jones, and Karen Stephenson. Primary funding comes through Allied Health Special Project grants from the Associated Health Professions Branch, Division of Associated, Dental, and Public Health Professions, in the Department of Health and Human Services (1-D37 AH00156 and 2-D37-AH00156).

References

Byrnes, DA & Kiger, G. (1992). Prejudice-reduction simulations: ethics, evaluations, and theory into practice. Simulation & Gaming, 23, 457-471.

Fisch, EA. (1993). Understanding and improving the user interface design process. ACM SIGSOFT  Software Engineering Notes, 18, 27-29.

MacKinnon, JR. (1984). Health professional's patterns of communication: cross-purpose or problem solving? Journal of Allied Health, 13, 3-12.

National Telecommunications and Information Administration. (1993). The National Information Infrastructure: Agenda for Action. NTIA NII Office, Department of Commerce, Washington, DC.
(Document distributed in ASCII format as file niiagenda.asc via the Internet: FTP address - enh.nist.gov).

Rintala, DH, Hanover, D, Alexander, JL, Sanson-Fisher, RW, Willems, EP & Halstead, LS. (1986). Team care: an analysis of verbal behavior during patient rounds in a rehabilitation hospital. Archives of Physical Medicine and Rehabilitation, 67, 118-122.

VanSickle, RL. (1986). A quantitative review of research on instructional simulation gaming: A twenty-year perspective. Theory and Research in Social Education, 14, 245-264.

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