Students in the problem based learning track of the MCP*Hahnemann School of Medicine at Allegheny University of the Health Sciences (the academic component of AHERF) are using the Knowledge Bank as a first demonstration of its effectiveness in medical education by replacing one of the regular paper cases with an online multimedia case, and one of the faculty expert resource sessions with a synthetic interview accessed from the Knowledge Bank.

Computer-Based Case Presentation:

The case begins with a small group (6-7) of students signing onto the Knowledge Bank computer system and accessing the records of the patient in question. The case is presented as a dialog between the patient and the examining physician. The relevant patient information, including video and audio segments, is all stored in digital form on the Knowledge Bank computer system. Students are able to interact with the sequence of presentation, but the amount of information that is available is identical to that in the original paper case.

As the patient describes her problem, students use integrated collaborative tools to record their notes on a shared whiteboard and begin to compile an online clinical record. Similarly, facts obtained from the personal and family medical histories are be added to the whiteboard and the online record. At this point, students adjourn from their small group and undertake independent study revolving around learning issues raised by the case.

Two days later, the group reconvenes and discusses the results of their independent learning. They begin to formulate several alternative hypotheses to explain the patients problem. These hypotheses are added to the computer whiteboard, and the students begin to compose a concept-map of the case using integrated computer based tools.

Students then perform a comprehensive physical examination of the patient using the computer system. Previously recorded video and audio segments of components of the physical exam can be accessed on demand from the Knowledge Bank. Again, students record their observations into the online clinical record. After further discussion and refining of the hypotheses, students formulate additional learning issues and adjourn.

Synthetic Interview: Students attend a resource session where they have an opportunity to ask questions pertinent to the case of a faculty expert. The Knowledge Bank provides a synthetic interview with a basic science faculty expert. This interview consists of previously recorded audio and video segments of the faculty expert answering a comprehensive series of questions on the topic of interest. During the synthetic interview, students query the computer system, which is uses speech recognition to access and display the appropriate segment.

The use of this type of multimedia clinical data repository has tremendous potential to change not only how medicine is practiced, but also how learning occurs. It will move learning closer to that ideal when knowledge is available when the learner needs it and is able to be delivered to wherever the learner is.

Paper:

Introduction
This presentation describes the use of a comprehensive online multimedia clinical data repository (the National Medical Practice Knowledge Bank) in medical education. Using this system, students can perform a virtual history and physical examination, obtain laboratory and radiological data, and construct an online clinical record. In addition, students can access expert faculty for interactive dialog, using previously recorded synthetic interviews. The technology that makes this possible is a large scale multimedia database that uses video indexing and abstracting, coupled with speech recognition and case based reasoning to provide anywhere anytime access to patient information and to faculty experts.

The National Medical Practice Knowledge Bank
We are building the National Medical Practice Knowledge Bank (NMPKB) under an Advanced Technology Project grant from the National Institute of Standards and Technology of the Department of Commerce. The central goal of this project is to develop technologies that support nationwide information networks to facilitate the dissemination of state-of-the-art information on current treatment guidelines and other information needed by the practicing healthcare professional. A joint venture, led by the Allegheny-Singer Research Institute and including experts in information networks, large database systems and multimedia from AT&T Business Communications Services, NCR Enterprise Solutions, and NCR Human Interface Technology Center, is currently developing technologies for a prototype networked medical "knowledge bank."

The proposed NMPKB provides central repositories for complex medical information diagnostic indicators, details of preferred treatments or surgical procedures, current treatment guidelines, and in short, the information a doctor would usually get from an expert consultant. Accessible over wide-area computer networks, the NMPKB will provide the equivalent of 24-hour-access to world-class consultants in an array of medical specialties.

The project presents several challenging technical objectives, including the development of a multimedia repository that can archive, browse, retrieve and, most importantly, index and search not only text data but still image, video and audio data. Other challenges include developing indexing and searching methods for video data and medical case data, developing a novel case-based reasoning algorithm to recognize similarities between new medical cases and previously stored cases, developing massively parallel multimedia database technology capable of handling petabytes of data, and developing an appropriate user interface to the registry to meet physicians' needs.

The Program for Integrated Learning at the MCP®Hahnemann School of Medicine At the MCP®Hahnemann School of Medicine at Allegheny University of the Health Sciences, students may choose either a traditional lecture and laboratory based track or a problem based learning track, called the Program for Integrated Learning (PIL). Approximately 20% of first and second year medical students are in the PIL track. In PIL, most learning is self directed, focusing on a sequence of paper clinical cases that are discussed by students in small groups with a faculty facilitator. Complementary to these small group sessions is a series of resource sessions on basic science and clinical material relevant to the case under study. We selected one group of students in the PIL track to assess the effectiveness of using two of the aspects of the NMPKB technologies for medical education. One aspect, the multimedia clinical data repository, was used as a replacement for one of the paper clinical cases. The second aspect, simulated access to an expert consultant, was used as a replacement of one of the resource sessions. At the time that the assessment was performed, several of the key technologies were still under development, including video indexing and speech recognition. In these cases, other, less advanced technologies were substituted.

Computer-Based Case Presentation
The case begins with a small group of students signing onto the NMPKB computer system and accessing the records of the patient in question. The case is presented as a dialog between the patient and the examining physician. Relevant patient information, including video and audio segments, is all stored in digital form on the NMPKB computer system. Students are able to interact with the sequence of presentation, but the amount of information that is available is identical to that in the original paper case.

As the patient describes her problem, students begin to compile an online clinical record. Similarly, facts obtained from the personal and family medical histories are be added to the online record. Students, with a faculty facilitator, discuss the basic science and clinical issues that have been raised by the case material, and formulate a strategy for independent learning. At this point, students adjourn from their small group and undertake their independent study.

Two days later, the group reconvenes to discuss the results of their independent learning. They begin to formulate several alternative hypotheses to explain the patient's problem. These hypotheses are added to the computer online record, and the students begin to compose a "concept-map" of the case. Students then "perform" a comprehensive physical examination of the patient using the computer system. Previously recorded video and audio segments of components of the physical exam can be accessed on demand from the NMPKB. Again, students record their observations into the online clinical record. After further discussion and refining of the hypotheses, students formulate additional learning issues and adjourn.

Synthetic Interview
Students in the PIL track attend resource sessions where faculty experts present material that is relevant to the case under discussion. In these sessions, students have an opportunity to ask questions that are pertinent to the case. The NMPKB provides a "synthetic interview" with a basic science faculty expert as an alternative to the live resource session. This interview consists of previously recorded audio and video segments of the faculty expert answering a comprehensive series of questions on the topic of interest. During the "synthetic interview", students query the computer system, which accesses and displays the appropriate segments.

Evaluation
After the students experienced both the computer-based case presentation and the synthetic interview with a faculty expert, they were interviewed by a team from the NCR Human Interface Technology Center. In addition, an interview session was also conducted with faculty who had been involved in the development and implementation of the project. The results of these interviews are as follows. The Problem Based Learning Case The PIL case was liked both by the faculty and students; however, there is still the need to tailor elements of the interface, in order that the PIL experience is enhanced by the system. The need for the student to have complete coverage of learning issues must be addressed, making sure that the properties (summary of case, latency, availability, etc.) of the paper case are reflected in the online case. Support will be needed to make sure the students "trust" the information given to them, and that the all the information they need is provided, in order that learning issues can be raised. The video presentation will provide context and humanize the whole experience, but should not be relied on as the primary way to establish learning issues. The system should allow students to capture hypotheses, concept maps, learning issues, and should make sure that all issues are captured by assessing the input of students, either by the analysis of free text notes or by evaluating the way students fill in a pre-defined version of the patient record. The system should then be able to prompt the student to what is correct, what is misdiagnosed and what has been overlooked and more importantly why.

The Resource Session
The online resource session, while less favored than the case presentation by both students and faculty, was seen as having great potential. This is especially true of the faculty respondents. There appeared to be different primary reasons for this lack of enthusiasm for the current embodiment of the user interface. The faculty were more concerned with the navigation of the site, finding it confusing and not as instant as they had hoped. The primary problem the students had was more in terms of the material rather than the presentation of the material. They were concerned that the resource session was not deep enough for their needs, and because of the structure of the prototype, no additional or follow-up information was available to them.

Conclusions
Our experience in using these technologies in medical education has proved to be very informative. The current implementation was limited in part by the lack of availability of key technologies and in part by interface design issues. Both of these limitations are currently being addressed, and another trial is planned. Despite these current limitations, it is clear that the use of this type of multimedia clinical data repository has tremendous potential to change not only how medicine is practiced, but also how learning occurs. It will move learning closer to that ideal when knowledge is available when the learner needs it and is able to be delivered to wherever the learner is.