Susan Albright, Director of Educational Technologies, Tufts University Sciences Knowledgebase
Cook and Triola recently published an excellent review of the use of and research concerning Virtual Patients (VPs) for medical education (Medical Education, 2009). Virtual Patients represent "a specific type of computer program that simulates real-life clinical scenarios; learners emulate the roles of health care providers to obtain history, conduct a physical exam, and make diagnostic and therapeutic decisions.". The article proposes that:
The opposing forces of increased training expectations and reduced training resources have greatly impacted health professions education. VPs, which take the form of interactive computer-based clinical scenarios, may help to reconcile this paradox.
Cook and Triola suggest that the most unique and cost-effective function of VPs is to facilitate the development of clinical reasoning skills and conclude from their extensive literature review that there should be increased use for this purpose while calling for more research to determine the VPs effectiveness.
In 2007, research published in Academic Medicine (Huang, et al) based on an AAMC survey of medical schools found that virtual patients "possess numerous educational benefits but are costly to develop-few medical schools can afford to create them." Twenty-six of 108 responding medical schools reported they were producing virtual patients but many were reluctant to share. Huang's conclusion was that "broader access to cooperative development of these resources would allow medical schools to enhance their clinical curricula."
A Technical Standard for Virtual Patients
In 2005, the MedBiquitous Consortium, an ANSI-accredited developer of information technology standards for healthcare education and competence assessment, began the trek to develop standards for VPs by creating a working group of individuals and organizations. The MedBiquitous VP (MVP) Working Group has 45 members representing 28 institutions in the US and Europe, many of whom are developers of interactive VP systems. The group's mission was to create an XML standard for virtual patients to enable interoperability, accessibility and reusability of Web-based virtual patient learning content. We learned early on that there is a great deal of variation in styles of VPs. The most notable defining factor describes how much control the user is allowed in moving through the case. The variation reminiscent of the "choose your own adventure" children's books, where the patient story can have many endings depending on the path chosen by the student, has become knows as a branching VP. Linear VPs, in the other hand, occur when the path through the story is more controlled. However, even within some linear VPs, the student can be allowed some degree of control as he/she moves through the case. The MedBiquitous standard would accommodate all these.
A glimpse inside the specification reveals five components; the VP data, Media Resources, the Activity Model, the Data Availability Model and a VP player specification. The VP data provides the data relevant to the clinical scenario, including personal data, clinical data, and narrative. Media resources comprise the images, animations, videos, audio files and any other discrete digital objects needed for the VP. The Data Availability Model determines when data is made available to the student and the Activity Model encodes what a learner can do and how they engage the virtual patient. These two elements together reflect the navigation style of the VP on the continuum of branching to totally linear. The player specification describes how a VP player interprets the data captured in the other components and presents the virtual patient to the learner. It also specifies how the player gathers and parses learner input. Fig 1 reflects these elements.
In May 2009, after nearly four years of work, the MVP Working Group decided at the MedBiquitous Annual Meeting that it was time to put the specification to a vote. After approval, the specification will be submitted to the MedBiquitous Standards Committee for review, following which it will be released for public review and scrutiny on its journey toward official publication as an American National Standard.
The eViP Project - A European Trial at Implementing and Sharing Across Institutions
The European members of the MVP working group agreed to try not only to help develop the standard but also to secure funding to assist in a proposed collaboration. They proposed to try to pool their large collection of existing virtual patients as adapted to a common technical standard so they could be repurposed and adapted according to multicultural and multilingual needs as well as locally enhanced. It was agreed that non-member partners would also be allowed to share these resources so that these would "maximize VP update by educators in all countries to underpin and extend current teaching and learning, minimize inefficient practice, reduce costs, and improve the consistency and quality of care and well being of patients throughout the world." In 2006, the group secured funding from the European Union under the econtentplus program and the eViP program began officially in 2007. As part of their work they conducted an international Virtual Patient Survey in the fall of 2008. The results of the survey are available at the eViP website. While half the surveyed institutions currently use virtual patients, nearly 83% reported the need for virtual patients in the curriculum and a similar number reported wanting to use VPs for assessment. One survey question asks, "If time was not a barrier, what would be the main barrier to more widespread use of virtual patients at your institution?" Cost to create the VP was by far the most common answer reminiscent of the early Huang study.
EViP Lessons Learned: A First Attempt at Interoperability
The four systems tested during the eViP project represent the range of Virtual Patients. Causus and Campus from Germany tend to be Linear as does Web-SP from Norway. The OpenLabyrinth system from the UK is a branched system. All of these were configured to export data in a format that meets the MedBiquitous specification. They were studied in detail for conformance to the specification as well as export/import methodology. The technical teams at each partner institution worked on the transformation of virtual patients across institutions. It was assumed that certain parts of the cases would transform by machine and other parts would require human intervention. The eViP work is not yet complete but two reports have been published: "Best Practice Guidelines for the eViP Application Profile and Associated Conformance Metrics" and "VP Profile Implementation and Conformance Testing". Early reports suggest best practice guidelines for exchanging VPs and some initial findings on the exchange. For example, it is more difficult to move virtual patients across type. That is, it takes more time to adapt a linear authoring system to a branched one, and vice versa.
The Future: Our Challenge
The MVP XML standard will begin the formal process for acceptance soon. A number of US and Canadian schools have developed authoring systems, such as Tufts, University of Pittsburgh, University of Connecticut, and McGill. These systems will need to achieve conformance to the standard and if they do, sharing across institutions can be a reality. The US and Canadian schools should pick up the research where the eViP project concludes and perform interoperability testing and develop tools and best practices to facilitate sharing. We hope to create an AAMC survey of authoring systems that will rate their adherence to or willingness to become compliant with the MedBiquitous specification. We will also collect descriptive metadata about these systems on a variety of continua. These data can become the basis for a collaborative project focusing on creating and sharing VPs which has been called for in the literature. In addition, we should heed the call from Cook and Triola and create consortia for sound educational research to assure that VPs are meeting our educational goals for curriculum delivery and assessment.
Association of American Medical Colleges. Effective Use of Educational Technology in Medical Education: Summary Report 2006 AAMC Colloquium on Educational Technology. Washington DC: AAMC 2007 p.7
Virtual patient simulation at US and Canadian medical schools. Huang G. Reynolds R. Candler C. Academic Medicine. 82(5):446-51, 2007 May.
Virtual Patients: A Critical Literature Review and Proposed Next Steps. Cook D. Triola M. Medical Education 43(4):303-311, 2009 April
Building a virtual patient commons.Ellaway R. Poulton T. Fors U. McGee JB. Albright S. Medical Teacher. 30(2):170-4, 2008
VP Profile Implementation and Conformance Testing, eViP Technical Reference Group, eContentplus, May 2009
Best Practice Guidelines fore the eViP application Profile and Associated Conformance Metrics, eViP Technical Reference Group,econtentplus May 2009
MedBiquitous Virtual Patient Specifications and Description Document, V.0.52, 12 January 2009, (accessed May 12, 2009)
MedBiquitous Virtual Patient Player Specifications and Description Document, V.0.52, 12 January 2009, (accessed May 12, 2009)
MedBiquitous Virtual Patient XML Schemas, 19 November 2008, https://ns.medbiq.org/virtualpatientdata/v1/virtualpatient_schemas.zip (accessed May 12, 2009)