CliniSpace: a design analysis

Practice makes perfect! – “Flight simulators” for hospitals Parvati Dev, PhD Wm LeRoy Heinrichs, MD, PhD Innovation in Learning Inc. www.innovationinlearning.com

Abstract Capt. “Sully” landed his disabled plane on the Hudson safely because he had practiced similar landings on a flight simulator. Healthcare personnel need similar training opportunities for rare but critical events as well as for routine activities. We will present CliniSpace™ - a next generation online immersive training environment that replicates the familiar surroundings of daily work in a hospital – and we will use it to discuss numerous different learning opportunities. These will include clinical decision making, communication skills, and protocols, for critical events as well as routine care. We will use these examples to open a discussion on the value and the problems in using these “healthcare simulators” to augment the learning process. © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Our Studies at Stanford University (with many collaborators) Studied usability, acceptance of technology, and learning efficacy with a number of virtual worlds 2005: Virtual ED 4th year medical students and 1st year residents 2006: Virtual ED 2 pilot fire fighters and first responders 2007, 2008: Virtual ED 2 practicing physicians and nurses 2008: CPR SimErgency high school students in PE course © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Study of learning efficacy (VED 1, 2005) © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011 Subjects: 4th year medical students and 1st year residents Task: Manage trauma cases according to ATLS protocol Study design: Pre-test scenario, 4 learning and debrief scenarios, post-test scenario Evaluation instrument: EMCRM performance rating sheet

Study results: Comparing learning with HPS manikin and Virtual ED © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011 Subjects: 4th year medical students and 1st year residents Task: Manage trauma cases according to ATLS protocol Study design: Pre-test scenario, 4 learning and debrief scenarios, post-test scenario Evaluation instrument: EMCRM performance rating sheet Outcome: No significant difference in learning with manikin compared to virtual ED Youngblood P, Harter PM, Srivastava S, Moffett S, Heinrichs WL, Dev P (2008), Design, development, and evaluation of an online virtual emergency department for training trauma teams, Simulation in Healthcare: The Journal of the Society for Simulation in Healthcare; 3(3): 146-53.

Question: If these systems are effective for learning, why do we not see more use of virtual world simulations for healthcare education?

Diffusion of Innovation (Rogers, 1962) Awareness Not inspired to learn more Interest Seeks more information Evaluation Weighs advantages/disadvantages; decides to accept or reject Trial Uses innovation; determines usefulness Adoption Decides to continue using; seeks to maximize potential © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Diffusion of Innovation – a funnel (applied to immersive environments for healthcare training) Awareness – Not inspired to learn more Significant loss here Interest – seeks more information Then drops to ~ 10% Evaluation – accept/reject after initial use Most are at this stage Trial – uses in daily work to determine usefulness A few sites with strong champion (universities, webinar companies) Champion is usually also the developer (or leads development) Adoption – use is institutionalized Duke University has issued an RFI UK Imperial College is expanding its use of virtual environments © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Approach: How does one move from Evaluation to Trial? From Innovators, across the chasm, to Early Adopters? To study this problem, we conducted a retrospective analysis of the questionnaires, notes and transcripts. We also conducted informal market research.

Overview of Findings (based on - Atmosphere, OLIVE, Second Life, Unity systems) Local IT problems (infrastructure) IT problems with immersive environment Learning curve Engagement Usefulness of content Availability and fit with curriculum Cost © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Local IT Problems These issues are primarily from notes taken during system installation and operation. Server installation is complex, needs skilled technical support. A SaaS (Software as a Service) model is desirable, where the server is maintained at a third party or company site. Accessing an outside server, for installation or operation, is impossible when institutions have a firewall. The solution is to have the user’s client software be web browser-based, since the port for HTTP, or web browser, communication is kept open by the firewall. Client software installation is usually not difficult But it must be permitted by hospital IT policy. Client crashes may be an issue Hospital computer security of patient data (HIPAA). A long term solution is a VPN (Virtual Private Network). © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

IT Problems with Immersive Environment Most need a ‘gamer’ computer High performance graphics Usually requires purchase of a computer Most require software download and configuration Need help from IT person Most require network ports that are usually closed More help from IT May prevent use of software © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Learning Curve – Usability This data is from observation of use by the subjects, and from transcripts of focus group discussions. Navigation was more difficult for non-gamers to learn. Subjects learnt to use the arrow keys for navigation but would prefer to point at a location and automatically move there. W A S D keys used only by gamers. Visualization – Multiple cameras are useful but complex. The different camera views caused the most problems: First-person view, third-person view, free movement of camera. Occasional failure of “collision” allowed the camera to move through a wall, causing confusion. Interaction with the patient was difficult (comments from transcript). “ Too hard to assess patients; takes too many steps.” “ Need a way to know what’s going on with that patient without being attached to the bed.” “ I need a different button to listen to the heart, and a different button to listen to the lungs. That’s silly, just need to assess…heart, lungs, secretions … then do the high level cognition of .. OK this patient is just going to require a little bit of mask… no big deal, ...and this person is really sick” “ I don’t need to listen to the heart; I don’t need to listen to the lungs, I don’t need to touch their skin…I just look at them and go, “sh**, we’re in trouble. OK, let’s go, now!!” © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Engagement From questionnaires, and transcripts of focus groups. 17 out of 22 subjects rated immersion as high or very high. “ It’s a lot more real here than in the text. We can read the text—but we forget” “ The fact that it was interactive; it stays with you.” “ What’s good about this is you actually feel more involved with it, than with the dummy (instrumented manikin-based simulation). I felt like I can immerse myself more in this than working with the dummy…” “ More realistic way to practice a mass casualty drill than the ones done once a year.” About being a triage team leader versus a team member. “ I thought it was pretty real. In reality you are not going to know how many patients are out there; you do have to rely on somebody to tell you how sick they are and how many there are… it’s tough to figure out how many people you need where. I thought that was good.” © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Usefulness From transcript of focus group, mass casualty scenario training I think it’s a more realistic way to practice a mass casualty drill than having a once a year hospital thing when you close down the ER. In the live drill it’s chaos, it’s not clear what your role is and what you’re supposed to do If you’re having to decon somebody and that’s not something you do regularly… you’re not going to remember. So if we can do it on a computer 3 or 4 times a year and then actually do a hands on it makes it so you’re like I know exactly how to do that. You can kind of see how you improve. Yeah, you can do it over and over again. And about hands-on management vs higher level decision making… I think the importance of these types of simulators is more to train mid and upper level people how to do more complex systems management, more complex decision making and treatment algorithms. make the actual assessment of the patient less difficult and less cumbersome, so then we can move into those higher level skills that are more difficult, because that’s actually where you make the difference © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Availability of content and Fit with curriculum “ How many scenarios do you have?” Most common question Reflects a comparison with mannequin-based simulators Reflects need to have readily usable content “ Can I change the scenarios?” “ Can I author my own scenarios?” From more academically oriented sites “ We have many scenarios. Can you implement them?” From organizations with a large throughput of learners “ Can this be used for self-learning?” Mostly from nursing schools May stem from large student-teacher ratio No questions about curriculum rather than scenarios May reflect overall state of simulation Scenarios seem to solve point problems and do not seem to reside within a larger curricular context. © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Cost Initial purchase cost Earlier systems (OLIVE, etc) were deemed very expensive Second Life, Wonderland and other platforms were cheap New platforms now, and new pricing Cost of development Absorbed into student stipends or existing staff This may not be sustainable for production use Cost does not seem to be the primary barrier © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Review of issues Review of issues: We implemented a new Virtual Medical Environment, CliniSpace™ IT Browser-based application Transparent download, with self-install Server maintained externally (Firewall and ports remain problem) <<<< Learning curve Simplified navigation, cameras, interaction Engagement 3D and immersive Realistic environment, avatars and patients Usefulness Rich environment for patient care and management, and for communication Virtual patients that satisfy learning objectives for junior and advanced learners Content and Curriculum Scenarios for team and crisis management learning Strong interest in nursing and patient safety scenarios (Need more and better defined scenarios and curricula) <<<< © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Content and Curriculum Clinical decision making Dynamic pathophysiology models – trauma, sepsis Designing a Patient Authoring Tool for custom scenarios Designing additional user interaction tools Communication skills Can practice SBAR, repeat back, workload distribution, assertiveness Technology supports this; scenarios need to be scripted Protocols Constructing authoring tool for safety bundle setup © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

Conclusion We posed a problem Slowness of adoption of immersive environments for learning, even when they have been proved effective for learning Used ‘Diffusion of Innovations’ model to identify possible locus of failure of adoption Evaluation stage And identified numerous issues IT, learning curve, usefulness, content, curricular fit Conclusions: Fixing of early problems has put some systems into educational use Most systems are still in the ‘Evaluation’ phase, with few in ‘Trial’ or ‘Adoption’ The users are ‘Early Innovators’, and there is a ‘chasm’ to cross before ‘Early Adoption’ Content and Curriculum may be the Bridge across the Chasm ! © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

THANK YOU & QUESTIONS Demos available on request Please visit www.clinispace.com My slides are on SlideShare. Search for ‘parvatidev’ Email us at [email_address] [email_address] © 2011 IIL Inc. Virtual Thursdays at ILN, Feb 24, 2011

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