Though it was longer ago than I care to admit, I can remember checking out every copy of the Choose Your Own Adventure® series my local library had to offer. Whether it was “Prisoner of the Ant People” or “Zombie Penpal” (nope, I didn’t make those titles up!), those books allowed me to control my own destiny, choose my own fate – escape from the ant people or allow my long-distance pal to eat my brains for breakfast.

Imagine my surprise when I found a similar concept had been applied to the curriculum at the University of Pittsburgh’s School of Medicine. While the brand name DecisionSim™ doesn’t have quite the ring to it that, say, the title “Tattoo of Death” does, it sounded techie enough to pique my interest.

Developed at the university by Dr. J.B. McGee, the company behind DecisionSim was formed to commercialize Dr. McGee’s vpSim™ technology, the driving force behind DecisionSim. According to the company’s website, healthcare educators use DecisionSim to create computer-based, interactive clinical scenarios commonly known as “virtual patients,” (VPs) which give students the opportunity to experience both routine and not-so-routine clinical scenarios in a safe yet realistic and immersive environment. The technology is currently in use at 11 schools including the University of Pittsburgh, Cleveland Clinic, and the Feinberg School of Medicine at Northwestern University.

I recently spoke with Dr. McGee to learn more about the origin of the technology, and how he sees it evolving beyond the medical school environment.

Could you tell me a bit more about your specific involvement with designing/developing the product?
DecisionSim came from work done in my Laboratory for Educational Technology at the University of Pittsburgh’s School of Medicine. It is a culmination of my work with virtual patients over the last 15 years, including many authoring systems and hundreds of cases dating back to the pre-Internet days. The idea for DecisionSim came from working with educators who needed an easy way to create branched case simulations as opposed to the more common linear virtual patients. At the lab, we did a careful needs analysis, beyond just the need for branching cases and standard compliance, and designed an application around the results of that analysis and feedback during the design and development process. Dozens of mock-ups and prototypes later, we released vpSim, which was licensed as DecisionSim in 2010.

How does it differ from traditional VP platforms?
Traditionally, VPs are linear in their structure, with every learner receiving more or less the same experience and the VP having the same outcome. While linear VPs are perfectly appropriate for many teaching topics, the ability to branch and experience different outcomes and receive tailored, personalized feedback based on your decision-making differentiates branched VPs, like those possible with DecisionSim, from other VPs. The branched approach tends to be very effective in helping learners develop clinical decision-making skills.

There are other, more logistical reasons DecisionSim is different and easier to use. It employs a drag-and-drop graphical user interface to design your VP’s branching paths. This makes complex cases much easier to visualize and edit. Much of the complexity of creating a VP is hidden behind the scenes to construct an easy-to-use authoring environment and a clean, uncluttered learner interface. Additionally, it is a hosted solution, so educators do not need to get their IT departments involved to get started. By being completely Web-based (both playback and authoring), DecisionSim can be accessed from any computer with a Web browser and connection to the Internet. 

How is the University of Pittsburgh School of Medicine using this technology today?
Use at the University of Pittsburgh began with the Pharmacy School, which is now in its third year of using vpSim technology as a formative assessment tool given mid-way through an advanced therapeutics course. Faculty members Neil Benedict and Christine Schonder wrote cases for their pharmacy students, who interact with a series of cases to test their skills and receive immediate online feedback. Others use VPs in a small group learning setting, similar to PBL (problem-based learning), where students sit around a table with the VP case projected on a screen. They make their own decisions on what to do to diagnose and treat their online patient. There is a facilitator (faculty member) in the room to help guide their learning and explain what happens when things go wrong with the patient. Here students have the chance to try again to achieve a better outcome and investigate why one test or therapy was more effective than another.

A third approach is using VPs as adjunct to traditional coursework. Students and trainees are assigned VP cases to work through on their own in parallel with other learning activities like lectures and live clinical interactions. Here the cases may fill in gaps for students that may not otherwise encounter uncommon diseases, or as reinforcement and assessment of clinical skills.

What have students’ reactions been to this method?
Students’ reactions to virtual patients in general are positive. They enjoy the opportunity to learn while interacting with a patient and receive feedback that is specific to their performance. The ability to practice and learn in a safe environment is appreciated since there are (appropriately) few opportunities to make decisions independently when in your early training. For more advanced learners, it is a chance to learn about new approaches to diagnosis and therapy, but in a convenient, case-oriented fashion, at your own pace and time.

Are professors taking students’ experiences with DecisionSim and using that information to help customize the course? For example, do they notice a predilection for different groups of students to make the same decision in the same module, which leads the professors to present course material in a different way? 
Yes, in particular the pharmacy course mentioned above where VPs have been in use for three years is a good example. The instructors realized that much of what they thought students understood was not, and some of the more difficult concepts were better comprehended than expected. Thus, they were able to adjust the didactic portions of the course and now are seeing the results as the students are performing better on the cases in subsequent years. We’re likely to see more of this in the future as experience increases.

Do you foresee this type of technology being used, perhaps in a slightly different format, to train physicians and nurses on new forms of healthcare IT? For example, would this type of narrative approach be helpful in training someone on an EMR?
As a physician myself, I see the need for better use of EMR and IT tools on a daily basis. Some of the early adopters of DecisionSim have already incorporated screenshots of the EMR into the VP teaching scenarios. Others are directing learners to online support tools, to assist in solving the VP cases. Since DecisionSim cases can track things like patient satisfaction, cost and time – case authors can demonstrate how one approach may be better than others. By combining the use of IT tools with the process of taking care of a patient, learners appreciate the value of effective use of EMRs and electronic resources in attaining the best outcome for their patients while managing costs and other resources.

How do you see this product further evolving in healthcare?
DecisionSim was initially designed for medical students in their early stages of developing clinical decision-making skills. However, decision-making skills are not unique to medical students, and learning how to make complex decisions that involve data gathering, synthesis of disparate information and coming up with a solution tailored to the specific problem at hand is a challenge for all health professionals and administrators.

DecisionSim could be used to help experienced clinicians understand new therapies, how to better contain costs and apply new guidelines. Healthcare administrators could develop scenarios that demonstrate the variable outcomes of resource allocation decisions. With emerging changes in healthcare financing, VP cases could help care givers at all levels understand and practice more efficient delivery in a resource-constrained environment.

Ultimately, it is improving real patients’ outcomes that is the measure of success. Well-designed DecisionSim cases can help achieve that goal for a wide range of learners.

 Jennifer Dennard is Social Marketing Director for Atlanta-based Billian's HealthDATA and Porter Research.