Use of Simulation Technology, EHR Systems, and Open Source Solutions for Medical Education and Training

Shepherdstown 24 June 2010Touring the new facilities of the School of Nursing Education at Shepherd University, it was interesting to see how technology is changing the traditional classroom settings. The tour took us through state-of-the-art classrooms set up as Intensive Care Units (ICU) and hospital patient rooms occupied by life sized robotic human mannequins. These human patient simulators are life-sized robotic mannequins that breathe, have pulses, respond to injected drugs and can be programmed to create simulations of life-threatening emergencies. Shepherd University is now in the process of installing and interfacing the 'open source' VistA electronic health record (EHR) systems to the robotic human mannequins to further refine and enhance the educational experience for their students. The use of simulation technologies in medical education and training continues to advance and become more widespread. This article attempts to provide a high level overview for management of healthcare provider organizations on the topic of simulation technology and its use in medical education and training. It attempts to pull together relevant information and representative examples of medical simulation technology currently being employed. The article also highlights selected issues such as ethical concerns, cost/benefits, and possible open source alternatives. Finally, it offers a set of recommendations to senior management on next steps to take with regards to the use of simulation technology in healthcare.

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Background

Models of human patients have been used in medicine for thousands of years. Some of the first medical 'simulators' were simple representations in clay and stone that were used to demonstrate clinical features of disease states and their effects on humans. Examples of these models have been found from many cultures on continents around the world. The models were often used to help teach students about human anatomy. They were also used as a diagnostic tool, allowing women in certain cultures to consult male physicians while upholding social laws of modesty.

Today, ever more sophisticated medical simulation tools and techniques have been developed and integrated into the education and training programs for medical professionals. There are now approximately 300 medical simulation centers in the U.S. Most are affiliated with medical schools, nursing schools, and major teaching hospitals. The tools and techniques being pioneered at these centers will continue to mature and become ever more sophisticated and be adopted by other academic institutions, health plans, hospitals and physician groups over time.

Description & Definitions

Simulation technology is often used in the training of personnel in highly skilled and complex professions, e.g. pilots, physicians, etc. The use of simulation technologies usually occurs because it may be prohibitively expensive or simply too dangerous to allow trainees to use real systems or perform a particular task in a 'live' environment. Instead, they spend time using simulator systems or equipment and performing dangerous tasks in a 'safe' simulated operating environment.

Definitions

Simulation is the imitation of something real , a state of affairs, or a process.

Physical simulation refers to simulation in which physical objects are substituted for the real thing.

Interactive simulation, also known as 'human in the loop' simulation, is a special kind of physical simulation in which physical simulations include human operators, e.g. flight simulators or driving simulators.

Computer simulation is an attempt to model a real-life or hypothetical situation on a computer, often in a virtual reality environment.

Medical simulators are increasingly being developed and deployed to teach therapeutic and diagnostic procedures as well as medical concepts and decision making to personnel in healthcare professions, e.g. physicians, nurses, pharmacists, etc. Simulators have been developed for training procedures ranging from such basic tasks as drawing blood draw to highly complex surgical procedures.

Medical simulation fills an intermediate stage in the medical education continuum, between classroom learning and practice in actual clinical settings. Simulation training complements other educational practices or events such as lectures, reading, laboratory work, problem-based learning and more. It is not a substitute for sound traditional educational practices.

In medical simulation, computer-controlled systems and devices can advance medical education while protecting patient safety by enabling medical students, residents and practicing clinicians to learn treatment protocols and master procedure skills in a 'safe' environment before using them on actual patients in a real setting.

Other new innovative simulation training solutions are now being used to train medical professionals in an attempt to reduce the number of safety concerns that have adverse effects on the patients. For example, virtual reality (VR) simulators are now used to educate surgeons and other medical specialists on complex procedures that are too dangerous to practice on live patients. See "Virtual Reality, Medical Informatics, and EHR Systems" at www.hoise.com/vmw/08/articles/vmw/LV-VM-02-08-9.html

Finally, simulation training has also become a new approach for preparing first responders to handle disasters. Simulations can replicate emergency situations and track how learners respond. Disaster preparedness simulations can involve training on how to handle bioterrorism attacks, natural disasters, pandemic outbreaks, or other major emergency situations.

See http://en.wikipedia.org/wiki/Simulation for more information.

Examples of Medical Simulation Organizations and Selected Software Solutions

The following are examples of a selection of notable organizations and software products associated with the use of simulation tools and techniques in medical education and training. For more detailed information about them, use the provided hyperlinks.

Organizations

The Medical Simulation Group - Formed in February, 2001, this multi-disciplinary research team was organized under the leadership of Dr. Steve Dawson to investigate how technology can improve medical education and increase patient safety. Based in Boston at the Massachusetts General Hospital, their work focuses on cutting edge research that will transform medical training from the current apprentice model to realistic, real-time, authentic computer-based medical simulations. See http://www.medicalsim.org

The Center for Medical Education + Innovation (CME+I) at Riverside Methodist Hospital is a comprehensive medical training facility featuring innovative human patient simulation and education technologies. The Center facility features innovative human patient simulation and education technologies, many of which have never been used outside the military. Their Cardiac and Endovascular Simulation Lab, called the SimSuite, was one of the first such systems in the country. For a more detailed description of the center, see http://www.hoise.com/vmw/05/articles/vmw/LV-VM-07-05-23.html

The Veteran's Health Administration (VHA) within the Department of Veterans Affairs (VA) has developed a new program for simulation in health care training called Simulation Learning Education and Research Network (SimLEARN). The program's goals include the establishment of a national simulation center with the focus on improving employee training and outcomes of care for veterans. VHA will collaborate with Department of Defense, academic affiliates, and other non-VHA entities to advance the use of simulation technologies. The national SimLEARN center will be located in the new VA Medical Center in Orlando, Florida. It is anticipated to be completed in mid 2012. A satellite office providing support for ongoing collaborative efforts is located in the Palo Alto Health Care System in California. Visit http://www.simlearn.va.gov to read more about VHA's research, publications, methods, and curricula related to simulation learning and education in health care.

At the University of Missouri's Clinical Simulation Center medical, nursing, pharmacy, respiratory therapy, health management, and informatics students participate in interdisciplinary simulations that mimic busy emergency rooms. A typical simulation can be quite hectic with crying babies and people shouting in pain and asking for help. Students are orientated to the scenario and then must work together to efficiently treat several patients. Students are instructed to recognize safety risks, communicate effectively, and work with other health professionals. For more detail about their medical simulation education and training program, see http://www.hoise.com/vmw/09/articles/vmw/LV-VM-06-09-11.html and http://som.missouri.edu/SimCenter/

Other organizations of interest to explore include:

Commercial Software

Medical Education Technologies, Inc. (METI) is a company committed to developing learning tools that impact the education of future doctors, nurses, first responders and military medics. They are committed to providing technologically advanced learning tools - including a complete line of human patient simulators, surgical simulators, and medical examination trainers. For more information about the simulation products they offer, see www.meti.com

Immersion Medical develops systems and technology for integrating touch feedback into licensed medical simulation products. According to Daniel Chavez, senior VP and General Manager of Immersion's Medical line of business, "By combining realistic touch feedback with our virtual reality environments that provide true-to-life simulation, Immersion is helping more and more doctors become skilled at critical new techniques that can save lives every day." To see the wide range of products they offer, visit http://www.immersion.com/markets/medical/products/ or read http://www.hoise.com/vmw/09/articles/vmw/LV-VM-04-09-19.html

Medical Simulation Corporation (MSC) is a recognized healthcare industry leader in providing full-service simulation training, education, and consulting services to hospital personnel, medical product manufacturers, and medical societies. For more information on the products and service they offer, see www.medsimulation.com

Other commercial simulation software solutions or projects of interest include:

'Open Source' Software

General Physical Simulation Interface (GiPSi) is an open source/open architecture framework for developing organ level surgical simulations. The framework consists of the Simulation Object API, which also includes the object interfacing API, the Visualization API and the Haptics API. The implemented Modeling Tools and Computational Tools form an initial set of GiPSi compliant libraries to support development of GiPSi based simulations. The open source, open architecture software development model provides an attractive framework to address the needs of interfacing models from multiple research groups and the ability to critically examine and validate quantitative biological simulations. See http://gipsi.case.edu

Simulation Open Framework Architecture (SOFA) is an open source framework primarily targeted at real time simulation and the simulation research community. The main objectives of the SOFA framework are to:

  • Provide a common software framework for the medical simulation community
  • Enable component sharing and exchange to reduce development time
  • Promote collaboration among simulation research groups
  • Enable validation and comparison of new algorithms
  • Help standardize the description of anatomical and biomechanical datasets
For more information about SOFA, visit http://www.sofa-framework.org and http://wiki.sofa-framework.org/wiki/Main_Page

The 'open source' VistA & RPMS Electronic Health Record (EHR) systems contain interfaces to a wide variety of medical devices and data sources. Shepherd University's School of Nursing Education and the West Virginia School of Osteopathic Medicine (WVSOM) are in the process of installing and interfacing the human simulation mannequins used in their simulation laboratories to these EHR systems. This should take their simulation laboratories to another level. The two universities are partnering on a number of health IT research initiatives related to medical education. To learn more about these and other open source solutions, visit http://www.shepherd.edu/surc/cosi/

Other 'open source' medical simulation software solutions include:

Selected Issues

According to a 2006 paper prepared by Dr. L. Spillane, "With the surge to create simulation centers, one might assume that the evidence supporting the use of simulation for teaching and evaluation is substantial. Although using simulation technology to train professionals in many industries has proven to be effective, the evidence to support its effectiveness in medical training is still limited." See http://www.saem.org/SAEMDNN/Portals/0/SAEM%20Obj_3a_Summary.pdf

Costs

Medical simulation technology can be an expensive proposition. For example, HealthPartners invested more than $600,000 to establish a simulation center. The annual operating budget for the center is $450,000. Then there are costs to acquire new products since the technology keeps changing and improving. Keeping pace requires ongoing investment. For more information, read the following article by Dr. Patow, Executive Director of the Institute for Medical Education at HealthPartners in Minneapolis, MN - See http://findarticles.com/p/articles/mi_m0DUD/is_12_26/ai_n15950804/pg_2/?tag=content;col1

Benefits

Learning medical procedures traditionally has meant making mistakes on real patients. Hands-on, experiential learning is indispensable for healthcare professionals during their training, but mistakes can put patients in harms way. Considering the potential risk to patients and institutions when errors are made on real patients during training, simulation centers may turn out to be very cost effective, especially in reducing insurance premiums and avoiding litigation.

Emergency medicine physicians and simulation experts from the Rhode Island Hospital discuss the benefits of advanced medical simulation in five manuscripts appearing in the November 2008 issue of Academic Emergency Medicine - now available on-line. The articles describe how simulation centers, along with new portable simulation technology, offer unique cost effective training opportunities for dynamic, complex and unanticipated medical situations in acute care fields. See http://www.hoise.com/vmw/08/articles/vmw/LV-VM-12-08-10.html

Ethics

In an article entitled "Simulation-Based Medical Education: An Ethical Imperative", by Dr. Amitai Ziv et al, the authors succinctly discuss the ethical issues related to using simulation technology in healthcare. In their abstract it states, "Medical training must at some point use live patients to hone the skills of health professionals. But there is also an obligation to provide optimal treatment and to ensure patients' safety and well-being. Balancing these two needs represents a fundamental ethical tension in medical education. Simulation-based learning can help mitigate this tension by developing health professionals' knowledge, skills, and attitudes while protecting patients from unnecessary risk. Simulation-based training has been institutionalized in other high-hazard professions, such as aviation, nuclear power, and the military, to maximize training safety and minimize risk. Healthcare has lagged behind in simulation applications for a number of reasons, including cost, lack of rigorous proof of effect, and resistance to change." See http://www.aap.org/nrp/simulation/Ethics.pdf

Conclusions & Lessons Learned

Simulation training is now a central thread in the fabric of medical education and training programs for health care professionals. For large health care provider organizations, medical schools, and nursing schools, the acquisition and use of simulation technologies is growing.

Based on lessons learned to date, the following are 12 key features of simulation-based medical education (SBME) which every SimInstructor should know in order to maximize the educational benefit of simulation education.

  • Feedback is the most important variable in the effective use of SBME. Through the use of debriefings SimLearners can improve clinical performance rather than simply being presented with a passing or failing grade.
  • Deliberate practice - Deliberate and repeated practice is used to shape, refine and maintain SimLearner(s) knowledge, skills and attitudes.
  • Curriculum Integration - Simulated events and practice should complement other educational events, such as lectures, reading, laboratory work, problem-based learning and more. Simulation training is not meant to be a substitute for traditional educational practices.
  • Outcome measurement is the foundation needed for facilitators to reach valid decisions, judgments or inferences about learners. Reliable data, captured by observation or sensors during simulation sessions, is vital for instructors to evaluate and provide accurate feedback to learners.
  • Simulation Fidelity (low to high, multi-mode) - Fidelity refers to the "realism" the simulation provides as an approximation to clinical situations, principles or tasks. Low fidelity refers to basic procedural skills like suturing or intubation. High fidelity refers to more complex clinical events such as team responses to simulated hospital 'codes' or medical emergencies.
  • Skill Acquisition and Maintenance - Clinical and procedural skill acquisitions and maintenance are the most common learning objectives of simulation-based medical education (SBME).
  • Mastery learning - The goal in mastery learning is to ensure that all learners accomplish all educational objectives with little or no outcome variation.
  • Transfer to Practice indicates skills acquired in SBME laboratory settings generalized to real clinical settings. Studies have shown simulation-trained learners show greater compliance, more skillful behavior, significantly fewer procedural complications, and improved patient outcomes.
  • Team Training - Health care team training is an important educational goal. It provides an opportunity to practice both task- and team-related skills in a "consequence-free" simulation environment, where errors are truly opportunities for learning.
  • High-stakes Testing - The standardization, fidelity and reproducibility of medical simulation make the technology well suited for evaluations of clinical competence. The medical community can use SBME to make 'high-stakes' decisions involving evaluation of a learner's qualities, attributes, and procedural skills as they seek to pass a course or gain certification or licensure.
  • Instructor Training - The role of the SimInstructors in facilitating, guiding and motivating learners effectively is important and additional research in this area is still needed. It appears that clinical experience alone is not a proxy for simulation instructor effectiveness.
  • Educational and Professional Context - Authenticity should have a high priority when programs for the assessment of professional competence are being designed. Developing realistic training scenarios that take full advantage of the simulation technology is a critical success factor.

Recommendations & Next Steps

Simulation technologies will contribute significantly to the revolution in medical education and training over the coming decade and will have a positive impact on the quality of care and clinical outcomes at healthcare provider organizations. The following set of recommendations is presented on possible next steps for large health care provider organizations, medical schools, and nursing schools to take with regard to using medical simulation tools and techniques:
  • Consider establishing a multidisciplinary working group to investigate and oversee the acquisition and use of simulation technologies for medical education and training purposes at your institution.
  • Monitor and obtain 'lessons learned' and 'best practices' from the growing body of information on medical simulation technology projects and their impact on medical education, training, and clinical outcomes.
  • Consider actively pursuing grants and becoming actively involved in selected medical simulation research and development (R&D) efforts.
  • Conduct Cost/Benefit Analyses (CBA) and Return On Investment (ROI) studies of medical simulation technologies before making any major commitment by your organization.
  • Investigate changes in clinical practices, medical education and training programs, and business processes that your organization may need to make if or when you acquire medical simulation technologies.
  • Recognize that simulation technologies and their application in medical education and training is beginning to mature very rapidly and widespread usage will occur during this coming decade.

Other Selected Links

Authors

Peter Groen previously served as a CIO at several VA Medical Centers and as a national director of various health IT related program offices at the U.S. Department of Veterans Affairs (VA). He is now an adjunct faculty member at Shepherd University in West Virginia and is one of the founders of the Shepherd University Research Corporation (SURC). He can be reached at groenpj@cs.com

Jaime Groen is a graduate of Shepherd University and is a project manager and senior health IT training and education specialist within the Veterans Health Administration (VHA).


Peter Groen, Jaime Groen

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