The next in the series of “What features can we expect to see in the MedEdQR application in the future?” Improving Case Fidelity

The question of the month: The fifth in the series of “What features can we expect to see in the MedEdQR application in the future?”

  • Gamification / Goal setting
  • Case metadata
  • Template media type
  • URL media type
  • User metadata
  • Improving Case Fidelity*
  • Competency / Entrustable Professional Activities
  • Case Preview in Web-app
  • Enhanced reporting
  • Learner portal

We are now on the fifth item in the list of the potential feature updates that may find their way onto the MedEdQR platform development timeline. But I have decided to highjack this month’s message to discuss improving the fidelity* of virtual patient cases that are typically presented on paper or in digital form.

I know that this might be backtracking for some, but it is paramount that we start this discussion from that same viewpoint. To that end, I am going to use the often-cited definition of a “virtual patient” by the American Association of Medical Colleges (AAMC) which delineates virtual patients as “A specific type of computer-based program that simulates real-life clinical scenarios; learners emulate the roles of health care providers to obtain a history, conduct a physical exam, and make diagnostic and therapeutic decisions” [1]. There is one more foundational piece that we have to agree on before I discuss fidelity, and that is a “classification” of virtual patient delivery/competency/technology types. I have found the following and I would expect that most of us would agree on its simplified classifications. By implication “fidelity” (or simulation realism) improves as one moves from top to bottom in the following chart.

Class LabelPredominant competencyPredominant technologyShort description
Case Presentation
Multimedia systems
Interactive multimedia presentation of a patient case to teach primarily basic medical knowledge
Interactive Patient Scenario
Clinical reasoning
Multimedia systems
Interactive multimedia presentation of a patient case to teach mainly clinical reasoning skills
Virtual Patient Game
Clinical reasoning or team training
Virtual worlds
Virtual world to simulate high risk scenarios and team training situations
High Fidelity Software Simulation
Procedural or basic clinical skills
Dynamic simulations or mixed reality
Real-time simulation of human physiology to teach mainly procedures or skills such as surgical simulations. Non-standard devices (e.g. haptic technology) can be included.
Human Standardized Patient
Patient communication skills
Multimedia systems
Video-recorded actors who role-play a patient to train patient communication skills.
High Fidelity Manikin
Procedural and basic clinical skills, team training
Manikins or Part Task Trainers
Manikins with realistic anatomy to train complex procedures such as endoscopy.
Virtual Standardized Patient
Patient communication skills
Conversational characters
A virtual representation of a human being using artificial intelligence technologies and natural language processing to train communication skills.
Table 1: Adapted virtual patient classification with two levels of description [2].

How would I classify the MedEdQR platform? At its simplest, MedEdQR would be classified as “Case Presentation” – a computer/mobile device based system whereby virtual patient information and interactions are presented digitally to learners in a multimedia enhanced way. Yet, one of the reasons MedEdQR was developed, was to enhance Case Presentation so that it was not limited to knowledge acquisition only, but could include clinical reasoning. And because the use of virtual patient cases are most often found in a “Case/Problem Based Learning” (PBL) team or small group encounters, it also makes sense to increase fidelity even more to respond to the learning situation.

What aspects of MedEdQR promote increasing fidelity?

Clinical skill is the capability to perform acceptably those duties directly related to patient care – anything that a healthcare provider does. Often when clinical skills are discussed, the discussion relates to either the learners ability to perform physical examinations of the patient (procedural skills) or their ability to have rapport with the patient in taking health history and being empathic with the patient (professionalism). Yet, one of the most important aspects of clinical skills training is the development of clinical reasoning, which is the learner’s ability to make decisions about the patient scenario given their medical knowledge and the other clinical skills findings.

The branching between a case’s content is how the MedEdQR platform provides a means to improve clinical reasoning fidelity. Case designers can create multiple branching points throughout the case, each branching point with multiple branching options, all giving the learner the ability to choose their own path through the case. Here the learner is using their medical knowledge and the known case content to reason out or choose their next steps. Those next steps might provide more clarity about a possible diagnosis, give example or definitional content, or even take the learner down a rabbit hole.

Another aspect of the MedEdQR platform is its gamification implementation. When a case designer lays out case content through the use of “Case Pages”, those content snippets can be defined to be on the information “critical path” – i.e. the sequence of activities in the case, which must be completed and done so in a timely way for the case to conclude. Since a case can contain many “Case Pages”, not all have to be critical to the completion of the case. In fact, if the case designer is using branching, some of the case pathways may not be critical at all (at least when it comes to making the diagnosis and treating the patient). So MedEdQR has implemented a means to empower case designers to define which content is to be on a critical path, and the learner can watch their critical path progress through a case by the “progress bar” gamification element shown on their mobile device. Again, this increases the fidelity of the case.

So why discuss fidelity at all? It is clear there are more case simulation methods to improve fidelity, but they come at a price. For example high fidelity is typically attributed to the use of simulation manikins, which can be quite pricy, require dedicated spaces and require specialized technicians for case development and operation of the equipment. The use of standardized patients (SP) is another method to improve fidelity, but their use is often limited to clinical skills and professionalism (communication skills), and not clinical reasoning. They also come at a high cost, for they have to be trained, and they are paid for their time. Another factor relating to both simulation types just discussed, is that there is a practical limitation to the number of simultaneous learners that can be involved with the manikin or SP. Finally, there is the fact that both of these methods require an environment where the learners meet together at the same time – same time, same place. That can be alleviated to some extent by “telemedicine” activities, but that increases the cost of the encounter.

The MedEdQR platform continues to evolve to improve fidelity while maintaining the original goal of providing an anytime/any place learner platform to access virtual patient scenarios collaboratively.

In the Tips and Tricks section of this newsletter, learn how to improve fidelity even more through the use of a few third party applications.

If you’d like to give feedback on this topic or any other existing or proposed MedEdQR feature, click here.

Isn’t it time to give the MedEdQR platform a try? If it has been a while since you saw a demonstration, or if you have not experienced a demonstration yet, we would be happy to show you how this platform can enhance your educational program. Click here to request a demonstration.

John Morris, CEO

* Fidelity definition: The degree of realism or authenticity within a virtual patient encounter which can range along a scale from completely artificial to an actual real-life situation. A stem of a patient description or a clinical vignette that entails the examinee to make a clinical decision is a simulation at the low end of the fidelity continuum (low). Assessments using SPs are at the other end of the fidelity continuum (high), giving a more realistic context for measuring clinical skills and competencies.

  1. Association of American Medical Colleges. Effective Use of Educational Technology in Medical Education. Summary Report of the 2006 AAMC Colloquium on Educational Technology. Washington, DC: Association of American Medical Colleges; 2006. p. 2007.
  2. Kononowicz et. al., “Virtual Patiens – what are we taking about? A framework to classify the meanings of the term in healthcare education”, BMC Medical Education, (2015) 15:11

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