Acad Psychiatry 30:528-533, November-December 2006
doi: 10.1176/appi.ap.30.6.528
© 2006 Academic Psychiatry
Virtual Reality, Telemedicine, Web and Data Processing Innovations in Medical and Psychiatric Education and Clinical Care
Donald M. Hilty, M.D.,
Dale C. Alverson, M.D.,
Jonathan E. Alpert, M.D., Ph.D.,
Lowell Tong, M.D.,
Kemal Sagduyu, M.D.,
Robert J. Boland, M.D.,
Arash Mostaghimi, B.S.,
Martin L. Leamon, M.D.,
Don Fidler, M.D. and
Peter M. Yellowlees, M.B.B.S., M.D.
Received February 10, 2006; revised April 16, 2006; accepted June 5, 2006. Drs. Hilty, Leamon, and Yellowlees are affiliated with the University of California, Davis, Sacramento, California. Dr. Alverson is affiliated with the University of New Mexico, Albuquerque, New Mexico. Dr. Alpert and Mr. Mostaghimi are affiliated with Harvard Medical School, Boston, Massachusetts. Dr. Tong is affiliated with the University of California, San Francisco, California. Dr. Sagduyu is affiliated with the University of Missouri, Kansas City, Kansas. Dr. Boland is affiliated with Brown Medical School, Providence, Rhode Island. Dr. Fidler is affiliated with West Virginia University, Morgantown, West Virginia. Address correspondence to Dr. Hilty, University of California, Davis, 2230 Stockton Boulevard, Sacrament, CA 95817; dmhilty{at}ucdavis.edu (e-mail).
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ABSTRACT
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OBJECTIVE: This article highlights technology innovations in psychiatric and medical education, including applications from other fields. METHOD: The authors review the literature and poll educators and informatics faculty for novel programs relevant to psychiatric education. RESULTS: The introduction of new technologies requires skill at implementation and evaluation to assess the pros and cons. There is a significant body of literature regarding virtual reality and simulation, including assessment of outcomes, but other innovations are not well studied. CONCLUSIONS: Innovations, like other uses of technology, require collaboration between parties and integration within the educational framework of an institution.
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INTRODUCTION
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Technologies of all kinds are evolving for use in medical education and will continue to change well into the future. It is all too easy to become overly enamored with particular kinds of electronic wizardry and forget that all educational technology is fundamentally dependent on the underlying pedagogy and learning principles employed to deliver the educational programs themselves. New technologies facilitate learning, no matter what field one turns to in society: business (e.g., e-courses), airlines (e.g., simulations), undergraduate education (e.g., information analysis of college papers); medicine (e.g., surgical simulations); and psychiatry (e.g., treatment of phobias).
Simulation and virtual reality, in particular, are emerging as popular modalities for learning in medicine. Virtual reality immerses people in incredible worlds that offer unique and fruitful educational experiences. Students can learn standard or complex procedures without worrying about harming humans or animals in the process (1). Through telehealth outreach, collaboration has occurred between participants at institutions in different states, using interactive problem-based learning exercises (e.g., subdural hematoma case). In an era in which competence is increasingly assessed, virtual reality and simulations could supplement objective structured clinical examinations (OSCEs), including those that use video (OSVEs) (2, 3). The OSVE, virtual reality, and simulations have two advantages over OSCEs: exact reproducibility and potentially reduced overall development and implementation costs.
Other innovations in the field of medicine are Web-based courses. These, like virtual reality and simulation, increase interaction during the learning process, as they are associated with better achievement and more retention of knowledge (4–8). These technologies also facilitate assessment of an important component of adult learning, the learner’s ability to access and integrate multiple sources of information, and avail themselves of reliable and valid information through search engines and e-databases.
This article will describe new technologies applicable to psychiatric education and clinical care, and assess data regarding their pros and cons.
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School-Specific Examples of Curricular and Web-Based Education Innovations
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University of California, San Francisco
The University of California, San Francisco (UCSF) medical school curriculum challenges old assumptions about the way students are best taught and encourages their active participation in the process of study and investigation. Medical education must inspire and engage students and teachers. UCSF innovations include case-based and integrated block courses in the first 2 years, the third-year "Intersessions," and the fourth-year "Areas of Concentration." A highly flexible Web-based digital curriculum called iROCKET is used throughout the medical school curriculum, with modules on key topics, such as renal physiology, EKGs, brain anatomy, dopamine pathways and function in pre-clerkship courses, and specialty-specific interactive learning modules in clerkships.
Ilios is a Web-based electronic database for curriculum planning, tracking, and oversight that facilitates communication among course designers and serves as a development forum. It offers faculty, students, and staff a means of tracking course information and generating comprehensive reports about the integration of themes, concepts, and learning objectives. It includes longitudinal monitoring of the required and elective curriculum in the Essential and Clinical Core; customized reports that include a wide range of search parameters; a learning materials database that houses multimedia content; and real-time data to iROCKET to create online course calendars with small group, lab, and lecture details, and even personalized downloadable daily schedules with room numbers for individual students.
EncounterIT is a Web and personal digital assistant-based patient and clinical problem tracking software. E-Value is a Web-based student, teacher, and course evaluation program that was incorporated across the entire range of UCSF undergraduate and graduate medical school training programs on a mandatory basis. Since all departments and courses use it, standardized data are accessible for a large number of purposes, including benchmarking and comparison studies.
Both Ilios and EncounterIT were created by UCSF’s Office of Educational Technology from the ground up; iROCKET is an adaptation of a commercial course management software, and E-Value is a commercial program.
Harvard
The Interactive Case-based Online Network (ICON) is a platform originally designed to enhance learning of neuroscience at Harvard College (9) (Figure 1). More recently, it has been adapted for use in the second-year medical school neuroscience course, called "Human Nervous System and Behavior." A preliminary assessment of medical student and faculty utilization and perceptions is very positive in terms of the interactive learning (10). At Harvard Medical School, ICON makes use of Web-based Internet/intranet software installed on a secure Harvard Medical School Web server using the portal, http://mycourses.med.harvard.edu. (It can be explored to some degree by clicking on "About MyCourses," which calls up a detailed description of specifications and a 30+ page tutorial).
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FIGURE 1. ICON "Virtual Contact" Module
The names and faces of students have been obscured for confidentiality. The right column lists students and virtual patients/consults (whose roles are assumed by faculty) who are available for real-time conference. The asynchronous dialogue threads (middle column) allow students to ask questions of virtual patients, receive critical laboratory data from virtual physicians, and create patient management plans with virtual attendings. A library (left column) is populated with resources from a pre-selected database as students reach specific case milestones.
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Students and faculty (usually seven to eight) interact virtually, over the school network, e-discussing a virtual case which unfolds in real time over the course of a week. Students and faculty draw from and contribute to a set of modules including a virtual contact module, in which faculty typically participate as characters (patients, attendings, consultants) and initiate a dialogue with students. Rich faculty-student and peer interaction occurs throughout the case as students and faculty log on after hours or in-between other scheduled activities, and it is responsive to student interests and faculty suggestions for related topics. Students may request consultations, laboratory tests or additional clinical information. A resources module provides selected readings and a neuroimaging module provides radiological scans and graphic illustrations relevant to an understanding of the virtual case (e.g., synaptic physiology). Other modules emphasize the specific learning objectives of the case and permit students to problem-solve with their student peers on the team "out of earshot" of faculty characters. ICON concludes with face-to-face sessions with faculty.
ICON is being explored for use in Harvard’s core clinical rotation and second-year psychopathology course, despite challenges. This informal curriculum needs to be assessed with regard to how it complements core rotations and learning experiences. The estimated faculty contribution is considerable (e.g., 4 hours per faculty member per week on a case). In addition, there is concern that the time students devote to ICON may encroach upon other valuable experiences, particularly direct patient contact. On the other hand, ICON promotes integration of neuroscience and clinical psychiatry and broadens the consistency of the exposure of students to a diverse range of patient problems, as required by the LCME.
University of Missouri, Kansas City
The University of Missouri, Kansas City (UMKC) Psychiatry Department has put together a Web-CT based interactive test module that has 800 Subject-Exam style questions geared to both basic science and clinical teaching. Each item begins with a case format, in the A-type USMLE subject examination style. Students directly log in with their university identity number through the UMKC intranet or through the Internet from any computer. On each entry, a question module of 50 randomly selected questions pops up. Students answer each question, turn in the answer key electronically and get instant feedback.
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Virtual Reality, Simulation, and 3-D Environments
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Clinical and Educational Foci
Virtual reality has been used to enhance domain-specific learning, which relates to memory and the conceptual organization of material. Experts have an integrated, well-structured organization of material on a topic compared with trainees. Training effectiveness can be measured by pre- and post-tests, both in comparison to experts doing the same exercises (11). Virtual reality is usually experienced through goggles or the Internet or room-sized simulation, along with a virtual hand or wand. Artificial intelligence systems and position-tracking software (e.g., Flatland) are used. Steps involve expert consensus of a core concept on a subject, pre-reading by students of material with the concept, a video, practice virtual reality time, a pre-test, the virtual reality experience, a concept mapping exercise, and comparison versus experts’ mapping. Students’ knowledge structures become more integrated and similar to those of experts (1). Most importantly, virtual reality facilitates reification (the process of making abstract concepts and events concrete and accessible) (12). Applications have included understanding renal physiology and managing disorders (e.g., head trauma at the roadside and phobias). Controlled studies have shown that virtual reality training is valid and reliable and in some cases superior to traditional methods of learning (1, 13). Cons to such environments include time to construct, cost, and (sometimes) the inability to simulate real situations.
Advanced communications networks, such as Internet2, allow dissemination of these simulations at a distance (14). The Universities of Hawaii and New Mexico and Uniformed Services collaborated to develop an integrated, interdisciplinary, fully immersive three-dimensional environment. The single-participant environment allows individual training, exploration, practice, and self-evaluation. The multi-participant environment allows simultaneous training, team participation, and interaction with tools and patients. Evaluation revealed that subject matter has high face and content validity, better learning through interaction, and improved conceptual learning (15).
Three-dimensional environments on the Internet help learners navigate digital representations of themselves, called "avatars," through a virtual psychiatric ward (16). This system is designed to help students learn more about the subjective experience of psychosis and, ultimately, to improve care of their patients. The virtual auditory and visual hallucinations are based on actual patient experiences, which have been recreated in the virtual environment, and then validated by the patients themselves as being reasonable representations of the symptoms they had experienced. In this environment, Internet users (N=800) reported that seeing and hearing the hallucinations as a patient was both useful and educational. Cons are patients needing to learn and accept such modalities, upkeep, and (sometimes) the inability to simulate real situations.
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Psychiatric Applications of Virtual Reality and Simulation
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Potential applications for virtual therapy include patients logging in as avatars from any number of different sites to meet their therapists online, receive cognitive behavior "virtual in vivo" treatments, or attend programs for anxiety (e.g., obsessions, trauma, phobias, panic and related fears), pain, rehabilitation, and other disorders (17). In terms of posttraumatic stress disorder, it is being evaluated for pre-exposure conditioning and post-exposure (i.e., graded exposure combined with cognitive behavior therapy) treatment by the Department of Defense (17). Similarly, often severe and debilitating panic disorder is now being treated with exposure therapy, usually combined with cognitive behavior and medication, internationally (17, 18). The same techniques would be expected to work with obsessive compulsive disorder, in which the graded exposure would be simplified greatly with technology.
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Telemedicine: Video, Secure E-Mail, and Telephone
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The effectiveness of telepsychiatry is established for the delivery of individual psychiatric consultations, especially to primary care providers, and for accurate psychiatric diagnosis and assessment (19, 20). It has occurred in many differing clinical environments, including clinics, hospital emergency rooms, homes, schools, and forensic facilities. Using telepsychiatry facilitates reliable and valid diagnoses for anxiety, cognitive, depressive, and psychotic disorders with high interrater reliability. Telepsychiatry to treat depression is comparable with face-to-face care in terms of treatment outcomes, patient adherence to treatment, patient satisfaction with treatment, and cost of health care (21). Despite these successes, telepsychiatry has not been used as widely as might have been predicted. This is due, in part, to the difficulty of physically organizing distant consultations and the prohibitive cost of broadband networks necessary for unequivocally clear visual and audio communication, as well as to the lack of reimbursement in some situations (22).
Telepsychiatry is used as a key example for specialties that "must" be conducted using live, two-way videoconferencing, but primary care and psychiatrist consultation by secure e-mail and telephone are increasing. Synchronous telephone consultations are less cumbersome to arrange, though participants tend to go into a data-exchange mode with less shared meaning (19), while asynchronous e-mail consultations are timely, allow natural documentation, and reduce communication difficulty across time zones. For clinical care, the use of secure e-mail and telephone consultations between physicians accelerates the delivery of care (20). This case-based education for family physicians helps them provide better care for their patients and reduces the need to refer to typically inaccessible mental health services (21). Approximately 33% of information needs of family practitioners were met by these telephone specialty requests (23–26).
Are faculty and residents ready to participate in the global health care delivery system of today and the future, when patients contract for services over the Internet and assessment occurs through interviews and scanners? If so, faculty will need to teach an adapted clinical skill set with several core elements: 1) the ability to assess the pros and cons of a technology in order to compensate to achieve an adequate evaluation; 2) communication skills for the Internet, video, and other technologies (e.g., instead of handing a tissue to a patient in person, do you state, "If I were there, I would hand you one ... do you see a box?"); and 3) integration of data streams from patients, staff, and technologies.
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Store-and-Forward Technologies
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"Store-and-forward telepsychiatry" (SFTP) is synchronous, typically making use of the transmission of clinical information via e-mail or Web applications for review by a specialist (e.g., imaging, EKGs, dermatology). This mode of medicine is used throughout the world for consultation rather than management services, and is the future, when consumers will contract online for specific types of care (2, 27). The fundamental strength of "store-and-forward" technology is that the consultant and referrer do not have to participate at the same time. Delivery of clinical services in psychiatry can be improved using this modality, particularly in primary care, where patients more commonly access care and need to be better screened for disorders.
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Ex-Ray: Text, Image, and Voice Analysis
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The field of machine learning offers substantial potential to psychiatry. Machine learning techniques are part of "data mining" or "knowledge discovery in databases." Data mining is the stepwise process of automating knowledge discovery in databases, to find comprehensible rules and relations in data sets of various types. Often these rules are abstractions (describing significant components of a database) and hence require the application of machine-learning techniques.
Text, image, speech, and other multimedia information analyses are used in many fields (e.g., law enforcement, security, business), including education. For example, two essays submitted by a college student can be scanned and analyzed to determine if they are written by a single student. A clinical example is Ex-Ray, a patented machine learning tool, under evaluation regarding its capacity to analyze medical reports and derive psychiatric diagnoses, using unsupervised machine learning algorithms. Studies are also in progress of videos of physician-patient encounters, which are being analyzed for key terms, phrases, and other dimensions in order to assess the likelihood of a diagnosis, quality of engagement and/or adherence outcomes.
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Lessons Learned
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- A central educational technology office at each school can be very helpful in coordinating, tracking, serving as a point of networking and education, suggesting common platforms, and potentially providing some resources (expertise, funds) for pilot projects.
- Standardize applications across an entire medical school so that data are more easily managed, used, and accessible.
- Medical students are a tremendous resource for development and refinement of these technologies. Each class seems to have at least a few students who are as capable as if not more capable than professional techies/programmers. Using hired or volunteer students also has the advantages of creating better curricula and applications because of student input, as well as the general good principle of increasing engagement of students and their sense of ownership in their own education.
- New technologies may change how we process information to diagnose, treat, and make other medical decisions.
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Conclusions
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There are an infinite number of innovations underway using technology for medical student, resident, and faculty education. This overview may be of interest to colleagues as we consider available technologies and how we make use of them in our respective programs. Innovations, like other changes in medicine and education, require careful assessment of how they fit current programming with regard to pros and cons of implementation. Collaboration between parties can be fruitful in implementing innovations and evaluating them, since problem-solving, creativity, and findings from assessment can be shared—and therefore be more applicable to others.
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ABSTRACT
INTRODUCTION
