PBTT,  Problem Based Tele-Training in Open Source

• Summary:
  • Medical education is a challenge, particularly in remote regions.
  • A very large set of medical knowledge is already available everywhere on Internet as "Open Data", similar to traditional "lectures" listened in a passive way.
  • Having access to the facts, the next level of education is training. Tele-training is important in order to provide training in remote areas for junior doctors, medical students, nurses, etc... who could not afford to go abroad.
  • The main question is here the training in "medical methodology", i.e. how to handle medical information. The typical issue is " Given all what is known up to now about a patient, what to do next ? " The use of the above "Interactive Medical Mind Maps" could become very useful.
  • Call for medical coaches willing to help groups of junior healthcare professionals training on virtual cases across Internet.
• Objectives:
  • Continued education for healthcare professionals, as medical students, junior doctors, nurses, etc... making health education available and affordable in remote regions.
  • Applied research about how to work as a collaborative team across internet.  Evaluation of new paradigms of healthcare, as today made possible by means of new informatics technologies, i.e. more than simple simulations of old paper era methods.
  • At a later stage, support of remote health centers where there are no specialists, or even no doctors on site, but where support is possible by means of telemedicine.  Support of meaningful data acquisition before a case can be presented to a remote expert.
  • However no attempt to provide automated final decisions, but only an environment supporting rigorous work methodology, well documented step by step.
     
• Approaches:
  • Proposed Medical Methodology:
    • Education rely on 2 pilars:
      • Access to knowledge:
        • Access to medical knowledge is no more a big issue. Student can find knowledge on Internet.  They can read it at own timing and they do no need to attend passively many "lectures".  However the study of dry theoretical knowledge require a lot of motivation. Electronic documents over internet are far more affordable and can more easily maintained up to date than paper documents.
      • Training:
        • Assuming the availability of knowledge, the main question is training how to manage the problems of a patient.  Therefore the recommended approaches "Problem Based Learning", http://en.wikipedia.org/wiki/Problem-based_learning , a method already in use in several universities.
        • A life long process.
    • "Iterative Care Model":
      • http://www.chos-wg.eu/Models/iterative-care-model.html , summary:
        
        • The first step is a set of complaints and/or abnormal observations.
        • At any point in time, given this available information about the patient, try to formulate explicit assessments about the current understanding of the "health issues".  Initially one or several hypothesis with their current degree of belief. Anyhow a health issues are points of concern, either abnormal observations to be understood or diagnoses to be treated.
        • Given the current identified issues, take a decision about what to do next:
          • Request for more information ?
          • Prescribe a treatment ?
        • The "results" of these actions will augment the knowledge about the patient and lead to the next iteration.
      • From an educational point of view, interesting discussions may arise here about the motivation of such "orders", in function of:
        • Expected benefits
        • "Global Medical Costs", a notion including multiple factors as time, risk of unwanted side effects, money, etc...
           
  • Virtual care team:
    • Meetings:
      • The exercise proposed to students is to play as a kind of virtual multidisciplinary care team in charge of a common patient, while the members of the team are located anywhere in the world across Internet.
      • A virtual meeting should not be very different from a physical meeting.  Rather than to raise a hand in order to ask the word, one will type a line or press a button.
    • Roles of typical team members:
      • Introduction:
        • The goal is here to define roles.  However one person may often play more than one role.  Team should be not be too large, maybe not more than a dozen participants ?
      • Patient representative:
        • Someone should represent the patient.  In a telemedicine scenario the patient is by definition at one location.
        • The patient representative should and be able to answer questions from other members of the team:
          • He should have access to the complete patient record.  However he should answer to the questions one at a time and not disclose the final diagnosis in advance.
          • In case of contact with a real patient, he should ask questions to the patient on request of other team members.
        • This role could be plaid maybe by the tutor, maybe by a student or maybe by a nurse.
      • Medical students:
        • Trying to play the role of a GP.
      • Junior doctors:
        • Seeking continued training,
      • Multidisciplinary team:
        • Assistants specialists:
          • Trying to play the role of a specialist.
        • Other healthcare professional may also participate, as nurses, social workers, etc...
      • Moderator:
        • The moderator manage the discussion allocating the microphone to only one participant at a time and taking care that everybody will have an opportunity to speak, to write on the white board or present some documents.
        • Who is willing to speak will "raise the hand", now by means of a button.
      • Tutor or coach:
        • The tutor has more medical experience and coordinate the discussion when necessary.  At the same time he could be the moderator.
        • The tutor is not intended to provide himself extensive "lectures" during team meetings, but to provide references to relevant medical knowledge in function of the current case.  This knowledge is expected to be studied by the students before the next meeting a few days later.
      • Teacher:
        
        • The participation of a teacher in training sessions is optional.
        • The role of the professor is to provide access to quality virtual courses:
          
          • to prepare and maintain courses made available on internet.
          • to recommend links to relevant courses already available on internet from other sources.
      • Secretary:
        • The secretary takes care that the conclusions of discussions will be properly documented.  The formulation of these conclusion should appear immediately on the screen of all participants. who could sometimes make remarks in case they would disagree.
        • From a training point of view explicit step by step documentation is very important.  This will also provide the possibility of critical reviews the reasoning path.
    • Environment:
      • The scenario is similar regardless of the context.
  • Typical scenario:
    • Start with the reasons for encounter:
      • A short summary about why the patient, or his relatives, did ask for care.  This is in fact a provisional problem list as seen by the patient himself.
    • White board:
      • The white board contains views on the current patient record.
      • Start with a kind of dashboard, showing the problem definitions as far as known up to now.
      • Possibility to navigate and zoom on details.
      • In principle divided in 3 aspects, which can be zoomed and unzoomed:
        • Factual observations:
          • Some facts are available about the patient, i.e. what the patient did answer to questions, what was found by examination,as well the result of technical tests from labs or images processing departments.  This information is coming from the "patient representative" in answer to previous questions from the students.
        • Health Issues:
          • Current version of the assessments based on the observed facts.
        • Care plan:
          • Overview of ongoing orders in function of the identified issues.  This including considered orders with their priority level.
    • Interactivity:
      • Anybody may ask questions and provide comments.  Questions will be answered by the patient representative.  In some case with a delay simulating the time necessary to get results from lab or XRays.
    • Main scenario:
      • While in general about 10.000 different information requests could be required, the critical recurrent question is " Given what is already known, WHAT TO DO NEXT ? ".
    • Meeting coordination:
      
      • One speaker at a time according to the list of persons having asked the microphone by means of a button. 
      • Comments by means of a keyboard, should appear as "chat" with a colored background, one color for every participant.  The tutor should have an easy recognizable presentation (a reserved color ? a specific character size ?)
    • Timing:
      • The discussion about a case could be phased in several successive meetings, maybe once a week.  The purpose is here to give time to the students in order to seek fundamental knowledge about the challenges they did just encounter.
      • In such a once a week meeting, a few different patients could be followed, like the morning review in the rooms of a department in hospital, going from one bed to the next one.
    • Archives:
      • Everything will be recorded and could be plaid back.
      • It should be possible to go back at an earlier point in time, in order to try an alternative path of events.
    • Implementation context:
      • The scenario is similar regardless of the context.
  • Privacy:
    • Exclude any public diffusion of personal patient information, but anonymous data may be archived and reused for educational purposes.
    • For educational purpose and with explicit agreement of the patient, direct contact with a real patient may occasionally be useful.  The information is restricted to a well identified group of healthcare professionals including students, confirming to follow the healthcare ethical rules.
       
  • Languages:
    • The initial experimental work is in English, but the software itself will later be translated in other languages.
    • It is assumed that the teams will share a common spoken language, since translations of the content of discussions would not be possible at the current stage.  The representative of the patient may have to translate the answers from the native language of the patient into an international language.
       
  • Openness:
    • The knowhow of this educational project is shared using FLOSS, "Free/Libre and Open Source Software" license and the medical knowledge as "Creative Commons".
       
  • Technical requirements:
    • To be further defined in function of the teaching strategy as proposed here above.
    • Preliminary requirements:
      • The participants may be anywhere in the world, as long as they have an internet access, a standard browser like Firefox, a keyboard, audio and microphone.  Depending of the quality of the available internet access, the priorities are:  text chat > voice > still images > video.
      • A video conference system allowing to support discussions, between different partners having different opinions.
      • A way to share a functional patient record of a virtual patient:
        
        • To navigate between different views on the patient record:
          
          • Sequential view step by step as the information did arise.
          • Problem oriented view,
          • Domain oriented view, for example circulatory, digestive, etc...
        • To add new information in the patient record.  Since the central question of the exercise is " what to do next ? ", requests and answers will arrive step by step.
      • A way to play back the evolution of a case and to have discussion about different strategies.
    • Future developments:
      • Permanent student evaluation in order to propose appropriate lectures.
• Provisional list of partners:
  • Inended user to be contacted:
    • ISfTeH Student working group, http://www.isfteh.org/working_groups/category/students ,
    • Junior Doctors associations, http://www.isfteh.org/working_groups/category/junior_doctors ,
    • IFMSA, International Federation of Medical Student Associations,
    • ....
  • More participants and sponsors are very welcome, at the moment particularly participants willing to contribute to specifications and technical prototypes.