Computer-aided, patient-centered, discovery-based learning through early clinical exposure with a multidisciplinary collaborative team

Introduction: There is a striking deficiency in medical learning competencies attained by medical faculty and students that are hardly ever reflected on or brought to notice in the course of caring for their patients. A biochemist may not know how the HbA1c values that s/he regularly facilitates in his lab is actually utilized by the clinician and patient and the clinician may not realize how the HbA1c values are actually generated in the lab. The undergraduate students need to be trained to become a primary basic doctor who can take care of a rapidly growing patient population but in our current curriculum they end up being taught specialized subjects like biochemistry, pharmacology even before they get to see a patient and get to realize why they need to learn what they are learning, how this knowledge may be applied by them to meet their patient requirements and if their training can allow them to answer queries that arise naturally and not as a result of an outdated curriculum that compels them toward non-contextual rote memorization.This affects current day healthcare practice where a large proportion of health professionals are in danger of becoming apathetic to patient requirements. To resolve the above mentioned problems in current medical education and healthcare, Medical council of India MCI has recently proposed 'early clinical exposure (see this recent debate here:https://groups.google.com/forum/?hl=en#!topic/meu_india/p41ahzTVMvo) and building on it further, we propose a patient-centered computer aided learning project with a ‘learning team’ comprising of first years receiving ‘early clinical exposure’ ECE as well as experienced faculty engaged in blended collaborative learning around ‘individual patients.’

Methods: We shall utilize a mixed methods quasi-experimental study design. In the course of a learning session for 1 year,a team of faculty and students (n=25) will be exposed to regular 'patient encounters' in the inpatient and outpatient wards of LNMC &RC. The group shall also comprise of students from the 1st year MBBS toward effecting early clinical exposure.This team shall capture patient-data at the 'point of care' (in the form of images of clinical findings as well as radiology data) and then subsequently bring them to our 'computer aided learning' CAL lab for further processing.The patients selected will have a sufficient level of clinical complexity likely to generate maximum learning outcomes in terms of patient centered learning questions (detailed here:http://www.pcori.org/research-we-support/pcor/). In the CAL lab the collected 'patient data' shall be uploaded on to a 'patient centered online health record' PCOHR website currently active here:http://www.udhc.co.in/ and currently housing a regularly growing database of patient records here:http://www.udhc.co.in/INPUT/input_directory.jsp
Subsequently the prepared 'patient centered online health record' PCOHR link is shared on to our online social-media based processing forum that has a current global membership of 1000+ members, many of who actively participate in solving patient problems posted to the forum.   All this patient centered 'data collection and processing' activity shall be  subsequently documented in 'patient centered online health records' PCOHRs such as these http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=304 and research publications generated from them such as these http://casereports.bmj.com/content/2014/bcr-2013-202916.full The learning and patient-health outcomes of the CAL group of 'patients, students and faculty' shall be compared with a 'control group' of patients,students and faculty who receive a 'placebo' CAL intervention (after pragmatic randomization and blinding) and the results documented.

Results/Expected Outcomes: This mixed methods study design will document results through qualitative thematic analysis of student-faculty learning insights, qualitative insights on patient-health-outcomes and quantitative estimates in terms of the number of validated participatory learning inputs contributed by each student and faculty and quantitative estimates of patient health in terms of QoL. The results of the impact evaluation of our PCOHR educational intervention strategy will be validated as per currently known paradigms(http://en.wikipedia.org/wiki/Impact_evaluation). An additional feature of note in our project is the utilization of online learning portfolios of students and faculty, which are generated partly automatically online from their documented participatory learning conversations in our currently active online CAL forum. These portfolios will be thematically analyzed to assess the results/learning-outcomes of each faculty and student's CAL activity. The portfolio based quantitative learning points generated around each patient will be compared with the results/outcomes obtained in terms of their respective patient improvement using quantitative QoL estimates (SF36 etc).

Discussion and Implications for Practice: The 'patient-centered learning' process will further involve learning feedback provided to the patient's primary caregiver by our 'computer aided learning' CAL team and then noting the results in comparison to a 'control group' of patients whose providers receive no CAL feedback. Our hypothesis toward the expected outcome of this project is that the CAL team as well as their patients will have respectively better learning as well as QoL outcomes than the control group-team. CAL performed and scaled in an appropriate patient centered manner can go a long way toward improving health professional learning as well as improving patient outcomes and the combination of the two will be instrumental in augmenting national capacity building and transforming healthcare.

SWOT Analysis:

Strengths: Promising solution to current felt need that can bridge gaps in healthcare learning competencies as well as address patient outcome complexities.

Weaknesses: Quasi-experimental and complex study design and consequent potential of study sample selection bias. (Workarounds:ensure transparent and accountable online documentation of entire process that is naturally subject to external peer review in real time)

Opportunities:Potential to scale into a sustainable model of practice based learning toward
improving patient outcomes

Threats: Participant motivation leading to study attrition, patient privacy and confidentiality (Workarounds: regular motivational meets with participants of both groups with real-time transparent documentation of the interaction that transpires between all the stakeholders)

Other ongoing similar programs in our Institute:
Blended learning electives:http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml
Past Experience:

http://www.ncbi.nlm.nih.gov/pubmed/?term=rakesh+biswas

http://scholar.google.com/citations?hl=en&user=Sc3HgGAAAAAJ&view_op=list_works&sortby=pubdate
References/Bibliography:

Patient centered research and learning:

http://www.pcori.org/research-we-support/pcor/

Clinical Complexity:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327227/pdf/wpa010001.pdf

http://www.ajmc.com/publications/issue/2012/2012-9-vol18-n9/impact-of-clinical-complexity-on-the-quality-of-diabetes-care/3

Clinical complexity and teaching learning competencies:http://www.wpba4gps.co.uk/fileadmin/user_upload/secure/mindmaps/PDF_files_for_Competency/Medical_Complexity__Detail_.pdf

Quasi Experimental studies and identifying causation between intervention and effect:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1380192/pdf/16.pdf

https://www.academia.edu/1482786/How_investigating_mediators_and_moderators_helps_explain_intervention_effects

Patient centered learning through a medical-student driven global online community

Introduction:Patient centered learning and research are emerging areas in current movements to transform healthcare and much of this is done through online information exchange in globally connected networks.This process is also termed 'User Driven healthcare which aims at improved healthcare through clinical problem solving utilizing concerted experiential learning in conversations between multiple users and stakeholders, primarily patients, health professionals, and other actors in a care giving collaborative network across a Web interface. The term "user" includes health professionals as well as patients and anyone who uses the web with a user name. These "users" generate an information flow that "drives" the system's workflow (hence the choice of the term "driven"). Our current work attempts to focus on the contributions and learning of the medical student 'user.'
Methods:Qualitative analyses of web-based interactions between the health professional student members of the UDHC network engaged in ‘patient centered learning' around ‘real-patient’ problems uploaded to http://www.udhc.co.in/ by our 'patient information communication manager and research assistant' funded by LN Medical College.Results:All patients suffered from chronic diseases, experienced conventional medical care, were highly motivated, and assisted by a social worker to seek solutions. The patients received multidisciplinary inputs from multiple specialists and generalists. The caregivers felt this was one of the strengths of the system. Students involved with the system have benefited from the impact of learning medicine from real-life situations with real outcomes and consequences.There was some concern regarding the maintenance of patient confidentiality and privacy. A solution was devised by automatic allocation of botanical names and manual de-identification of uploaded files as per standard international HIPAA guidelines.Discussion and Conclusions:Patient centered care has been hidden at the core of medical practice since time immemorial and current information technology (IT) has the potential to amplify it in a radical manner. IT may allow different groups of computer users such as patients as well as health professionals to experience patient centered care in an optimal manner. This presentation describes the work of medical student users with the 'User Driven Health Care' UDHC network that has currently piloted in rural and urban Indian locations with encouraging responses from patients, medical students and global health professionals connected through the web. The network eventually hopes to propagate 'patient centered learning in India and globally such that medical students and health professionals take pride in their teamwork toward making a positive change in their patients' lives. It hopes to in this manner utilize patient centered learning to build a vital bridge between basic and clinical science professionals that may translate bedside patient needs to solutions from the bench.
References:

Go to http://www.udhc.co.in/ and click on inputs and enter 462 to see all the cases uploaded by
our 'patient information communication manager and research assistant' funded by LN Medical College.

1)The User Driven Learning Environment. In R. Biswas, & C. Martin (Eds.), User-Driven Healthcare and Narrative Medicine: Utilizing Collaborative Social Networks and Technologies (pp. 229-241). doi:10.4018/978-1-60960-097-6.ch017 http://www.igi-global.com/bookstore/titledetails.aspx?titleid=41908&detailstype=chapters

2)Understanding Clinical Complexity through conversational learning in medical social networks: Implementing User Driven Health care. In J.P. Sturmberg and Carmel.M. Martin (Ed.), Handbook on Complexity in Health (pp. ). New York, NY. Springer.

3)User driven health care - Answering multidimensional information needs in individual patients utilizing post EBM approaches: A conceptual model.  Journal of Evaluation in Clinical Practice, 2008, 14, 742-749. http://www.ncbi.nlm.nih.gov/pubmed/19018905

4)(2008) Electronic collaboration toward social health outcomes, in (Eds.) Salmon J, Wilson L, Handbook of Research on Electronic Collaboration and Organizational Synergy, Hershey, PA: IGI Global publishing http://www.igi-global.com/chapter/electronic-collaboration-toward-social-health/20208, http://www.irma-international.org/viewtitle/20208/,

5)( 2009)Open Information Management in User-Driven Healthcare, Chapter XVIII, in (Eds) Niiranen S, Yli-Hietanen, and Lugmayr, Open Information Management: Applications of Interconnectivity and Collaboration. Hershey, PA: IGI Global http://www.igi-global.com/chapter/open-information-management-user-driven/27805

6)Revitalizing primary health care and family medicine/primary care in India--disruptive innovation ? Journal of Evaluation in Clinical Practice, 2009 Oct; 15(5):873-80. http://www.ncbi.nlm.nih.gov/pubmed/19811603

7)User Driven Healthcare and Narrative Medicine, IGI Global, Hershey PA, September 2010, http://www.igi-global.com/bookstore/titledetails.aspx?titleid=41908&detailstype=chapters

Connecting all medical colleges in India through student user driven blended learning in healthcare?

Would it be possible to grow connections with all medical colleges in India toward reaching out healthcare services to the rural and remote masses?

Perhaps this can be done in two phases?

In the first phase, Two motivated medical students from each medical college in the country can avail of this medical elective program (detailed ad here:http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml)  that will enable them to develop learning competencies (as per this http://www.mciindia.org/tools/announcement/Revised_GME_2012.pdf MCI 2012 document). Electives are mentioned as desirable in page 23 of the same 2012 MCI document. Here's an account of a recent elective experience in our institute:http://userdrivenhealthcare.blogspot.in/2014/09/positive-role-of-medical-electives-in.html

In the second phase these students trained as above will be able to interview 'complex patients' in their own institute managed rural areas and upload to http://www.udhc.co.in/ wherein suitable inputs to these patient requirements can be provided by a global network of faculty who want to help patients in India.

There is no financial gain for any of the stakeholders in the above mentioned plan and this can only be done as a nation building exercise. There may be hidden gains however in terms of visibility that may be leveraged in further positive ways by all stakeholders.

Steps to upload your patient inputs to our 'Patient centered online health record.'

Open website www.udhc.co.in

 

Look towards your right for ‘ Are you a care seeker/ patient’ 

Select ‘Add your Health Issue’

A pop up will appear

Sign in using your Yahoo/Google Email  ID

Wait till your User ID is accepted by the site.

Close the pop up window when it asks you to do so

A new window will load on the previous screen.

Under ‘What is the problem in short?’ Mention the age and gender of the patient and a few words on what the chief complaint is and how long it has been for (e.g. 65y Male breathlessness for 6 months, or 40y Female Pain in Right Knee for 1year)

Kindly download the Consent form in whichever language the patient can understand or that you wish, the links are present below ‘Upload letter of consent’ with the respective languages. (Hindi, Bengali Or English)

After you have downloaded the same print it, this must be signed by the patient and a witness, it will explain how your information will be processed.

Once signed, kindly scan and upload the same onto the website by clicking on ‘Choose File’ and then select the file from your computer.

Click on the Red tab saying ‘I wish to add a new patient’ to begin submitting your complaints.

The site will automatically give you a botanical name ( Name of a plant ) which will then be further modified to become your reference name for the doctors to treat you. 

Below that you would need to enter the first 3 numbers of your Six Digit Postal Pin Code in the box.

Kindly ‘fill in a description’, of the complaints and problems faced by the patient in order of how they started and what happened throughout, till now during the illness. To help us understand your problem better, particularly describe the age & gender of the patient, how long has the problem been for, when the problem gets worse during the day, since when and how is it now- better or worse, does doing anything make the problem better or worse. Include, current/previous medicines or operations and if any related previous medical problems.

Proceed to the next step to upload any reports that you may have got done recently that relate to the problem. Make sure to cover any identifying information related to the patient (or doctor where appropriate) identity BEFORE scanning. No names, addresses, locations or information related to a patients’ (your) identity should appear anywhere in the uploads, this is to maintain your security and privacy. You could use a white piece of paper to cover your details (including name, address, doctor’s name) and then scan the report or take a picture to put it on the site.

Once uploaded this information will automatically reach us.

You may continue to update your patient information in the future by signing in like before (Steps 1-8)  and adding through the ‘I wish to add more reports to existing patients of mine’ which is a Red Tab below the ‘Upload the consent letter’ section.

You may also delete any report or document you uploaded by mistake by clicking the remove icon next to the uploaded document.

Thank you for choosing UDHC, we hope to continue serving you better and the more detailed information you would be able to give us, the more we would be able to solve your problem easily and faster

Early clinical exposure and formative assessment strategies for Indian Medical students

Students are naturally driven more toward curricular assessment preparations as they perceive these semester assessments as a key to their long term career goals and may want to spend time preparing more for what they perceive to be the dominant requirement of their assessment driven curriculum as well as future career, which is to pass their MBBS and get a PG seat of their choice. We clearly need to build in an appealing assessment strategy for the 'early clinical exposure' program matching student goals or else (as pointed out by Dr Deven) this program may fail in its early phase. We have implementable ideas for this assessment strategy that we can share with any of you who may be interested.

Most of our students are engaged in taking coaching for PG entrance right from 6th semester (anecdotally i am told they pay approximately an advance of Rs 90,000 for this foundation course). They spend whatever  little time they can spare from their coaching in meeting their formal curricular requirements by attending lecture classes and semester exams. In this current climate if we are to sustain ECE we have few options (below).

Our solution for the above problem statement is to take early clinical exposure to the lecture classes (or whatever else the students are interested or attuned to attend). In the last two months at our institute we have been taking a 'live patient' every week to the lecture class and have had the pleasure of seeing the 'joy' on students' faces when they are able to finally correlate 'real' life requirements (albeit complex) with the requirements of their curriculum. To meet curricular requirements, we introduce a few theory questions and PG MCQs around the patient's problem as soon as we finish with the patient's story and its associated clinical problem solving conversations.

This appears to have been acceptable to our 6th sem students as this week, even in the lecturer's absence the students continued the lecture class on their own and reported good outcomes in our blended learning forum. The lecturer was in Mumbai meeting medical educationists, Dr Tejinder, Dr Vinay, Dr Shobna and Dr Bipin Batra for a common project.

This last lecture in the lecturer's absence was presented by a brave 6th sem student wanting to share her experience around her close relative who was also a patient with hepatic encephalopathy due to non-alcoholic fatty liver disease (an increasingly common cause of cirrhosis in the West and now in India).

I had agreed for the student to present her close relative as i felt this brave step would enable her student colleagues to develop a 'real' life empathic connection between what they study for their exams and what can happen to any of them/us. The student not only presented the case and discussed theory in the power point slides she had herself prepared but the class also discussed, other than PG MCQs, the theory question around hepatic encephalopathy posed in this years past 'university' theory exams (shared by our intern who was present in the class and who had taken the same 'university' exam where that particular question had been posed). A PG pathology (we do not have PGs in medicine yet) was present in the lecture class to guide the UG students. All this activity was documented by the students in our online discussion forum (there is a hint here on how we can effectively shape a formative assessment strategy using these online information traces of our students).

Hope to continue this variety of 'early clinical exposure' in the coming months with our students but would also like to benefit from your inputs on if/how to be on the right track.

Online Learning portfolio summary

RB is a professor of Medicine in LN Medical College and Research Center, Bhopal, India. His interests include clinical problem solving applied to patient centered health care and health education.

He has in the past shared his experiences in clinical problem solving extensively through global academic journals and books and is currently a deputy editor for BMJ Case reports, UK (http://casereports.bmj.com/site/about/Biswas%20Rakesh-2.pdf), chief editor for the International Journal of User Driven Healthcare, US (http://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022 ) and a regional editor for the Journal of Evaluation in Clinical Practice, UK (http://www.wiley.com/bw/editors.asp?ref=1356-1294 ).

 

He is currently engaged in developing a health care blended-learning ecosystem through a network of global multiple learner stakeholders that includes medical student and health professionals from diverse disciplines. It also includes patients along with their relatives in rural and urban India so that they may benefit from this global learning toward their local caring.

As all these stakeholders are computer users communicating through the web with a user name the network is also known as 'User Driven Health Care' UDHC network. More here: http://www.udhc.co.in/

The network has currently piloted in rural and urban Indian locations with encouraging responses from patients, medical students and global health professionals connected through the web. The network eventually hopes to propagate 'patient centered learning in India such that medical students and health professionals take pride in their teamwork toward making a positive change in their patients' lives. It hopes to in this manner utilize patient centered learning to build a vital bridge between basic and clinical science professionals that may translate bedside patient needs to solutions from the bench.

Publications:

Research Gate list: click on:https://www.researchgate.net/profile/Rakesh_Biswas2/publications

Pubmed list: click on:http://www.ncbi.nlm.nih.gov/pubmed/?term=rakesh+biswas

Google Scholar list:http://scholar.google.com/citations?hl=en&user=Sc3HgGAAAAAJ&view_op=list_works&sortby=pubdate

Patient ownership of medical records and Patient centered outcomes research

Patient centered outcomes research has been an emerging area since 2010 http://www.nejm.org/doi/full/10.1056/NEJMp1207437 with an annual funding of 2 billion USD from PCORI to answer 'patient centered research questions such as the ones here:http://www.pcori.org/research-we-support/pcor/

One way of answering these questions for our patients could be a hybrid PHR-EHR 'Patient centered online health record' PCOHR where physicians and patients work together toward reaching optimal health outcomes.

Here's one example http://www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=1354 where the patient has shared the history and the physician provided treatment details are also available on scrolling through the images and the patient has also posted a recent update on his blood sugars measured over the week.

Question of ownership:

However in the above example the patient has simply consented (http://www.udhc.co.in/STATICS/docs/udhc-english.pdf) to his record being used by the hospital physician and 'patient information manager' to help him but he has no control over the record in the sense he cannot delete it. This is only because the patient is not computer or internet savvy enough to generate his own record and needs help from the hospital 'patient information manager' to share his/her information.

There are other patients, urban users who are quite computer savvy to generate and maintain their own records www.udhc.co.in/INPUT/displayIssueGraphically.jsp?topic_id=150, completely free from the physician's or administrator's guidance and they can easily delete their records at will but they do not do that mostly because they benefit from the online guidance of the physicians who monitor their health and guide them through their online updates.

Looking for learning partners in Patient centered research

We are currently looking for learning partners in the form of post-graduate MSc/MA students (anyone with basic computer skills, ability to communicate online 24x7 and an active interest in healthcare and patient centered learning) who may like to solve patient requirements and interact in a multidisciplinary platform to gather resources for the same (considering every patient as a separate research project: more here:http://www.pitt.edu/~super1/lecture/lec50661/015.htm,
http://globalhealthtrials.tghn.org/blog/post/6765/2013/07/a-learning-ecosystem-for-case-based-health-inf/ and here:http://www.pcori.org/research-we-support/pcor/

The rewards of this learning project are currently only in terms of 'learning' in the form of research publication opportunities offered by our online network of team based learning facilitators who are also part of our editorial team managing our journal IJUDH http://www.igi-global.com/journal/international-journal-user-driven-healthcare/41022.

The candidate can convert this learning experience toward a Phd degree if an appropriate university willing to support this activity can be found. Most of this research can be achieved through our online guidance with the candidate who would need to carry out the 'patient centered research' locally after a brief training session (free of cost) here in our institute in the form of an elective (details here:http://journals.bmj.com/site/marketing/landing-pages/Indian_Caseelectives.xhtml).

The students can return and utilize the hands on skills learned from us here to further develop this emerging area of 'patient centered research' in a local university with a guide willing to support them and the research (toward their Phd degree).