Virginia Research Day 2021

Authoring Software Tool, CASEAGE, and Integrated Dynamic Interactive PRESENTER for Case-based Learning Darren Patel, Joseph Manzi, Fred Rawlins, Dixie Tooke-Rawlins, Cameron Sumpter, Sepehr Sohraby, Harold R Garner ABSTRACT

Abstract ERM-1

DISCUSSION In today’s educational environment, resources are multifaceted and come in many different forms of media, most importantly of which is digital. E-learning has become the trend for educational reform worldwide. As such, medical education has followed suit and many components of medical student learning occur online – from quizzes and tests to certifications and learning modules. By encouraging autonomous training online, learning skills are fostered which build a commitment to lifelong learning, a trait that is integral for a career in medicine. The case-based learning format is flexible and allows for the incorporation of various types of media, learner engagement, and incorporation of the tenants of adult education. Two theories of adult education were drawn upon in the development of CASEAGE, self-directed learning, and experiential learning. Self-directed learning is based on the premise of self-motivation, management, and direction. A flexible education platform and student empowerment allow learners to excel. Experiential learning occurs with more formal stages of the learning cycle and include performing a task, a reflection of the task, identifying areas of improvement, and readjustment before a new cycle. Feedback, debriefing, and reflection can occur during the event, afterward, or both. A large component of success in the medical curriculum can be found within these principles of adult education. When a student is empowered with curricula that allow them to direct their learning and provide real-time feedback, their success is boundless. As such, the VCOM has embraced the student patient encounter diagnosis and procedure logging application, CREDO, for use throughout the pre-clinical and clinical education years. CREDO serves as an intuitive, visual system that allows students track, quantify, and qualify their clinical education. The integration of PRESENTER (and cases authored in CASEAGE) into CREDO allows for self-directed case-based education founded on principles of adult education, and its corresponding benefits to student education. Further details of CREDO are discussed below. CASEAGE CASEAGE is a curriculum management system where medical school cases can be created, edited, reviewed/verified, and then made available for different uses. Cases include all standard components, including case description, metadata, case presentation through a management plan. The system enables the incorporation of multimedia, including sound, video, and other data types in the presentation of a case. Each case includes questions, annotated answers, and references. These questions are used to make the presentation of the case dynamic, as correct answers, in addition to being used for grading, and can be used to release other case components as the case unfolds when being completed by students. Other questions are used as reading comprehension checks as the case progresses. It has been designed to track the case author’s progress in developing and validating a case as well as facilitates team feedback and interaction. Lastly, cases can be presented in CREDO, and dynamically linked to patient encounter logging or used as part of curriculum presentation. CASEAGE serves as a platform within the web-based CREDO system for the delivery of case-based learning. This learning format allows for both horizontal and vertical integration of information. Case-based learning is supported by the principles of adult education as it provides self-directed cases, occur in an interactive environment, provide immediate feedback, and concrete application of knowledge through board style questions to increase learner engagement and retention of information. The incorporation of case-based, board-style questions and non-cased based, reading comprehension checks follows Bloom’s taxonomy which is a hierarchical model of knowledge acquisition. Case-based, -board-style questions require a higher level of cognitive processing which facilitates knowledge consolidation, retention, and improvement on question performance. Jamkar et al. found that students who engaged in case-based learning scored higher on assessments and the students found case-based learning to be a valuable tool that improved their clinical reasoning skills, competence, and motivation to learn. Further evidence for the effectiveness of case-based learning was demonstrated by Turk et al. who compared United States Medical Licensing Exam (USMLE) Step 1 exam results of three different year groups and found significantly high scores after a case-based learning curricular reform. Studies conducted by Waliany et al. and Felszeghy et al. indicated that case based learning and use of online game based platforms help improve student performance and engagement. In this study, a high quality, dynamic, interactive, and multifaceted case was developed for the CASEAGE case-based learning PRESENTER. Feedback was garnered from the case authors, third- and fourth-year medical students, as well as faculty across all three VCOM campuses. The results demonstrated that the author's experience of CASEAGE is positive, as the building process walks the author through the development of learning objectives and materials for a case along with the full presentation and clinical assessment for a patient. As other studies have demonstrated, case-based learning is associated with increased student satisfaction as well as performance on assessments. CONCLUSION Case-based instruction continues to grow as an instrumental pedagogical model in preclinical education to impart real-world clinical cognitive skills. Incorporated alongside CREDO, CASEAGE and PRESENTER enhance this experience by integrating case-based learning into the system to further provide students with access to self-directed, high-quality clinical curricula based on the principles of adult education. The creation of two tools, CASEAGE for consistent case authoring and PRESENTER for interactive, dynamic case interaction, has advanced our ability to rapidly create uniform, validated cases with fully interactive multimedia and provide them in an environment where students can learn at their own pace and administrators can monitor the progress of each student by monitoring their success with sophisticated, board-level questions. The results of the study found that authorship of cases using CASEAGE is well directed and efficient to use while users of the Case PRESENTER found the system to be of appropriate pace, intuitive to use, and beneficial to their education. Possible improvements include layout and design, interactive elements, and inclusion of a variety of media. Feedback from the study will be incorporated into the final development of CASEAGE.

Medical school instruction comes in many forms including case-based. Precise management of these modules is essential for creating effective learning materials. We have developed a web-based authoring tool which can create learning “cases”, track their validation, and adjust before deploying for use. We also created a PRESENTER tool as part of our patient logging application, CREDO, which presents the case to users and tracks their performance. The Case PRESENTER allows learners to access a bank of cases and automatically offers relevant cases to students based on their patient encounters to provide comprehensive learning. Cases were deployed for users by creating PRESENTER that runs in an existing patient logging system to provide a dynamic user experience while capturing learning metrics for evaluating student progress. Faculty can create cases for instruction, review, and testing; students can interact with deployed cases, and administrators can assess student’s performance on embedded questions for grading purposes. The initial survey results indicated that the Case Presentation was intuitive, organized for autonomous learning, and offered suggestions for further improvement. METHODS Design The primary goal of this case-based learning system is to create a cloud-based application accessible through the web which is accessible to faculty and clinician case authors, to student users/learners, and medical school administrator student progress monitors. For each of these groups, they must have a good user experience, by providing a user interface that is quick, intuitive, uniform, and efficient. The design and implementation team consisted of full- stack experienced programmers, medical school faculty, clinicians, and school administrators. The team also included medical students working to provide feedback by authoring test cases, conducting validation testing, and satisfaction surveys from both student and faculty testers. Code Implementation The entire system, including both the authoring tool, CASEAGE, and the case presentation tool, PRESENTER, is implemented in the Google Linux-based Cloud. There are several instances on servers in different locations for redundancy and security, all of which are synchronized approximately every 10 seconds. Being on the cloud makes it possible to scale up to an arbitrary number of users quickly, making the user experience fast, uniform, secure, and with very high uptime. The platform uses a responsive JavaScript-driven front-end mated to a RESTful PHP API running on a set of distributed Debian-based cloud instances that utilize MySQL for persistent storage. Beta Testing Participants The initial beta testing of the system was carried out in two ways: 1) two medical students worked with software developers to create a realistic case, specifically a case entitled “Assessment and Management of Thermal Burns,” to help refine the case authoring and presentation; and 2) those medical students and software developers then surveyed 3 rd and 4 th year medical students as well as faculty to obtain a second round of feedback to further refine the system before final deployment. Survey Data Analysis Our goal was to test the efficacy of the new platform as well as provide feedback and suggestions as to how to best integrate it into the curriculum. This was accomplished by a short online survey completed after completion of the learning module. The target audience was the student population in the 3rd and 4th year students as well as faculty among the three VCOM campuses that will be utilizing CASEAGE and PRESENTR in their courses. Quantitative data regarding CASEAGE and adult education was gathered from the post-completion survey in the form of multiple-choice questions. Qualitative data consisted of several questions at the end of the survey that allowed for additional feedback and suggestions. At the conclusion of the survey period, the data from the online survey was used to determine what students and faculty felt was most valuable, what improvements should be made, and how to best integrate the learning tool into the curriculum. RESULTS The case was developed with the principles of adult education in mind, and users found the case to be appropriately paced, with an average completion time of 30 minutes to one hour. Additionally, users indicated that the case and content were of quality and explained knowledge, skills, and concepts presented in the learning objective. The survey results indicate that the Case PRESENTER user experience is positive, with respondents agreeing that the system is easy to become familiar with and intuitive to use. Feedback did show that users requested more interactive content, a diversity of media for each case, and better content arrangement. Additionally, users indicated that gamification would assist with learning and case interest. Participant feedback also indicated that CREDO and CASEAGE are a valuable resource which can help prepare students for exams. Overall, the results found that Case Presentation was intuitive, organized for autonomous learning, and that case-based positively impacted their medical education.

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