as cross-border and cross-cultural issues of eHealth/mHealth
  • systematic studies examining the quality of medical information available in various online venues
  • methods of evaluation, quality assessment and improvement of Internet information or eHealth applications
  • proposals for standards in the field of medical publishing on the Internet, including self-regulation issues, policies and guidelines to provide reliable healthcare information
  • results and methodological aspects of Internet-based and social media studies, including medical surveys, psychological tests, quality-of-life studies, gathering and/or disseminating epidemiological data, use of the Internet/mobile apps/social media for clinical studies (e-trials), drug reaction reporting and surveillance systems etc.
  • electronic medical publishing, Open Access publishing, altmetrics, and use of the Internet or social media for scholarly publishing (e.g. collaborative peer review)
  • information needs of patients, consumers and health professionals, including studies evaluating search and retrieval behavior of patients
  • web-based studies, e.g. online psychological experiments
  • evaluations of mhealth (mobile) applications, as well as ambient / ubiquitous computing approaches, sensors, domotics, and other cutting edge technologies
  • personal health records, patient portals, consumer health informatics applications
  • behavior change technologies
  • Reviews, viewpoint papers and commentaries touching on the issues and themes listed above are also welcome, but should be grounded in data and/or a thorough literature review
  • In addition, the Journal will occasionally publish original research, reviews and tutorials on more generic, related topics such as:

    In order to be considered for JMIR, clinical informatics papers should have a clear connections to the major themes in this journal of consumer/patient empowerment and participatory healthcare, and/or evaluate the use of mobile/Internet-based/emerging technologies.Other clinical informatics studies with no relationship to consumer health informatics, or more technical papers can still be submitted and be peer-reviewed within JMIR, but are likely to be transferred to other JMIR sister journals, most notably the Interactive Journal of Medical Research (i-JMR, a general medical journal with focus on innovation), JMIR mHealth and uHealth, JMIR Medical Informatics, or JMIR Human Factors (in prep.). Formative work such as usability studies, pilot studies, proposals and protocols are transferred to JMIR Research Protocols. Papers with focus on games in health or gamification aspects of apps and theoretical issues/commentary on gaming are now primarily published in / transferred to JMIR Serious Games.

    Submitted manuscripts are subject to a rigorous but speedy peer review process. Starting in 2012, we aim for a standard review time of less than 2 months, and a fast-tracked review time of 3 weeks (see Current Statistics, in particular 1.4 Time from submission to initial decision).

    The review process is designed to help authors to improve their manuscripts by giving them constructive comments on how to improve their paper, and to publish only those articles which comply to general quality criteria of a scholarly paper, especially originality, clarity, references to related work and validity of results and conclusions.

    Journal Format

    The Journal of Medical Internet Research publishes articles "continuously," i.e. articles are published online as soon as they are available (peer-reviewed and copy-edited). Since 2013, the journal publishes daily (weekdays only).

    The Journal collates articles into archival "issues" (before 2012, about 4 issues per year; since 2012 6 issues per year, since 2013 12 issues per year) and "volumes" (one per year).

    The journal is entirely free, subscription is not necessary. However, we encourage authors and readers to support the journal by considering our subscription (membership) scheme where PDF reprints of single articles and "issues" are made available as value-added service.

    ', 'statisticsSectionIds' => array ( 0 => '10', 1 => '26', 2 => '11', 3 => '1', 4 => '12', 5 => '16', 6 => '18', 7 => '21', 8 => '22', 9 => '27', 10 => '19', 11 => '23', 12 => '17', 13 => '25', 14 => '24', 15 => '28', 16 => '15', 17 => '13', 18 => '30', 19 => '31', 20 => '29', 21 => '32', 22 => '2', 23 => '14', 24 => '3', 25 => '4', 26 => '5', 27 => '6', 28 => '7', 29 => '8', 30 => '9', 31 => '37', 32 => '38', 33 => '39', 34 => '33', 35 => '34', 36 => '35', 37 => '41', 38 => '40', 39 => '49', 40 => '50', 41 => '51', 42 => '52', 43 => '54', 44 => '55', 45 => '56', 46 => '57', 47 => '58', 48 => '59', 49 => '60', 50 => '61', 51 => '62', 52 => '63', 53 => '64', 54 => '65', 55 => '66', 56 => '67', 57 => '68', 58 => '69', 59 => '70', 60 => '71', 61 => '72', 62 => '73', 63 => '74', 64 => '75', 65 => '76', 66 => '77', ), 'statNumPublishedIssues' => false, 'statItemsPublished' => false, 'statNumSubmissions' => false, 'statPeerReviewed' => false, 'statCountAccept' => false, 'statCountDecline' => false, 'statCountRevise' => false, 'statDaysPerReview' => false, 'statDaysToPublication' => false, 'statRegisteredUsers' => true, 'statRegisteredReaders' => true, 'statSubscriptions' => false, 'statViews' => true, 'numWeeksPerReview' => 2, 'restrictReviewerFileAccess' => 1, 'reviewPolicy' => '

    When we receive a manuscript, the Managing Editor and/or Assistant Editor and/or the Section Editor will first decide whether the manuscript meets the formal criteria specified in the Instructions for Authors and whether it fits within the scope of the journal. When in doubt, the editor will consult other members of the Editorial Board. Manuscripts are then assigned to a section editor, who sends it to 2-4 external experts for peer review. Authors are required to suggest at least 2 peer-reviewers (who do not have an conflict of interest) during the submission process. JMIR reviewers will not stay anonymous their names will be revealed and stated below the article in the event that the manuscript will be published. Authors and reviewers should not directly contact each other to enter into disputes on manuscripts or reviews.

    Speed of Peer-Review

    Criteria for Selection of Manuscripts

    Ethical Issues:

    GUIDELINES FOR REVIEWERS

    Dear reviewer,

    thanks for agreeing to peer-review this article for us. Our aim is to be extremely rapid in our review process, so please look at the manuscript immediately after you agreed to review it. Review in JMIR should be a matter of days, not weeks, as in other journals.

    Should you due to some unforeseen circumstances not be able to review the manuscript within the allotted timeframe, please notify us immediately.

    All communication should be done via this manuscript tracking system. That way, all communications related to this manuscript are automatically logged and stored.

    If you are reviewing a fast-tracked manuscript (in JMIR authors may request to fast-track a paper for an additional fee), the first two reviewers who return their peer-reviewers report are eligible for a honorarium of $25. As NIH and other government officials are often not allowed to accept a honorarium, please explicitly note this in the confidential section to the editor when returning your report that you wish to be considered for the honorarium.

    If you have any questions as to the form and scope of the journal, please refer to the Instructions for Authors (http://www.jmir.org/instruction.htm) .
    We mainly wish to get your comment on the originality of the paper, validity of the conclusions and clarity of the writing - it is not necessary to copy-edit grammatical or spelling errors.

    STEP I:

    Please copy and paste the form below into a word processor, fill in the form, and save the file for your own use.

     

    STEP II:

    To submit your review, please go back to this site, click on the review icon above (under 4.), and copy & paste your review back into the two textboxes (confidential comments for editors and open comments for author and editor) which appear in the REVIEW window after you clicked the review icon.
    Please note that all formatting will be lost, so do not use bold, italics etc.

    After you clicked "save", your submitted comments should appear in the REVIEW window.

    Once submitted, you cannot edit your review, but you can scroll down in the REVIEW window to add additional comments at any time.

    STEP III:

    Close the REVIEW window, and upload any supplementary files under 5., if you have any.

    STEP IV:

    Finally, do not forget to also select a recommendation in the drop-down box under 6. (above), even if you have already pasted these recommendations into the textbox for editors.

    STEP V:

    IMPORTANT: Do not forget to click "Submit review to editor" next !!!

    Do not discuss the paper with its authors either during or after the review process. Although it may seem natural and reasonable to discuss points of difficulty or disagreement directly with an author, especially if you are generally in favor of publication and do not mind revealing your identity, this practice is prohibited because the other reviewer and the editor may have different opinions, and the author may be misled by having "cleared things up" with the reviewer who contacted him/her directly. The manuscript sent to you for review is a privileged document. Please protect it from any form of exploitation. Do not cite a manuscript or refer to the work it describes before it has been published and do not use the information that it contains for the advancement of your own research or in discussions with colleagues.

    In your comments intended for the author (section I), do not make statements about the acceptability of a paper; suggested revisions should be stated as such and not expressed as conditions of acceptance (you can make such remarks in the confidential comments). Organize your review for the author so that an introductory paragraph (general comments) summarizes the major findings of the article, gives your overall impression of the paper, and highlights the major shortcomings. This paragraph should be followed by specific, numbered comments, which, if appropriate, may be subdivided into major and minor points. (The numbering is important as it facilitates both the editor\'s letter to the author and evaluation of the author\'s rebuttal.) Criticism should be presented dispassionately; offensive remarks are not acceptable.

    Confidential remarks directed to the editor should be typed in section II. of the peer-review template. Advise the editor of your recommendation for acceptance, modification, or rejection.

    Best regards,

    G. Eysenbach MD MPH

    Editor-in-chief, JMIR

    --------------------------

    Reviewers Report Form

    --------------------------

    Please copy & paste the sections below into a text editor of your choice, complete all sections, and then click the review icon above (4.) to copy & paste the two parts into the two separate textboxes.

    -------------------------- PART I: For Author and Editor --------------------------

    I. Suggestions for Authors and Editors (will be forwarded to authors).

    [When writing the Suggestions for Authors, please 1) do not mention acceptability for publication, and 2) number your specific comments]

    General Comments

    =================

    This paper...



    Specific Comments

    =================

    This paper...



    Major Comments

    -----------------

    1.

    2.

    3.

    ...



    Minor Comments

    -----------------

    4.

    5.

    6.

    ...



    -------------------------- PART II: For Editor --------------------------

    II.1. Confidential comments for editors

    [tell us what you think and especially comment if the manuscript does not meet one of our acceptance criteria: the study conducted is ethical; the material is original; prior/related work is discussed and cited appropriately; the writing is clear; the study methods are appropriate; the data are valid; the conclusions are reasonable and supported by the data; the information is important; and the topic is interesting for our readership.]

    ...

    ...

    ...

    ...

    II.2. Please note any potential conflicts of interests, which would interfere with your objectivity

    II.2. Please note any potential conflicts of interests, which would interfere with your objectivity

    II.3. If there are any parts of the manuscript, which you cannot referee because of lack of expertise in this area (e.g. statistics, English), please specify here. If you have suggestions for external reviewers, who could assess the respective part, please make them here:

    ...

    ...

    ...

    ...

    II.4. Note here if you are interested in writing a editorial or commentary about this paper (outline its content)

    ...

    ...

    ...

    ...

    II.5. Recommendation (please also select the respective drop-down box under 6. after submitting your narrative review under 4.):

    A ( ) Accept Submission

    B ( ) (Minor) revisions required

    C ( ) Resubmit for (re-)review (after revisions)

    D ( ) Resubmit elsewhere (or try major revision and rereview)

    E ( ) Decline Submission - fatal flaws that cannot be corrected or topic unsuitable for JMIR

    ', 'delayedOpenAccessDuration' => 0, 'delayedOpenAccessPolicy' => '', 'enableOpenAccessNotification' => false, 'enableAuthorSelfArchive' => true, 'authorSelfArchivePolicy' => 'In JMIR, authors keep the copyright of their material and are allowed to self-archive their work as HTML or Word file in institutional repositories and on the web, or to republish it for example as a book chapter (note that publication in another scholarly journal - while possible from a copyright point of view - is generally considered duplicate publication and scientific misconduct). In all cases of republication or self-archiving, the original source (citation) should be provided, including the link to the original JMIR article on www.jmir.org, and a note should be included that the work is licensed under the Creative Commons Attribution License CC-BY 2.0.
    ', 'enableSubscriptionExpiryReminderBeforeMonths' => true, 'numMonthsBeforeSubscriptionExpiryReminder' => 1, 'enableSubscriptionExpiryReminderBeforeWeeks' => true, 'numWeeksBeforeSubscriptionExpiryReminder' => 0, 'enableSubscriptionExpiryReminderAfterMonths' => true, 'numMonthsAfterSubscriptionExpiryReminder' => 1, 'enableSubscriptionExpiryReminderAfterWeeks' => true, 'numWeeksAfterSubscriptionExpiryReminder' => 1, 'mailSubmissionsToReviewers' => 0, 'reviewGuidelines' => '

    GUIDELINES FOR REVIEWERS

    Dear reviewer,

    thanks for agreeing to peer-review this article for us. Our aim is to be extremely rapid in our review process, so please look at the manuscript immediately after you agreed to review it. Review in JMIR should be a matter of days, not weeks, as in other journals.

    Should you due to some unforeseen circumstances not be able to review the manuscript within the allotted timeframe, please notify us immediately.

    All communication should be done via this manuscript tracking system. That way, all communications related to this manuscript are automatically logged and stored.

    If you are reviewing a fast-tracked manuscript (in JMIR authors may request to fast-track a paper for an additional fee), the first two reviewers who return their peer-reviewers report are eligible for a honorarium of $25. As NIH and other government officials are often not allowed to accept a honorarium, please explicitly note this in the confidential section to the editor when returning your report that you wish to be considered for the honorarium.

    If you have any questions as to the form and scope of the journal, please refer to the Instructions for Authors (http://www.jmir.org/instruction.htm) .
    We mainly wish to get your comment on the originality of the paper, validity of the conclusions and clarity of the writing - it is not necessary to copy-edit grammatical or spelling errors.

    STEP I:

    Please copy and paste the form below into a word processor, fill in the form, and save the file for your own use.

     

    STEP II:

    To submit your review, please go back to this site, click on the review icon above (under 4.), and copy & paste your review back into the two textboxes (confidential comments for editors and open comments for author and editor) which appear in the REVIEW window after you clicked the review icon.
    Please note that all formatting will be lost, so do not use bold, italics etc.

    After you clicked "save", your submitted comments should appear in the REVIEW window.

    Once submitted, you cannot edit your review, but you can scroll down in the REVIEW window to add additional comments at any time.

    STEP III:

    Close the REVIEW window, and upload any supplementary files under 5., if you have any.

    STEP IV:

    Finally, do not forget to also select a recommendation in the drop-down box under 6. (above), even if you have already pasted these recommendations into the textbox for editors.

    STEP V:

    IMPORTANT: Do not forget to click "Submit review to editor" next !!!

    Do not discuss the paper with its authors either during or after the review process. Although it may seem natural and reasonable to discuss points of difficulty or disagreement directly with an author, especially if you are generally in favor of publication and do not mind revealing your identity, this practice is prohibited because the other reviewer and the editor may have different opinions, and the author may be misled by having "cleared things up" with the reviewer who contacted him/her directly. The manuscript sent to you for review is a privileged document. Please protect it from any form of exploitation. Do not cite a manuscript or refer to the work it describes before it has been published and do not use the information that it contains for the advancement of your own research or in discussions with colleagues.

    In your comments intended for the author (section I), do not make statements about the acceptability of a paper; suggested revisions should be stated as such and not expressed as conditions of acceptance (you can make such remarks in the confidential comments). Organize your review for the author so that an introductory paragraph (general comments) summarizes the major findings of the article, gives your overall impression of the paper, and highlights the major shortcomings. This paragraph should be followed by specific, numbered comments, which, if appropriate, may be subdivided into major and minor points. (The numbering is important as it facilitates both the editor\'s letter to the author and evaluation of the author\'s rebuttal.) Criticism should be presented dispassionately; offensive remarks are not acceptable.

    Confidential remarks directed to the editor should be typed in section II. of the peer-review template. Advise the editor of your recommendation for acceptance, modification, or rejection.

    Best regards,

    G. Eysenbach MD MPH

    Editor-in-chief, JMIR

    --------------------------

    Reviewers Report Form

    --------------------------

    Please copy & paste the sections below into a text editor of your choice, complete all sections, and then click the review icon above (4.) to copy & paste the two parts into the two separate textboxes.

    -------------------------- PART I: For Author and Editor --------------------------

    I. Suggestions for Authors and Editors (will be forwarded to authors).

    [When writing the Suggestions for Authors, please 1) do not mention acceptability for publication, and 2) number your specific comments]

    General Comments

    =================

    This paper...



    Specific Comments

    =================

    This paper...



    Major Comments

    -----------------

    1.

    2.

    3.

    ...



    Minor Comments

    -----------------

    4.

    5.

    6.

    ...



    -------------------------- PART II: For Editor --------------------------

    II.1. Confidential comments for editors

    [tell us what you think and especially comment if the manuscript does not meet one of our acceptance criteria: the study conducted is ethical; the material is original; prior/related work is discussed and cited appropriately; the writing is clear; the study methods are appropriate; the data are valid; the conclusions are reasonable and supported by the data; the information is important; and the topic is interesting for our readership.]

    ...

    ...

    ...

    ...

    II.2. Please note any potential conflicts of interests, which would interfere with your objectivity

    II.2. Please note any potential conflicts of interests, which would interfere with your objectivity

    II.3. If there are any parts of the manuscript, which you cannot referee because of lack of expertise in this area (e.g. statistics, English), please specify here. If you have suggestions for external reviewers, who could assess the respective part, please make them here:

    ...

    ...

    ...

    ...

    II.4. Note here if you are interested in writing a editorial or commentary about this paper (outline its content)

    ...

    ...

    ...

    ...

    II.5. Recommendation (please also select the respective drop-down box under 6. after submitting your narrative review under 4.):

    A ( ) Accept Submission

    B ( ) (Minor) revisions required

    C ( ) Resubmit for (re-)review (after revisions)

    D ( ) Resubmit elsewhere (or try major revision and rereview)

    E ( ) Decline Submission - fatal flaws that cannot be corrected or topic unsuitable for JMIR

    ', 'authorSelectsEditor' => 0, 'privacyStatement' => '

    The names and email addresses entered in this journal site by readers, authors, reviewers and others will be used exclusively for the stated purposes of this journal and will not be made available for any other purpose or to any other party. Readers who sign up for content alerts (User Homepage - Profile) agree to receive an email whenever an article has been published. Occasionally we will include sponsor messages in our content alerts or send out special messages (e.g. on conferences, job ads etc) to JMIR content alert subscribers, however, we will never share our data with third parties. For our record keeping policy for authors see "Record Keeping and Research Policy".

    ', 'openAccessPolicy' => NULL, 'enableAnnouncements' => true, 'enableAnnouncementsHomepage' => true, 'numAnnouncementsHomepage' => 1, 'announcementsIntroduction' => '', 'volumePerYear' => 1, 'issuePerVolume' => 12, 'enablePublicIssueId' => true, 'enablePublicArticleId' => true, 'enablePublicSuppFileId' => true, 'enablePageNumber' => false, 'homeHeaderTitleTypeAlt1' => 0, 'homeHeaderTitleAlt1' => NULL, 'homeHeaderTitleTypeAlt2' => 0, 'homeHeaderTitleAlt2' => NULL, 'pageHeaderTitleTypeAlt1' => 0, 'pageHeaderTitleAlt1' => NULL, 'pageHeaderTitleTypeAlt2' => 0, 'pageHeaderTitleAlt2' => NULL, 'emailSignature' => '________________________________________________________________________ Journal of Medical Internet Research - The leading peer-reviewed ehealth journal - Open Access - Fast Review - Impact Factor (2013): 4.7 *** JMIR is top-ranked in the Medical Informatics (#1) and the Health Services Research (#4) categories! http://www.jmir.org', 'customAboutItems' => array ( 0 => array ( 'title' => 'Why you should choose JMIR to publish your research - advantages of the journal', 'content' => '', ), 1 => array ( 'title' => 'Indexing and Impact Factor', 'content' => '

     

    JMIR is indexed in more than 18 bibliographic databases and abstracting services, including Medline [Index Medicus], CINAHL, Information Science Abstracts, INSPEC (Institution of Electrical Engineers), Communication Abstracts, The Informed Librarian Online, LISA (Library and Information Science Abstracts), EMBASE, Scopus, Science Citation Index Expanded, PsycINFO, LISTA (Library / Information Sciences & Technology Abstracts), ASSIA (Applied Social Sciences Index and Abstracts) database, CSA Social Services Abstracts database, Pubmed Central, and others.

    Impact Factor (2010): 4.7 (5-yr impact factor: 5.0): JMIR is top-ranked in the ISI Thompson Reuters disciplines medical informatics (#1) and health services research (#2) !

    ', ), 2 => array ( 'title' => 'Editorial Board Policy', 'content' => '

     

    Purpose: The Editorial Board is a group of outstanding individuals committed to helping JMIR to produce an excellent multidisciplinary scientific publication of the highest quality.

    Selection criteria for EB members: Editorial Board members are appointed by the publisher/editor-in-chief for a 3-year-term that is renewable. Editorial Board members should have reviewed for JMIR and should have published at least one article in JMIR.Editorial Board members should not sit on editorial boards of competing journals during their term, but exceptions are possible. Nominations for Editorial Board appointments come from a variety of sources including self-nominations, the current Editorial Board, journal authors, and readers. The editorial board should constitute an appropriate interdisciplinary mix from a wide range of disciplines, including health care researchers, researchers from the engineering sciences, social sciences, and even patient representatives. EB members should be productive and respected members of the scientific community. In addition, JMIR is actively looking for consumer presentation on its board. Being a editorial board member for JMIR means that actual work is required, so EB members should have appropriate time and motivation.

    Main responsibilities •General advocacy for open access publishing in general and publishing high-quality work in JMIR specifically •Strategic and operational advice (unsolicited, as well as in editorial board meetings) •Guiding papers in their area of expertise through the peer-review process Individuals interested in sitting on the Editorial Board should contact the editor-in-chief.

    ', ), 3 => array ( 'title' => 'Record Keeping and Research Policy', 'content' => '

     

    For record keeping, accountability and research purposes, JMIR preserves the right to retain all communications and manuscripts (including rejected manuscripts) indefinitely in its manuscript management system, unless submitting authors explicitly ask for removal of the records. While authors retain the copyright to their work, they agree with submitting a manuscript that JMIR has the right to (but is not obliged to) internally store and retain manuscripts and communications indefinitely. Submitting authors also acknowledge that the JMIR publisher, editor, or their designates have the right to analyze communications and statistics e.g. for peer-review research, education, marketing, or other purposes. Excerpts from communications may be quoted in a research, educational or marketing publications if the author remains anonymous.

    ', ), 4 => array ( 'title' => 'Subscriptions (Membership)', 'content' => '

     

    Readers are invited to join the FREE electronic content alert service by registering here. Registered readers also receive access to a free PDF sample issue.

    JMIR is an open access journal - articles are available free of charge as HTML files. Frequent readers and researchers working in the ehealth field are encouraged to become a paying/supporting individual or institutional member, which provides additional benefits such as downloading articles or entire issues as PDF files, or (for some institutional memberships) Article Processing Fee waivers or discounts, to encourage faculty and students to publish in JMIR. With becoming a member you support the overarching mission of the journal, which is to improve health through prudent use of information and communication technology.

    ', ), 5 => array ( 'title' => 'Theme Issues and Guest Editors', 'content' => '

     

    JMIR reaches tens of thousands of readers interested in information and communication technologies in health, and is therefore the preeminent knowledge translation venue in this area. We are happy to support, produce and co-edit JMIR Theme Issues as major knowledge translation activities in important and emerging areas of ehealth, with leaders in the respective fields as guest editors. We are looking for guest editors who wish to compile a theme issue on a special topic (for example: electronic publishing, telemedicine, quality of health information, patient education, decision-support, Internet in psychiatry, theory in ehealth, mobile technologies, Web 2.0, ...). This may be particularly interesting for workshop and conference organizers putting together a grant-funded event (e.g. with invited experts) on an eHealth-related topic. JMIR is an excellent dissemination vehicle of ehealth-related workshop results. Theme issues may also be used as a knowledge dissemination vehicle for results from large collaborative grant-funded projects. Theme issues may contain for example state-of-the-art papers from selected/invited experts, research results from a large grant proposal (e.g. a series of connected studies), or simply articles submitted in response to a specific open call for papers. The task of the guest editor(s) is generally

    * to solicit manuscripts from colleagues/experts concerning the selected topic,

    * to select peer-reviewers for incoming manuscripts,

    * to make decisions (together with the editorial board) on article revisions and acceptance,

    * to write an editorial for the theme issue

    * to secure funding to sponsor the APFs {Article Processing Fees) for published papers (usually in the $10-25k range, please budget $1590 per paper). If the guest editor has a network of colleagues who have indicated that they can carry the APF themselves, then author-funded theme issues are also possible.

    Funding through grants or other sources is usually required and should be budgeted for in grant proposals. In the past, funding agencies such as NIH/NCI, CIHR, or private foundations have successfully been approached by the Guest Editor(s) to secure the funds. For example, CIHR has launched a new program called "End of Grant Knowledge Translation Supplement," worth $25k, which enables the funding of a theme issue (more information here). Peer-reviewers at granting agencies also expect a portion of the budget devoted to knowledge dissemination and knowledge translation, and JMIR theme issues can be proposed to facilitate dissemination of research results (due to the Open Access policy, results reach a broader audience beyond the research community). We urge principal investigators of any larger team grant proposals related to health and information/communication technology to budget for a theme issue (or at least a series of JMIR papers). Letters of support and quotes from JMIR are available on request (please contact the editor-in-chief). Another possible funding venue are workshop funding programs. Again, that granting agencies such as NIH or CIHR usually expect to see some sort of knowledge dissemination activities in workshop proposals, and have in the past funded the JMIR APFs.

    The editor of JMIR is happy to support and actively help with any knowledge translation component in grant proposals incorporating some of the ideas listed above (as well as novel ideas e.g. mutlimedia, podcasting etc., cobranded with JMIR).

    ', ), 6 => array ( 'title' => 'Trademarks and Service Marks Policy', 'content' => '

    Certain names, graphics, logos, icons, designs, words, titles or phrases on this Web site or in JMIR articles may constitute trade names, trademarks or service marks of JMIR or other entities. As customary in scholarly articles, trademarks and service marks are not necessarily indicated as such by using the trademark (TM), service mark (SM), or registered trademark (R) symbols. Omission of these symbols do not imply the absence of a trademark registration. The display of trademarks on pages at this Web site does not imply that a license of any kind has been granted.
    JMIR, Medicine 2.0, Healthbook, and WebCite are registered trademarks owned by JMIR Publications.

    ', ), 7 => array ( 'title' => 'Subscribe to RSS Feeds / add JMIR headlines to your homepage or blog', 'content' => '

    Add any of the following Headline Animators (dynamically updated with the latest JMIR articles) to your homepage, your blog, or use your favorite newsread or live bookmarks to stay abreast of the latest research published in JMIR:

    Journal of Medical Internet Research: Latest Papers

    ↑ Grab this Headline Animator

    JMIR RSS Feed

    ↑ Grab this Headline Animator

    J Med Internet Res

    ↑ Grab this Headline Animator

     

     



    Or add the Facebook badge on your Blog or homepage:



    To display the badge above, simply copy & paste the following HTML on your webpage/blog (for a wider representation change width from 200px to 700px in the code):


    ', ), 8 => array ( 'title' => 'Fee Schedule', 'content' => '

    As we aim to publish widely indexed, carefully copyedited, high-quality manuscripts, that are also deposited in repositories such as PubMed Central, publication of an accepted paper requires expensive production steps such as copyediting, reference checking and XML tagging. In the editing & production stage, JMIR employs professional full-time staff and freelancers, and we have to pay our bills too. To defray these costs (and because we cannot sell subscriptions like toll-access journals) we require authors to pay certain fees.
    Authors publishing in JMIR are paying a nominal submission fee ($90), an article processing fee (APF) only in case of acceptance, and (optionally) a fast-track fee for expedited review.
    These fees are usually funded from research grants, and new researchers in the area are urged to budget for open access publications in their grant proposals, much as they budget for conference presentations (please budget about $2000 per article).

    When comparing the costs for publishing in JMIR against the cost of publishing in other OA journals, please consider that 1) JMIR is consistently ranked #1 in its field by impact factor, 2) JMIR employs professional copyediting after acceptance, which is a service many OA journals with lower costs do not provide. Given these considerations, JMIR is currently one of the most cost-effective OA journals on the market.

    For a detailed fee overview see Instructions for Authors.

    JMIR Article Processing Fee Waiver Policy


    Only the APF can be waived, and only in exceptional circumstances. Please contact the editor BEFORE submission to get an informal opinion on whether or not a particular paper/topic may get sufficient priority for an APF waiver. You will also need to fill in an application form, signed by ALL coauthors, and ALL of their department heads, confirming that no other funds are available. The application form with all signatures of all coauthors and their department chairs should preferably be made on submission (upload a scanned form as supplementary file).


    In exceptional cases we grant fee waivers, but we have to set the bar high for these exceptions, as any APF waiver means that we have to subsidize the publication, even though we are not a granting agency. Usually the onus is on the author to find funding sources from any entity that benefits from publication of the article. For example, due to the high impact-factor ranking of JMIR, usually your department benefits directly or indirectly from publication of the article, so in the absence of extramural funding we would expect the department to carry the costs.

    Article Processing Fees (APFs) for Open Access journals have become an increasingly accepted method to defray the costs for publication, and fortunately most institutions have developed mechanisms and funding sources to cover publication costs in high-quality open access journals.

    Most researchers pay APFs from their grants (if you have money to travel to conferences, you also have money to pay for an APF – both are knowledge dissemination activities!). If this is not the case, institutions and departments may have funds or bursaries for such purposes. Some institutions or departments may have purchased an institutional JMIR membership – the APF is automatically waived if the corresponding author is from an institutional member.

    JMIR is waiving APFs for non-members only under exceptional circumstances if all of the following conditions are met:
    1) neither of the authors (including coauthors) have funding sources enabling them to carry the APF
    2) or: in case of having a funding source (e.g. a project/research sponsor listed in the “Acknowledgements”), the funding source(s) declined to pay for open access publishing charges,
    3) the departments/institutions of all authors have no funds, bursaries, or other means to pay for open access charges.

    In order to consider an application for a fee waiver, we require in writing from each coauthor a written declaration that they have explored all avenues of potential funding. We need these declarations from each co-author, each counter-signed by the head of the department or university mentioned in the authors’ affiliation lines.
    If an author lists multiple affiliations, we need to have the head/chair/director from each affiliation sign the form (APF Waiver Form).

    If a funding source (e.g. granting agency, foundation etc.) is named as a project sponsor in the acknowledgement section of an article, we require a written statement signed by a representative of that sponsor explicitly declining payment of the APF and explaining why (we are not aware of any major funders not covering APFs, so we need assurance that the funder has been approached by the authors). We reserve the right to publish a blacklist and our experiences with certain institutions or funders who have no open access-friendly policies, ultimately to put public pressure on these organizations.

    Requests for APF waivers are usually not granted if any coauthor is from a institution which is a signatory of the “Compact for Open Access Equity” (OACOMPACT) (http://www.oacompact.org/signatories/), as in these cases there is documented and guaranteed institutional financial help available to cover publication fees. In this case it is the responsibility of the author to contact the respective university body (OACOMPACT contacts) to request financial support for the APF. This includes for example authors from the following institutions (check http://www.oacompact.org/signatories/ for an updated list and details - do NOT contact us to inquire about details):
    • Cornell University
    • Dartmouth College
    • Harvard University
    • Massachusetts Institute of Technology
    • University of California at Berkeley
    • University of Ottawa
    • Columbia University
    • Memorial Sloan-Kettering Cancer Center

    If any author has any of these organizations listed in their affiliation lines, and payment of the APF has been turned down by the OACOMPACT contact, we will require a letter from the OACOMPACT contacts addressed to the author detailing why an author-application for financial help has been rejected.

    APF waivers are usually not granted if one author is affiliated with a commercial for-profit organization, or a commercial organization being acknowledged as sponsor of the project. We will make a case-by-case decision if the CEO or another management-level officer of the company provides us with a compelling reason why payment of APF is not possible.


    If an article has been approved for a fee waiver, the following statement will be added to the “acknowledgements” of the publication: “Publication of this article was co-sponsored by the Journal of Medical Internet Research. All authors declared that they failed to identify any funding source for the project described in the paper to enable coverage of the publication costs. All department/division heads/chairs of the author institutions have declared that no institutional funding mechanisms for knowledge dissemination activities and/or coverage of open access publishing costs at their department or university level exist.”

    Note that we will treat any cases of forged signatures or false declarations as scientific misconduct.

    ', ), 9 => array ( 'title' => 'Instructions for authors', 'content' => '

    Before submitting, please read our instructions for authors. To submit the paper, create a user account as author and submit the paper in the author section of your user homepage.

    A Word-template of an article compatible with journals from JMIR Publications can be downloaded from http://jmir.org/ojs/public/journals/1/InstructionsForAuthorsOfJMIR.docx. Note that the references can be in any format, as long as the in-text citations are sequentially numbered in the manuscript with square brackets and as long as the reference at the end has a PMID in the format PMID:123456. See Instructions for Authors for details. .

    As a service for our authors we now offer the possibility to have a submission considered in partner journals, which means that the manuscript and peer-review reports may be transferred to a JMIR sister/partner journal, if the paper is not found suitable for publication in JMIR, but is publishable in another journal. These journals include e.g. i-JMR, JMIR Res Protoc, JMIR mHealth and uHealth, JMIR Medical Informatics, JMIR Human Factors, JMIR Mental Health, JMIR Public Health, JMIR Cancer, Medicine 2.0 and others. The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript is rejected for J Med Internet Res and transferred, and at that time can decide if they want to pursue publication in a sister/partner journal. If authors do NOT wish an automatic transfer to an alternative journal after rejection for JMIR, this should be noted in the cover letter.

    ', ), 10 => array ( 'title' => 'About the publisher', 'content' => '
    Vision

    JMIR Publications is the leading ehealth publisher, advancing progress in the health, engineering and social sciences to ultimately help people to live happier and healthier lives using technology.

    Mission Statement

    JMIR Publications helps innovators in the health technology space to collaborate and to disseminate their innovations, ideas, and research results to the widest possible audience, in a timely manner, adding value to the quality of the work and adhering to the highest ethical and quality standards.

    We achieve this by using the Internet and the latest available technologies as well as by producing conferences and social media, and other innovative knowledge translation products. We also innovate in the scholarly communication space itself, experimenting with new business models, new models of peer-review and dissemination, and new technologies.

    History

    JMIR Publications is a rapidly growing innovative academic publisher. It builds on the success of JMIR (Journal of Medical Internet Research), which started in 1998 as a pioneering, small independent open access project hosted at a university, which subsequently grew into the most influential journal in medical informatics (ranked #1 by Impact Factor by Thomson Reuters for five years, 2013 IF: 4.7) and health services research (ranked #4 by Thomson Reuters among 85 health science journals). Due to the growth in influence and submissions, and to make the operations more sustainable and professional, the journal was incorporated as company in 2011. Shortly after incorporation, several spin-off journals were launched. Currently, JMIR Publications Inc. publishes over 1000 articles annually in the following journals:

    1. JMIR (Journal of Medical Internet Research) (ISSN 1438-8871) http://www.jmir.org
    2. JMIR Research Protocols (ISSN 1929-0748) http://www.researchprotocols.org/
    3. i-JMR (interactive Journal of Medical Research) (ISSN 1929-073X) http://www.i-jmr.org)
    4. Medicine 2.0 (ISSN 1923-2195) http://www.medicine20.com/
    5. JMIR mHealth & uHealth (mobile and ubiquitous health) (ISSN 2291-5222) http://mhealth.jmir.org
    6. JMIR Serious Games (JSG, ISSN 2291-9279) http://games.jmir.org
    7. JMIR Medical Informatics (JMI, ISSN 2291-9694) http://medinform.jmir.org
    8. JMIR Human Factors (JHF, ISSN 2292-9495) http://humanfactors.jmir.org/
    9. JMIR Mental Health (JMH, ISSN 2368-7959) http://mental.jmir.org/
    10. JMIR Rehabilitation and Assistive Technologies (JRAT, ISSN 2369-2529) http://rehab.jmir.org/
    11. JMIR Cancer (JC, ISSN 2369-1999) http://cancer.jmir.org 
    12. JMIR Public Health and Surveillance (JPHS) http://publichealth.jmir.org
    13. iProceedings (iProc) http://www.iproc.org/
    14. JMIR Preprints http://preprints.jmir.org/

    Several other new journals are in development and will be launched in 2015 (the publisher also accepts new proposals by individuals and societies):

    JMIR Publications also produces and organizes the annual Medicine 2.0(R) World Congress series (http://www.medicine20congress.com), is curator of the Medicine 2.0(R) Social Network (http://medicine20.net), and owns several other trademarks in the health field [e.g. Healthbook(R), http://healthbook.com] and altmetrics area [Twimpact Factor(TM), WebCite(R), http://www.webcitation.org].

    ', ), 11 => array ( 'title' => 'New Journal / Editor-in-Chief Proposals', 'content' => '

    JMIR Publications is an open access academic publisher based in Toronto, Canada, and is the leading publisher of peer-reviewed journals in the ehealth domain. We are the leading open access publisher focussing on technology and bioengineering in health, and are expanding into other areas. Our mission is to reinvent research communication through grassroots, researcher-driven innovation in every aspect of peer-reviewed publishing, making use of Internet, social media, and mobile technologies, and we are currently expanding into other science domains.

    Recent successful journal launches include JMIR Research Protocols and interactive Journal of Medical Research (i-JMR). To expand our journal portfolio we are continuously looking for gaps in the journal market, societies interested in creating new journals or looking for new publishers, and visionary and highly regarded scientists, primarily working at the intersections between technology and medicine, to lead the creation and development of new journals in emerging disciplines and rapidly expanding research areas. Building on the JMIR brand, possible new titles could include JMIR Bioinformatics, JMIR Biomedical Engineering, or individual titles without the JMIR branding in the title.

    Proposed editors-in-chief must be highly regarded and cited individuals (evidenced by their list of publications and their h-index, generally at least 15-20) and must have a clear vision for their journal, including a plan to solicit editorial board members and the first 20 submissions. The application process (which can be done by a society or an individual) consists of developing a journal proposal containing these details.
    Ongoing tasks will be to guide submissions through the peer-review process, (light) academic editing of submissions, and liaising with the JMIR production team.

    An honorarium/stipend may be paid.


    Applications process:
    To apply as editor-in-chief for new journals, or as a society/community proposing a new journal, please develop and submit a journal proposal, containing for example:

     

    1. a short bio of the editor in chief, and a dump of the most cited publications (e.g. from Web of Science, Google Scholar, or Scopus), ranked by the number of citations, showing the h-index of the applicant (e.g. first 20 publications which are cited more than 20 times = h-index of 20).
    2. Name of the future journal ("JMIR [Discipline]" or an independent title not building on the JMIR brand)
    3. Scope and mission of the journal
    4. An estimate of the "market" size in terms of how many papers per year in this discipline are published, with projections (e.g. search PubMed). We are primarily interested in growing disciplines
    5. List competitor/similar journals and their impact factors, and how the new journal would distinguish itself from them
    6. Example titles for 10-20 articles to be published
    7. A list of future possible editorial board members
    8. A clear plan on how to solicit the first 20 papers for the new journal
    9. A list of other publishers you may have contacted or are in negotiation with (and their terms, and what you like or dislike about them, if applicable)




    Please email your application documents to jmir.editorial.office@gmail.com with the subject line "editor-in-chief [journalname]".

    ', ), ), 'enableComments' => '1', 'enableLockss' => false, 'lockssLicense' => '', 'authorGuidelines' => 'A Word-template of an article compatible with journals from JMIR Publications can be downloaded from http://jmir.org/ojs/public/journals/1/InstructionsForAuthorsOfJMIR.docx. Note that the references can be in any format, as long as the in-text citations are sequentially numbered in the manuscript with square brackets and as long as the reference at the end has a PMID in the format PMID:123456. See Instructions for Authors for details. .

    As a service for our authors we offer the possibility to have a submission considered in other journals, e.g. manuscript and peer-review reports may be transferred to a JMIR sister/partner journal, if the paper is not found suitable for publication in JMIR, but is publishable in another journal. These journals include e.g. i-JMR, JMIR Res Protoc, JMIR mHealth and uHealth, JMIR Medical Informatics, JMIR Human Factors, JMIR Mental Health, JMIR Public Health, JMIR Cancer and others. The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript is rejected for J Med Internet Res and transferred, and at that time can decide if they want to pursue publication in a sister/partner journal. If authors do NOT wish an automatic transfer to an alternative journal after rejection for JMIR, this should be noted in the cover letter.

    Our requirements for submitted manuscripts are in accordance with the Uniform Requirements for Manuscripts Submitted to Biomedical Journals, drawn up by the International Committee of Medical Journal Editors (JAMA 1997;277:927-934 ). Please read these Uniform Requirements first, then read our complementing guidelines given below. The journal editor is member of the World Association of Medical Editors (WAME, www.wame.org), and the Journal of Medical Internet Research is committed to adhere to WAME's principles. The Journal of Medical Internet Research also supports and acts in line with the Editorial Policy Statements of the Council of Science Editors (http://www.cbe.org/services/draft_approved.cfm [Archived in WebCite]). Instructions for Authors of JMIR The Journal of Medical Internet Research (JMIR) is an innovative, international, peer-reviewed medical journal that aims to contain articles relevant for medical professionals, system developers, and system users alike. Instructions for authors are subject to frequent revision. Please look them over carefully before submission. See Instructions for Authors for further details on how to format your manuscript.

    Note that since 2014 we require that all authors / coauthors to have an ORCID (a unique researcher identifier) at the time of publication. Application for an ORCID is free of charge and only takes a few minutes - please go to ORCID.org to apply for one. We also recommend that the corresponding author contacts all of his coauthors and encourages them to obtain an ORCID during the manuscript preparation process. While they can be added after submission, ORCIDs are required in case of acceptance.

    Please review our Fee Schedule prior to submission. While some of our journals do not charge any fees, some others do charge.

    ', 'submissionChecklist' => array ( 0 => array ( 'order' => '1', 'content' => 'The submission has not been previously published nor is it before another journal for consideration; or an explanation has been provided in Comments to the Editor.', ), 1 => array ( 'order' => '2', 'content' => 'The submission file is in Microsoft Word (.doc/.docx), or RTF document file format.', ), 2 => array ( 'order' => '3', 'content' => 'The text meets this journal's formatting requirements, in particular those summarizedin the Author Checklist found in Instructions for Authors. The text employs italics, rather than underlining or bold as emphasis; with figures and tables (portrait only, no landscape format) placed within the text, rather than at the end. Additional information has been put in separate files to be uploaded as Multimedia Appendix.', ), 3 => array ( 'order' => '5', 'content' => 'I have read and understood the fee schedule. In particular, I understand and agree that unless my department/organization is a institutional member BEFORE submission (see dropdown-list in step 1 of the submission process), I/my department will be billed for the article processing fee (see Instructions for authors) in case of acceptance. PLEASE MENTION IN THE COVER LETTER ON SUBMISSION THAT YOU 1) AGREE TO PAY THE APF, OR 2) IF YOU THINK THAT THE APF SHOULD BE WAIVED DUE TO MEMBERSHIP OR FOR ANY OTHER REASONS. Journal sections marked with * may be eligible for a fee waiver or reduction under certain circumstances (must be justified in the comments field for the editor on submission).
    APFs may not apply for article categories marked with * (check instructions for authors). ** Special fees (in particular a submission fee) apply for research protocols and grant proposals.
    Note that the APF will also be billed if the author retracts the manuscript after acceptance, or if a case of scientific misconduct prevents us from publishing a manuscript after acceptance.
    PLEASE NOTE THAT THE APF IS CURRENTLY US$1900 PER ACCEPTED ARTICLE (new price since April 21st, 2010).', ), 4 => array ( 'order' => '6', 'content' => 'All cited webreferences (webpages, online available PDF reports) which are NOT journal articles or which do not have a DOI have been cached using WebCite (www.webcitation.org) . Instead of citing the "live" webpage/website, the author should cite the WebCite archived webpage. No URLs in the body of the manuscript are allowed - all URLs are cited as references.', ), 5 => array ( 'order' => '7', 'content' => 'References are up-to-date - note that it raises red flags if the last cited reference is more than 2 years old. It also raises questions about the papers\' suitability for this particular journal if no related papers from this journal are discussed (Tip: Prior to submission search for related papers looking for title keywords).', ), 6 => array ( 'order' => '8', 'content' => '(please check this checkbox even if you do not wish to fast-track as an indication that you read this). I understand that if I wish to fast-track the paper, I will pay the Fast-Track-Fee immediately after submission (a payment link will be provided after submission) or at a later stage. The FTF guarantees an editorial decision within 15 working days (see website for further instructions)', ), 7 => array ( 'order' => '9', 'content' => 'I understand that all author names and their affiliations for the final publication will be taken from the database (metadata form), not the submitted manuscript, thus all author names must be entered in the metadata form during submission. Authors may remove author names from the manuscript if they prefer blind review. All coauthors have been/will be entered in the metadata form, and all coauthors fulfill ICMJE criteria in that they made 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. Authors should meet conditions 1, 2, and 3.', ), 8 => array ( 'order' => '10', 'content' => 'P-values are reported in accordance with our instructions for authors.', ), 9 => array ( 'order' => '11', 'content' => 'Since 26 Oct 2006, we now require payment of a US$ 90 submission fee for ALL articles EXCEPT letters or invited articles. Paypal or credit card immediately after submission. Authors will not be able to complete the submission process without payment. This fee cannot be waived (only exception: invited articles), needs to be paid also by institutional members, and is non-refundable. This fee is in addition to other potential fees such as the optional fast-track fee (FTF) and the article processing fee (APF) for non-members. Authors should understand that the submission fee is non-refundable, even if the manuscript is quickly rejected without peer-review (we do send out the majority of papers for peer-review, but we reserve the right to reject papers without peer-review for any reason, including the topic not being deemed interesting enough, which is a subjective decision by the editor).', ), 10 => array ( 'order' => '12', 'content' => 'Authors agree that the manuscript and peer-review reports may be transferred to a JMIR sister/partner journal (e.g. i-JMR, JMIR Res Protoc, and others), if the paper is not found suitable for publication in JMIR, but is publishable in another journal. The submission fee for that partner journal (if any) will be waived, and transfer of the peer-review reports may mean that the paper does not have to be re-reviewed. Authors will receive a notification when the manuscript is transferred, and at that time can decide if they want to pursue publication in a sister/partner journal. If authors do NOT wish an automatic transfer to an alternative journal after rejection for JMIR, this should be noted in the cover letter.', ), ), 'copyrightNotice' => 'Unless stated otherwise, all articles are open-access distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work ("first published in the Journal of Medical Internet Research...") is properly cited with original URL and bibliographic citation information. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.', 'metaDiscipline' => false, 'metaDisciplineExamples' => 'medical sciences; computer sciences; behavioral sciences; social sciences; communication sciences; psychology; library sciences; informatics; human-computer interaction studies', 'metaSubjectClass' => false, 'metaSubjectClassTitle' => 'Medical Subject Headings (MeSH)', 'metaSubjectClassUrl' => 'http://www.ncbi.nlm.nih.gov/sites/entrez?db=mesh', 'metaSubject' => true, 'metaSubjectExamples' => '[enter Medical Subject Headings (MeSH) and your own keywords, e.g.:] medical informatics; Internet; patient-physician relationship; email', 'metaCoverage' => false, 'metaCoverageGeoExamples' => '', 'metaCoverageChronExamples' => '', 'metaCoverageResearchSampleExamples' => '', 'metaType' => false, 'metaTypeExamples' => 'Survey/Interview; Qualitative; Mixed Methods; Systematic Review; Narrative Review; Randomized Trial; Cohort Study; Quasi-Experimental', 'publicationFormatVolume' => true, 'publicationFormatNumber' => true, 'publicationFormatYear' => true, 'publicationFormatTitle' => true, 'initialVolume' => 1, 'initialNumber' => 1, 'initialYear' => 1999, 'pubFreqPolicy' => 'The Journal of Medical Internet Research publishes articles "continuously," i.e. articles are published online as soon as they are available (peer-reviewed and copy-edited). The Journal collates them into archival "issues" (1999-2011: 4 issues per year, 2012: 6 issues per year; since 2013: issues per year) and "volumes" (one per year).', 'useCopyeditors' => true, 'copyeditInstructions' => 'Copyediting Instructions and Style Guide are now on our wiki at http://dev.jmir.org/convert/wiki/index.php/Copyediting/Style_Guide_guide (available to our copyeditors only)

    The copyediting stage is intended to improve the flow, clarity, grammar, wording, and formatting of the article. It represents the last chance for the author to make changes to the text. The file to be copyedited is in Word or .rtf format and therefore can be easily edited as a word processing document. Microsoft Word's Track Changes and the comments feature should be used. Microsoft Word's Track Changes Under Tools in the menu bar, the feature Track Changes enables the copyeditor to make insertions (text appears in color) and deletions (text appears crossed out in color or in the margins as deleted).

    The copyeditor should post queries to the author (Author Queries) and to the editor (Editor Queries - only in exceptional cases) by inserting these queries in square brackets. The copyedited version is then uploaded and the author is notified to address the queries.

    The copyeditor then revises the text and notifies the editor. Please point out any issues that require editorial attention in your cover letter.

     

    ', 'useLayoutEditors' => true, 'useProofreaders' => false, 'proofInstructions' => '

    Proofreading Instructions

    The proofreading stage is intended to catch any errors in the galley's spelling, grammar, and formatting. See JMIR wiki at http://dev.jmir.org/convert/wiki/index.php/Main_Page for copyediting style guide and XML-tagging/layout guidelines.More substantial changes cannot be made at this stage, unless discussed with the editor. Proofread the galley version in HTML, PDF or other file format. The text needs to be read closely in only one version for spelling and grammatical errors, while checked for formatting in each version.

    Please be particularly diligent when checking the tables, figures (including table and figure captions and footnotes) and the references, as this is where most typesetting errors are typically being made.

    We strive to have a weblink in as many references as possible, including links to webdocuments such as “grey” reports available as PDF on the Internet etc. If you have references citing reports which can be found as full text on the Internet, please provide us with the URL (which we will archive using WebCite).

    Please also check and flag layout issues, such as excessive white space, figures that do not come out well or are too large/small etc.

    Using the web version, please also check internal and external links by clicking at them (at least a random sample). Are they leading to the correct pages? Is the cited  webdocument still the  one you meant to cite or has it changed? Also check the multimedia appendices - are these files (listed under "supplementary files) the correct files? Do submission date, revised version received date etc. look correct?

    Also check and correct the metadata (View Metadata link), such as author names, title, final abstract, keywords etc. These metadata will be used to generate the entry in the table of contents, and will be submitted to various databases and indices, so it is important that this information is correct and complete.

    Please do not share the attached pdf with anybody, or make the link to the article above public, as the paper is not yet considered "published". Please also note that the URL and citation information may still change and the publication may be incorrect.

    We aim to publish your paper within 8-24 hours after getting your response, so the earlier we get your reply, the earlier we can “release” the paper.

    ', 'enableSubscriptions' => true, 'subscriptionName' => 'Gunther Eysenbach MD MPH', 'subscriptionEmail' => 'geysenba@gmail.com', 'subscriptionPhone' => '(+1) 416 340 4800 x 6427', 'subscriptionFax' => '(+1) 416 340 3595', 'subscriptionMailingAddress' => 'Senior Scientist, Centre for Global eHealth Innovation, 190 Elizabeth Street, Toronto M5G 2C4, Canada', 'homeHeaderTitleType' => 1, 'homeHeaderTitle' => 'Journal of Medical Internet Research', 'pageHeaderTitleType' => 1, 'pageHeaderTitle' => 'Journal of Medical Internet Research', 'homeHeaderTitleImage' => array ( 'name' => 'banner-404red.gif', 'uploadName' => 'homeHeaderTitleImage.gif', 'width' => 592, 'height' => 98, 'dateUploaded' => '2008-01-17 23:17:24', ), 'pageHeaderTitleImage' => array ( 'name' => 'JMIR-Banner-2014-07-30-v2.0.png', 'uploadName' => 'pageHeaderTitleImage.jpg', 'width' => 799, 'height' => 90, 'dateUploaded' => '2014-07-30 10:37:13', ), 'homepageImage' => NULL, 'readerInformation' => '

    We encourage readers to sign up for the publishing notification service for this journal. Please create a login account to register for email alerts.

    ', 'enableDelayedOpenAccess' => false, 'authorInformation' => '

    Interested in submitting to this journal? We recommend that you review the About the Journal page for the journal\'s section policies, as well as the Author Guidelines. Authors need to register with the journal prior to submitting, or if already registered can simply log in and begin the 5 step process.

    ', 'librarianInformation' => '

    We encourage research librarians to list this journal among their library\'s electronic journal holdings. An EL membership (access to PDF files for institutions, with automatic IP recognition) is available for a small fee, as are various other forms of institutional membership.

    ', 'subscriptionAdditionalInformation' => '

    Individual and Institutional Memberships provide value-added services and information, such as PDF files of issues and articles. Information on different membership models is available under "Support & Membership". To view a list of current membership institutions, please log in and click membership in your profile.

    NEW: We now also offer 3yr/5yr/10yr membership specials!  Prepay for 3, 5, or 10 years and enjoy significant discounts and protection from price increases. Also ideal for researchers who want to budget for JMIR membership in their grant applications, or for using unspent grant money or end-of-year funds.

    ', 'journalPageHeader' => '', 'journalPageFooter' => '
    ', 'displayCurrentIssue' => false, 'additionalHomeContent' => '', 'journalDescription' => '

    The leading peer-reviewed journal for health and healthcare in the Internet age.

    ', 'navItems' => array ( 0 => array ( 'name' => 'Subscribe', 'isLiteral' => '1', 'url' => '/cms/view/support_%26amp%3B_membership', 'isAbsolute' => '1', ), 1 => array ( 'name' => 'Submit', 'isLiteral' => '1', 'url' => '/cms/view/Instructions_for_Authors:Instructions_for_Authors_of_JMIR', ), 2 => array ( 'name' => 'Open Review', 'isLiteral' => '1', 'url' => '/reviewer/openReview/abstracts', ), 3 => array ( 'name' => 'Become Member', 'isLiteral' => '1', 'url' => '/payment/select/membership', ), 4 => array ( 'name' => 'Top Articles', 'isLiteral' => '1', 'url' => '/stats/overview?sort=views', ), 5 => array ( 'name' => 'JMIR Protocols', 'isLiteral' => '1', 'url' => 'http://www.researchprotocols.org/', 'isAbsolute' => '1', ), 6 => array ( 'name' => 'JMIR Mhealth', 'isLiteral' => '1', 'url' => 'http://mhealth.jmir.org/', 'isAbsolute' => '1', ), 7 => array ( 'name' => 'JMIR Serious Games', 'isLiteral' => '1', 'url' => 'http://games.jmir.org/', 'isAbsolute' => '1', ), 8 => array ( 'name' => 'JMIR Medinform', 'isLiteral' => '1', 'url' => 'http://medinform.jmir.org/', 'isAbsolute' => '1', ), 9 => array ( 'name' => 'i-JMR', 'isLiteral' => '1', 'url' => 'http://www.i-jmr.org/', 'isAbsolute' => '1', ), 10 => array ( 'name' => 'Med2 Proc', 'isLiteral' => '1', 'url' => 'http://www.medicine20.com', 'isAbsolute' => '1', ), 11 => array ( 'name' => 'JMIR Human Factors', 'isLiteral' => '1', 'url' => 'http://humanfactors.jmir.org/', 'isAbsolute' => '1', ), 12 => array ( 'name' => 'JMIR Mental Health', 'isLiteral' => '1', 'url' => 'http://mental.jmir.org/', 'isAbsolute' => '1', ), 13 => array ( 'name' => 'JMIR Rehab', 'isLiteral' => '1', 'url' => 'http://rehab.jmir.org/', 'isAbsolute' => '1', ), 14 => array ( 'name' => 'JMIR Public Health', 'isLiteral' => '1', 'url' => 'http://publichealth.jmir.org/', 'isAbsolute' => '1', ), 15 => array ( 'name' => 'JMIR Med Educ', 'isLiteral' => '1', 'url' => 'http://mededu.jmir.org/', 'isAbsolute' => '1', ), 16 => array ( 'name' => 'JMIR Cancer', 'isLiteral' => '1', 'url' => 'http://cancer.jmir.org/', 'isAbsolute' => '1', ), 17 => array ( 'name' => 'JMIR Preprints', 'isLiteral' => '1', 'url' => 'http://preprints.jmir.org/', 'isAbsolute' => '1', ), ), 'itemsPerPage' => 150, 'numPageLinks' => 15, 'rtEnabled' => false, 'rtVersionId' => 15, 'rtAbstract' => false, 'rtCaptureCite' => true, 'rtViewMetadata' => true, 'rtSupplementaryFiles' => false, 'rtPrinterFriendly' => false, 'rtAuthorBio' => true, 'rtDefineTerms' => false, 'rtEmailAuthor' => false, 'rtEmailOthers' => true, 'rtBibFormat' => 'BibTeX', 'journalAbbreviation' => 'J Med Internet Res', 'printIssn' => '', 'doiPrefix' => '10.2196', 'envelopeSender' => NULL, 'customHeaders' => '', 'remindForInvite' => 1, 'remindForSubmit' => 1, 'numDaysBeforeInviteReminder' => 3, 'numDaysBeforeSubmitReminder' => 5, 'rateReviewerOnQuality' => 1, 'reviewerAccessKeysEnabled' => 1, 'reviewerDatabaseLinks' => array ( 0 => array ( 'title' => '', 'url' => '', ), ), 'copyrightNoticeAgree' => false, 'copySubmissionAckPrimaryContact' => true, 'copySubmissionAckSpecified' => true, 'copySubmissionAckAddress' => 'jmir.editorial.assistant@gmail.com', 'disableUserReg' => false, 'allowRegReader' => true, 'allowRegAuthor' => true, 'allowRegReviewer' => true, 'restrictSiteAccess' => false, 'restrictArticleAccess' => false, 'articleEventLog' => true, 'articleEmailLog' => true, 'layoutInstructions' => 'Please carefully follow our XML tagging instructions, which are now on our wiki at http://dev.jmir.org/convert/wiki/index.php/Typesetting_guide', 'journalStyleSheet' => array ( 'name' => 'journalStyleSheet.css', 'uploadName' => 'journalStyleSheet.css', 'dateUploaded' => '2014-10-14 9:45:11', ), 'authorRevisionInstructions' => array ( 'manuscript' => 'Revised manuscript as word-document, no tracked changes or highlights. You can upload a manuscript with tracked-changes as additional supplementary file.', 'figures' => 'Upload high-quality figures as image (PNG/JPG) files. For manuscripts discussing web-based or mobile interventions we usually require 1-2 screenshots of the intervention as figure. Also, upload an "illustrative" figure or photo to be used for our homepage and the table-of-contents (we call this a "TOC image").', 'appendices' => 'Multimedia Appendices can be questionnaires, datasets, videos/screencasts, Powerpoint or PDF files showing multiple screenshots (please also use 1-2 screenshots as figures in the paper), files containing the source code of a computer program, informed consent documents. For protocols/proposals intended for JMIR Res Protoc also upload review reports from the funding agencies if available.', 'suppFiles' => 'We recommend to upload a tracked-changes version, and also the responses to the reviewers, as additional file. Also, upload potentially overlapping material submitted or published in other journals (make sure to outline in your notification to the editor how this paper is different, and why "salami-slicing" into multiple publications is justifiable). CONSORT-EHEALTH (for RCTs only), PRISMA (systematic reviews) and other reporting checklists should also be supplied, if available.', 'notify' => 'Must contain the point-by-point response to editorial and reviewer comments. While you can also upload this as additional file, we ask that you copy & paste the entire point-by-point response (which may be shared with reviewers) into the notification email.', ), 'authorStep4Instructions' => 'In this step in the submission process any figure or appendix files included in the manuscript, as well as any other supplementary files (related publications, CONSORT checklists, etc.) should also be uploaded as separate files.
    Reacting to feedback by some authors that this is too much work, we now allow initial submissions with no separate figure uploads (i.e. just leave them in the manuscript only). However, please be aware that -- at the latest -- after initial peer-review (when you submit your revised manuscript) you will have to upload each of your figures separately. In order to avoid delays during production we highly recommend to do this already on initial submission, so we can check and comment on the quality of the figures. We recommend to have no more than 5 figures in your main manuscript (the rest - e.g. a series of screenshots - could go into an appendix, e.g. as Powerpoint file). Manuscripts describing ehealth or mhealth applications should usually have at least one figure showing a screenshot.
    Figures: should be high-quality JPG, PNG or GIF files (no not upload figures as TIF, DOC, PDF or any other file type). The image should not have the figure title/caption embedded in the image; this should be added in the figure metadata (you will be directed to the form to provide this information after selecting a file for upload).

    Multimedia Appendices: in the case of text documents these should be uploaded as Word documents not PDF files. ', 'googleAnalyticsId' => 'UA-186918-1', 'homeHeaderLogoImage' => array ( 'name' => 'JMIR JMIR Home.png', 'uploadName' => 'homeHeaderLogoImage.jpg', 'width' => 155, 'height' => 102, 'dateUploaded' => '2014-04-01 15:51:02', ), 'googleAccountId' => 'ga:192168', ); ?>
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines using modern ICT via a common platform for sharing digital education content, as well as for assessing their quality through a multidimensional approach [13].

    Most of the digital teaching described in recent literature has been prepared as Web-based works because Web technologies allow for easy incorporation of multimedia objects, interactive algorithms, animated simulations, etc. The work may then be easily accessed from any computer and by a defined target audience (eg, students of a particular medical school or course). The developed tools and simulations cover a wide range of medical disciplines, such as critical care [14,15], cardiology [3], hematology [1], neurology [16], surgery [17], metabolic disorders, imaging methods [18,19], and cytogenetics [20].

    Acute medicine is a dynamic environment with high demands on team communication and leadership, requiring correct clinical reasoning and quick decision making under time pressure. Simulation offers a good and interesting platform for training multidisciplinary medical teams, facilitating interaction among the team members and enabling the team to function in an effective and coordinated manner [6]. Internet education resources for intensive care medicine have recently been reviewed by Kleinpell et al [14], who demonstrated that most of them are electronic forms of textbooks and articles rather than interactive algorithms and dynamic simulations. Davids et al [7] described an interactive Web-based simulation in which the user treats patients with electrolyte and acid-base disorders, selects the therapies and doses, and can immediately see the treatment results.

    In this paper, we present the education portal AKUTNE.CZ [21] as an important part of the MEFANET’s contents. It aims to be a comprehensive source of information and education materials covering all aspects of acute medicine for undergraduate and postgraduate students of the medical and health professions. We focus here primarily on the simulation-based tools for teaching and learning algorithms for acute patient care that form the backbone of AKUTNE.CZ. The simulations take the form of interactive algorithms and represent the basis for a new extension of MEFANET’s activities incorporating focus on serious games.

    Methods Overview

    MEFANET [12] has established itself as the standard-setting body for medical educators in the Czech Republic and Slovakia, 2 independent countries that once comprised a federation, have similar languages, and still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies. As an instrument, MEFANET has decided to develop an original and uniform solution for educational Web portals that are used, together with a central gateway, to offer and share digital education content. Students—approximately 16,500 potential users and academic staff and approximately 3900 potential users from all Czech and Slovak medical faculties—can find their e-learning materials at 11 standalone faculties’ instances of an educational portal with the use of the indexing and searching engine, MEFANET Central Gateway [22].

    MEFANET e-Publishing System

    The idea of a shared e-publishing system is based on a set of standalone Web portals rather than on a centralized application hosted for all medical schools, which might be an inflexible and more vulnerable alternative solution. Each portal instance represents an independent publication media with its own International Standard Serial Number (ISSN) code and an editorial board. Local metadata describing the digital educational contents are replicated regularly to the central gateway (see metadata harvesting in Figure 1). There are 3 fundamental elements that have to be rigidly maintained on the part of local administrators: (1) the medical disciplines linker, (2) the authentication/authorization framework, and (3) multidimensional quality assessment. The other features, properties, and functionalities can be adapted or localized to meet the needs of the particular institution. A detailed description of the 3 fundamental elements is as follows. See [13] for full and comprehensive information.

    The medical disciplines linker represents the main taxonomy of contributions within the frame of the network. With its single-level list of 56 medical specializations, it forms the only obligatory structure of a portal instance. Any change to its content is subject to approval of the MEFANET Coordinating Committee.

    The authors of the shared teaching materials can choose from the following user groups to permit or deny access to their materials: (1) nonregistered anonymous users, (2) registered anonymous users who accept the terms of use within their registration, (3) users of the MEFANET network, that is, a student or teacher from any Czech or Slovak medical school (MEFAPERSON), (4) users from a local university whose affiliation to that university has been verified at the portal via the local information system of that university, (5) users to whom attachments are made available only after the author’s explicit consent. Services of the Czech academic identity federation, eduID.cz [23], are used to check the affiliations of the users of the portal instances. This federation uses the Shibboleth technology, which is one of the several authentication frameworks allowing the sharing of Web resources among institutions using the Security Assertion Markup Language (SAML) protocol standard. The portal instances behave like service providers in this federation, whereas the information systems of the involved schools act as identity providers.

    There are 4 dimensions of critical importance when evaluating the quality of electronic teaching materials: (1) expert review, (2) education level of target users, (3) classification by type, and (4) self-study score. The review includes binary questions as well as open questions. The structure of the review form can be localized by modifying an extensible markup language (XML) template file. The second dimension is represented by the education level of the target group of the teaching material, which is a useful piece of information for the users and the reviewers. The next dimension is represented by a multiple-choice classification according to the types of attachments—the enumerated scale includes static files for Web-based learning and interactive e-learning courses encapsulated in the learning management systems. The last dimension—a self-study score—indicates what users think about the usability of a particular contribution in their self-studies. The values of the first 3 dimensions of the 4D assessment are composed by authors, guarantors, and reviewers. Their activities and the workflow of a contribution are explained in Figure 2. In addition to the 4D quality assessment, all contributions submitted to the central gateway undergo an additional editorial process called mentally active monitoring. It focuses on the following issues: (1) metadata is filled in properly, (2) granularity of the attachments is suitable, and (3) all attached documents and the links are accessible for at least MEFAPERSON users. The monitoring of these 3 important issues is done not only at the syntax level, but also semantically; therefore, it is carried out by a team of editors in cooperation with the editors responsible for the local Web portals.

    Recently, new tools for technology-enhanced learning have been introduced to the MEFANET network in addition to the common e-publishing portal platform. These new tools complement the portal platform suitably because they provide a higher level of interactivity for students during their self-study process. Figure 1 shows how the new 4 tools—Sandbox [24], WikiLectures [25], Moodle-MEFANET [26], and Serious Games [27]—are related to the already established and standardized MEFANET Central Gateway.

    The Serious Games extension is the latest development in MEFANET and it is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The first comprehensive set of such interactive learning objects is composed by algorithms for acute patient care published at the AKUTNE.CZ educational portal [21] together with other digital education materials covering a wide range of acute medicine topics.

    MEFANET involves all medical schools in the Czech Republic and Slovakia. They share one another’s digital teaching and learning materials by using an e-publishing system that consists of 11 educational Web portals and a central gateway. The extensions of the MEFANET e-publishing system appear as standalone platforms for their users. However, all teaching or learning materials indexed by the MEFANET Central Gateway undergo the same procedures of multidimensional quality assessment.

    The contribution workflow scheme: (1) the author and technical editor finishes the contribution, (2) the guarantor, who is associated with a particular medical discipline, is notified about a new contribution to his/her field of interest, (3) the guarantor, either alone or with the help of the faculty’s editorial committee, invites 2 reviewers to present their reviews online with the use of template-generated forms.

    Interactive Algorithms for Teaching and Learning Acute Medicine

    Each physician dealing with acute patients needs algorithmic thinking and correct clinical reasoning. Our interactive algorithms take the form of content-rich virtual cases because they link together process flowcharts and multimedia. Creating such algorithms or electronic virtual patients is laborious, time-consuming, and often accompanied by ambiguities and hesitations. Following the principles of student-centered learning, our authoring teams consisted of medical students in the final years of their studies, supervised by an experienced clinician. The complete workflow of the authoring process is outlined in Figure 3.

    It takes 10 to 50 hours of active work to produce 1 interactive algorithm. The time of the team members is spent on collaborative work, meetings, and on self-studying. Student–authors consult their problems and reservations with a supervisor assigned to them and the resulting product is then submitted to an external reviewer, usually an experienced clinician or an academic staff from another workplace. After the incorporation of all reviewers’ comments, the algorithm is completed by metadata to be published on the AKUTNE.CZ educational portal. Finally, sets of algorithms are compiled together with their metadata into a contribution to be published and indexed on the MEFANET Central Gateway. These contributions with a wider scope than individual algorithms are subjected to the multidimensional quality assessment described previously. Finished and published algorithms are used by other students either as outlines for problem-based learning (PBL) sessions or as supplementary materials for training and adopting correct clinical reasoning.

    The interactive algorithms are authored with the use of a Web-based (PHP/MySQL) BackOffice application that provides the student–authors the following functionalities through its online forms and drag and drop control: (1) node-based scenario design, (2) description of the situation in each node, including the intervals of parameter values of physical examinations, intervals of laboratory values, and multimedia, (3) description of the correct answers as well as distractors with the option to repeat or end in a fatality, and (4) data export for each finished algorithm into an XML document. The XML documents are then rendered into a Flash object resembling a serious game. A student–player uses the game or this simulation-based learning object by moving between the nodes, which may be of different types, as shown in the sample algorithm in Figure 4. Each move causes a shift in the timeline as a side effect of the student–player’s action, lending authenticity to the scenario and creating a stress effect, which is pronounced in real-life situations when dealing with acute patients. Continuous change of various numerical parameters reflecting the development of patient’s clinical status and vital functions in time (eg, blood pressure, pulse, oxygen saturation) is also available (see the example of a node of a selected algorithm in Figure 5).

    Students’ Feedback on the Interactive Algorithms

    We asked students about their attitudes and interest in using the interactive algorithms as part of their medical or health care studies. The purpose was to ascertain how the students perceived our efforts on authoring and implementing simulation-based learning tools that are so demanding to create. An anonymous questionnaire of 10 items (see Table 1 for complete overview of questions and answer options) was created and presented via SurveyMonkey [28], a free online survey software. Data collection lasted for 10 days in February 2013. The students who enrolled at 1 of the educational workshops or a conference organized by the group around the AKUTNE.CZ portal were asked to complete the survey. The first 4 questions were aimed at obtaining basic data about the respondents, so that the ones who did not study any field of medicine or health care could be filtered out as well as the ones who did know about our interactive algorithms at all. Further questions were answered with a 5-point Likert scale and 1 binary question was aimed at seeking feedback on the use of our interactive algorithms in the studies of acute medicine topics.

    The authoring workflow of an interactive algorithm from choosing the topic through a review process to deployment to teaching in the form of a moderated problem-based learning session.

    Various types of nodes and options/answers that may be used for authoring an interactive algorithm.

    An explained screenshot for 1 node of an algorithm for training clinical reasoning skills in acute coronary syndrome.

    Questionnaire for collecting the students’ feedback on the interactive algorithms.

    # Question Answer options
    1 State your gender. Male or female
    2 What is your field of study? General medicine
    Dentistry
    Health care specializations (MSc)
    Health care specializations (BSc)
    Midwifery (BSc)
    Postgraduate doctoral program. another (specify, please)
    3 What is your attitude toward the interactive algorithms AKUTNE.CZ? I do not know what they are
    I know what they are, but I have never used them
    I tried to solve at least 1 interactive algorithm
    I am an author or a coauthor of at least 1 interactive algorithm
    4 Have you ever used for your studies a serious game (simulation of real situations for teaching and learning) or-any other interactive algorithm AKUTNE.CZ? I have not used any at all, not even any interactive algorithm
    No. I have used only the interactive algorithms
    Yes. I have used also...(specify which):
    5 The interactive algorithms AKUTNE.CZ are an effective tool for my learning. 5-point Likert scale from strongly disagree to strongly agree
    6 The use of the interactive algorithms AKUTNE.CZ improved my knowledge in the field of acute medicine. 5-point Likert scale from strongly disagree to strongly agree
    7 The use of the interactive algorithms AKUTNE.CZ represents for me a better way to study than static textbooks. 5-point Likert scale from strongly disagree to strongly agree
    8 I like playing the interactive algorithms AKUTNE.CZ not only at home, but also at school under the supervision of teachers, together with consulting possible answers as well as with discussion on all issues related to the topic. 5-point Likert scale from strongly disagree to strongly agree
    9 Multimedia accompanying the decision nodes together with the time stressor evokes an authentic atmosphere of clinical reasoning and decision making. 5-point Likert scale from strongly disagree to strongly agree
    10 Would you recommend the interactive algorithms AKUTNE.CZ to your friends? Yes or no
    Results

    Over 5 years, almost 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ educational portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. Another 5 algorithms will be finished during 2013. They cover a wide range of acute medicine topics in the following 5 packages:

    Basic Life Support and Advanced Life Support

    Algorithms cover many basic life support (BLS) and advanced life support (ALS) procedures described in the current European Resuscitation Council guidelines. We developed a BLS for adults algorithm, ALS for bradycardia, BLS for choking children, and a foreign-body airway obstruction in adults algorithm.

    Emergency Medicine

    Emergency medicine is a very specific type of care in exceptional conditions. We tried to create an ambience of a real car accident in the interactive algorithm. Further topics of emergency medicine are algorithms for water rescue, severe hypothermia in the mountains in winter, out-of-hospital craniocerebral injury, and syncope.

    Critical Care Medicine

    Critical care medicine (CCM) is the flagship of medicine in general. It is no coincidence that the most demanding and complex algorithms are from this field. The surviving sepsis algorithm is based on the surviving sepsis guidelines of the Society of Critical Care Medicine (SCCM). The acute coronary syndrome algorithm provides a complete decision tree for a patient with acute myocardial stroke. The algorithm for diabetes mellitus deals with sudden loss of consciousness in a diabetic patient.

    Anesthesiology

    These algorithms cover both interesting acute and propaedeutic situations during anesthesia. We developed an algorithm describing the correct approach to the parturient with postdural puncture headache after epidural labor analgesia. Another acute situation is described in the algorithm for toxic reaction to anesthetic agents. Propaedeutic skills are represented by algorithms introducing the insertion of central venous catheter or the choosing of venous entry routes.

    Pain Management

    Providing good analgesia for acute and chronic pain is a global issue. We cover these issues with an acute postoperative pain algorithm and by algorithms with correct approach to analgesia in a general practitioner’s and a dentist’s surgery/clinic.

    User’s attendance to the interactive algorithms was analyzed with the use of Google Analytics in context of the whole website AKUTNE.CZ within a 1-month period (January 15 to February 14, 2013). In this period, 3342 unique users visited the website (5452 visits in total, 176 visits per day, SD 53.1). All interactive algorithms together had 816 unique users. Of 816 users, 297 (36.4%) accessed the algorithms from Brno and were, therefore, identified as students of the Faculty of Medicine in Brno. Other large groups of visitors were from Prague (99/816, 12.1%) and Bratislava (26/816, 3.2%), both major cities with established medical education facilities. On the other hand, 259 accesses (31.7%) were from places where no faculty of medicine exists. Although we are aware of the limited information value of such analysis (eg, not all visits from Brno are performed at school, or a visitor from a small village could be a student from the Brno faculty of medicine), these results document that the interactive algorithms have been used within the whole MEFANET network and a significant proportion of students use them in places outside of the school (ie, in their homes and during leisure time). The most frequently played algorithms were the diabetes mellitus (94/816 unique users, 11.5%), hypothermia (89 unique users, 10.9%), and surviving sepsis (52 unique users, 6.4%).

    In the feedback survey, 62 participants (13.5%) completed the online questionnaire out of the overall 460 asked to participate. Of all respondents, 66.1% were women and 33.9% were men. After filtering out the participants who were not students of any medical or health care program, and those who did not know about the availability of the interactive algorithms AKUTNE.CZ, the resulting responses from 54 participants were analyzed (see Figure 6). The participants were asked whether the interactive algorithms served as an effective tool for their learning. Four responses were negative or very negative (7.4%), 3 responses were neutral (5.6%), and 47 responses were positive or very positive (87.0%). The participants were further asked whether the interactive algorithms improved their knowledge of acute medicine. Six responses were negative or very negative (11.2%), 4 responses were neutral (7.4%), and 44 responses were positive or very positive (81.4%). In all, 40 participants agreed or strongly agreed (74.0%) that the interactive algorithms represented for them a better study method in comparison to static textbooks, whereas 6 participants disagreed or strongly disagreed (11.2%), and a further 8 respondents neither agreed nor disagreed (14.8%). The participants’ attitude toward interactive algorithms as a tool for face-to-face teaching and learning was positive or very positive in 46 responses (85.2%), negative or very negative in 3 responses (5.6%), and neutral in 5 responses (9.2%). Most participants agreed or strongly agreed (47/54, 87.0%) that multimedia and the time-stress factor provided an authentic atmosphere for pertinent clinical reasoning, whereas 4 participants disagreed or strongly disagreed (7.4%) with this fact and 3 were unsure (5.6%). All participants (100%) stated that the interactive algorithms were worth recommending to their friends.

    Attitudes and interests of students about using the interactive algorithms as part of their medical or health care studies.

    Discussion Principal Findings

    High-quality digital education content production has become a matter of prestige at medical schools in the Czech Republic and Slovakia, and the volume of teaching and learning materials available is growing rapidly thanks to the MEFANET project and its ICT platforms, which have been continuously developed and adopted to the needs of the MEFANET community during the past 6 years. Four new extensions, which complement the e-publishing portal platform standardized in MEFANET, are usable independently; however, their complex application in conjunction with the portal platform as a tool for final e-publishing will allow more effective repurposing of the materials created with the use of the extensions, as well as broader integration of the digital education contents among the MEFANET community. Further development aims to encourage the publication of materials for the teaching of clinical reasoning based on the concept of interactive algorithms or virtual patients. Such simulation-based learning objects are aimed to help the student in developing the much-needed confidence to manage acute conditions, to react accurately, and to avoid distraction by secondary issues.

    The unique advantage of interactive algorithms AKUTNE.CZ is the possibility to create complex and branching scenarios. Nevertheless, real-life medical emergencies offer little or no extra options; in many cases, there is only 1 correct course of action. Unfortunately, this feature has not been adopted on a wide scale. The reason could be the characteristics of real-time acute medicine situations that are often linear with no space for branching. On our part, we have complied as much as possible with the guidelines of medical societies. Any deviation from the approved procedures may lead to deteriorating outcomes in real clinical situations. This is the reason why we prefer creating simplified and linear algorithms. An algorithm that approaches realistic simulation (nonlinear or open format) could be more attractive for the students, but we believe that to happen at the expense of didacticism. We also prefer topics that are endorsed and processed by the guidelines or recommendations of the European medical societies (ie, European Resuscitation Council, SCCM, European Society of Regional Anaesthesia and Pain Therapy) and/or national medical societies (ie, Czech Society of Anaesthesiology and Intensive Care Medicine, Czech Society of Intensive Care Medicine, Czech Society of Hematology, Czech Society of Cardiology, Czech Gynecological and Obstetrical Society, and Czech Pain Society). The linear scenarios help to maintain a didactic focus of the interactive algorithms. This mechanistic approach may, however, be detrimental to the students’ understanding of the underlying physiological processes. In order to overcome this limitation, we prefer to use the interactive algorithms for teaching in the form of moderated PBL sessions. Inspired by several works in the field of advanced physiological simulators with a mathematical background [29-31], we will focus our future developments toward a technology mashup, which would allow to incorporate time-dependent, complex physiological simulation of multiple variables and their response to perturbations into the multimedia part of the interactive algorithms.

    We cover a wide range of acute medicine topics through the AKUTNE.CZ algorithms. Of course, there is room for additional themes, for example, the widely publicized case of methanol poisoning in 2012 in the Czech Republic, which led to fatalities. Other topics under consideration include selected amyotrophic lateral sclerosis scenarios and out-of-hospital medical emergencies. Interactive algorithms are also used during obstetric anesthesia and analgesia lessons for the midwives—severe peripartal bleeding, amniotic fluid embolism, and out-of-hospital delivery algorithms. The primary aim is to achieve a situation whereby each acute medicine teaching unit has at least 1 interactive algorithm for PBL.

    Although the algorithms were tailored to the teaching and learning of acute medicine issues, it is possible to use them for education in other medical and health care disciplines as well. The selection of the parameters from physical examination results and laboratory tests can be changed easily and, thus, adopting the tool for use elsewhere. In comparison with other examples of simulation-based learning objects, such as virtual patients [32], we have a different approach to handling the selected physical examination results and laboratory findings. We follow real-world scenarios and provide the possibility to record these parameters as they are recorded during management of real acute patients too. Each measurement is linked to an increase of the time-stress factor. Thus, students not only learn about dynamics of these characteristics, but also about the unpleasant price in terms of time spent for unnecessary measurements.

    A major problem with any medical issue is topicality. AKUTNE.CZ algorithms overcome such problems by ensuring regular updates through the combined efforts of medical students and the authors, in addition to holding regular meetings on time-scheduled updated topics. The algorithms truly reflect on the current medical recommendations and guidelines of the medical societies.

    In general, our survey points to a fairly strong preference for the AKUTNE.CZ interactive algorithms by the students as part of their medical or health care studies, although it is notable that the participants were only just aware of the interactive algorithms—a small proportion (9%) reported using other serious games or simulation-based learning objects for their studies. Nevertheless, positive attitudes toward the interactive algorithms outnumbered negative responses. Confirming our expectations, one of the strongest positive answers concerned the participants’ desire to use the interactive algorithms not only for their self-studies during leisure time, but also in face-to-face teaching and learning. Based on our several preliminary attempts at implementing the PBL principles into our teaching, we are fully confident about PBL-like sessions conducted on the node-based scenarios of selected interactive algorithms as the appropriate way to fulfill that wish. The medical and health care institutions in the Czech Republic and Slovakia involved in MEFANET are currently, however, in the very preliminary phases of implementing PBL into their curriculum. Hopefully, the use of interactive algorithms in the process of PBL implementation shall pave the way toward increased attractiveness of our teaching, as well as deeper interest on the part of the students not only in acute medicine issues.

    Limitations

    A limitation of the study is that we did not collect data to observe effects of the use of algorithms on expected improvements of participants’ knowledge or on their reactions in real situations. We can only guess about the positive impacts of the interactive algorithms from the fact that most of the student–authors did not have any difficulties launching their professional careers in acute medicine. Another improvement indicator can be inferred from the repeated successes of student–authors and student–players in international competitions of medical rescue teams.

    Conclusions

    The methodological aspects of our interactive algorithms for incorporation in the learning and teaching of acute medicine were presented. These interactive algorithms comprise the main part of the educational content of the AKUTNE.CZ portal and recently became the basis for a new extension for MEFANET, the education network of all medical faculties in the Czech Republic and Slovakia.

    There are 25 algorithms in the Czech/Slovak and English languages, published online and covering a wide range of topics in acute medicine. The peer-reviewed algorithms were used for conducting PBL-like sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) as well as in nursing (emergency medicine for midwives, obstetric analgesia and anesthesia for midwives).

    We investigated the students’ perception of our interactive algorithms as an adjuvant to their medical and health care studies, especially in relation to clinical reasoning. The feedback from the survey among the AKUTNE.CZ users suggests that the students identify the interactive algorithms as an effective learning tool, serving to enhance their knowledge in the field of acute medicine. In addition, they expressed their keen desire to apply them not only in their leisure time, but also during face-to-face contact with their teachers at school or during clinical practice in the university hospital.

    The AKUTNE.CZ interactive algorithms, as a software platform, are open to academic use worldwide. The already created and peer-reviewed algorithms, as simulation-based learning objects, can be included easily into any education website (subject to approval of the authors).

    Abbreviations ALS

    advanced life support

    BLS

    basic life support

    CCM

    critical care medicine

    ICT

    information and communication technology

    ISSN

    International Standard Serial Number

    MEFANET

    Medical Faculties Network

    PBL

    problem-based learning

    SAML

    Security Assertion Markup Language

    SCCM

    Society of Critical Care Medicine

    XML

    extensible markup language

    The grant project MEFANET clinical reasoning reg no: CZ.1.07/2.2.00/28.0038 is supported by the European Social Fund and the state budget of the Czech Republic.

    Daniel Schwarz is the principal investigator of the MEFANET clinical reasoning grant project, which funded development of the MEFANET e-publishing system as well as the interactive algorithms for teaching and learning acute medicine. The grant project also paid Daniel Schwarz, Petr Štourač, Martin Komenda, and Hana Harazim a small portion of their salaries at Masaryk University.

    Holzinger A Kickmeier-Rust MD Wassertheurer S Hessinger M Learning performance with interactive simulations in medical education: Lessons learned from results of learning complex physiological models with the HAEMOdynamics SIMulator Computers & Education 2009 2 52 2 292 301 10.1016/j.compedu.2008.08.008 Wong RW Lochnan HA A web-based simulation of a longitudinal clinic used in a 4-week ambulatory rotation: a cohort study BMC Med Educ 2009 9 8 10.1186/1472-6920-9-8 19187554 1472-6920-9-8 PMC2654557 Subramanian A Timberlake M Mittakanti H Lara M Brandt ML Novel educational approach for medical students: improved retention rates using interactive medical software compared with traditional lecture-based format J Surg Educ 2012 69 4 449 52 10.1016/j.jsurg.2012.05.013 22677580 S1931-7204(12)00138-9 Maloney S Haas R Keating JL Molloy E Jolly B Sims J Morgan P Haines T Breakeven, cost benefit, cost effectiveness, and willingness to pay for web-based versus face-to-face education delivery for health professionals J Med Internet Res 2012 14 2 e47 10.2196/jmir.2040 22469659 v14i2e47 PMC3376523 Brett-Fleegler MB Vinci RJ Weiner DL Harris SK Shih MC Kleinman ME A simulator-based tool that assesses pediatric resident resuscitation competency Pediatrics 2008 03 121 3 e597 603 10.1542/peds.2005-1259 18283069 peds.2005-1259 Pothiawala S Lateef F Hong Kong Journal of Emergency Medicine 2012 01 2013-02-27 Simulation training in emergency medicine (STEM): an integral component of residency curriculumhttp://www.hkcem.com/html/publications/Journal/2012-1%20Jan/p41-45.pdf 6Ek9Md4ig Davids MR Chikte UM Halperin ML Development and evaluation of a multimedia e-learning resource for electrolyte and acid-base disorders Adv Physiol Educ 2011 09 35 3 295 306 10.1152/advan.00127.2010 21908840 35/3/295 Beux PL Fieschi M Virtual biomedical universities and e-learning Int J Med Inform 2007 76 5-6 331 5 10.1016/S1386-5056(07)00060-3 17407747 S1386-5056(07)00060-3 Bamidis P Kaldoudi E Pattichis C Camarinha-Matos L Paraskakis P Afsarmanesh H mEducator: A best practice network for repurposing and sharing medical educational multi-type content Leveraging Knowledge for Innovation in Collaborative Networks 2009 Berlin Heidelberg Springer 769 776 Kaldoudi E Dovrolis N Konstantinidis S Bamidis P Social networking for learning object repurposing in medical education The Journal on Information Technology in Healthcare 2009 7 4 233 243 Kaldoudi E Dovrolis N Konstantinidis ST Bamidis PD Depicting educational content repurposing context and inheritance IEEE Trans Inf Technol Biomed 2011 01 15 1 164 70 10.1109/TITB.2010.2092442 21134819 Schwarz D Dušek L The MEFANET Project 2013-02-27 http://www.mefanet.cz/index-en.php 6EkA1pn4M Komenda M Schwarz D Feberová J Stípek S Mihál V Dušek L Medical faculties educational network: multidimensional quality assessment Comput Methods Programs Biomed 2012 12 108 3 900 9 10.1016/j.cmpb.2012.05.002 22640818 S0169-2607(12)00118-6 Kleinpell R Ely EW Williams G Liolios A Ward N Tisherman SA Web-based resources for critical care education Crit Care Med 2011 03 39 3 541 53 10.1097/CCM.0b013e318206b5b5 21169819 Creutzfeldt J Hedman L Heinrichs L Youngblood P Felländer-Tsai L Cardiopulmonary resuscitation training in high school using avatars in virtual worlds: an international feasibility study J Med Internet Res 2013 15 1 e9 10.2196/jmir.1715 23318253 v15i1e9 PMC3636066 Nathoo AN Goldhoff P Quattrochi JJ Evaluation of an Interactive Case-based Online Network (ICON) in a problem based learning environment Adv Health Sci Educ Theory Pract 2005 08 10 3 215 30 10.1007/s10459-005-7851-3 16193402 Servais EL Lamorte WW Agarwal S Moschetti W Mallipattu SK Moulton SL Teaching surgical decision-making: an interactive, web-based approach J Surg Res 2006 07 134 1 102 6 10.1016/j.jss.2005.11.583 16488433 S0022-4804(05)01179-0 Roubidoux MA Chapman CM Piontek ME Development and evaluation of an interactive Web-based breast imaging game for medical students Acad Radiol 2002 10 9 10 1169 78 12385511 Dikshit A Wu D Wu C Zhao W An online interactive simulation system for medical imaging education Comput Med Imaging Graph 2005 09 29 6 395 404 10.1016/j.compmedimag.2005.02.001 15996851 S0895-6111(05)00026-1 Holzinger A Emberger W Wassertheurer S Neal L Design, development and evaluation of online interactive simulation software for learning human genetics Elektrotech. Inftech 2008 5 125 5 190 196 10.1007/s00502-008-0537-9 Štourač P Křikava I Štoudek R Harazim H Smékalová O Kosinová M AKUTNE.CZ educational portal 2013-02-27 http://www.akutne.cz/index-en.php 6EkA9tNl4 MEFANET Central Gateway 2013-02-27 http://portal.mefanet.cz/index-en.php 6EkAEOHoF Czech academic identity federation eduID.cz 2013-02-27 http://www.eduid.cz/wiki/en/eduid/index 6EkAIeBd5 MEFANET SANDBOX 2013-02-27 http://sandbox.mefanet.cz/index-en.php 6EkAM8VLQ WikiLectures 2013-02-27 http://www.wikilectures.eu/index.php/Main_Page 6EkAPMgtf Moodle-MEFANET e-learning courses 2013-02-27 https://moodle.mefanet.cz/ 6EkATjZqo MEFANET GAMES 2013-02-27 http://games.mefanet.cz/index-en.php 6EkAfPUZp SurveyMonkey 2013-02-27 http://www.surveymonkey.com/ 6EkAiwxIh Kofranek J Matousek S Rusz J Stodulka P Privitzer P Matejak M Tribula M The Atlas of Physiology and Pathophysiology: Web-based multimedia enabled interactive simulations Comput Methods Programs Biomed 2011 11 104 2 143 53 10.1016/j.cmpb.2010.12.007 21232813 S0169-2607(10)00299-3 Thomas SR Baconnier P Fontecave J Françoise JP Guillaud F Hannaert P Hernández A Le Rolle V Mazière P Tahi F White RJ SAPHIR: a physiome core model of body fluid homeostasis and blood pressure regulation Philos Trans A Math Phys Eng Sci 2008 09 13 366 1878 3175 97 10.1098/rsta.2008.0079 18565814 BQ76741503223881 Iliescu R Lohmeier TE Lowering of blood pressure during chronic suppression of central sympathetic outflow: insight from computer simulations Clin Exp Pharmacol Physiol 2010 02 37 2 e24 33 10.1111/j.1440-1681.2009.05291.x 19769610 CEP5291 Cook DA Triola MM Virtual patients: a critical literature review and proposed next steps Med Educ 2009 04 43 4 303 11 10.1111/j.1365-2923.2008.03286.x 19335571 MED3286
    JMIR J Med Internet Res Journal of Medical Internet Research 14388871 JMIR Publications Inc. Toronto, Canada v15i7e135 23835586 10.2196/jmir.2590 Original Paper Interactive Algorithms for Teaching and Learning Acute Medicine in the Network of Medical Faculties MEFANET Bamidis Panagiotis Giordano Daniela Pattichis Constantinos Zary Nabil Woodham Luke Iliescu Radu Majernik Jaroslav Provaznik Ivo Schwarz Daniel MSc, PhD 1
    Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Kamenice 5 Brno, 625 00 Czech Republic 420 549492854 420 549492855 schwarz@iba.muni.cz
    http://orcid.org/0000-0002-7261-0022
    Štourač Petr MD, PhD 1 2 Komenda Martin MSc, Dr 1 Harazim Hana MD 1 2 Kosinová Martina MD 2 Gregor Jakub MSc, PhD 1 Hůlek Richard BSc 1 Smékalová Olga MD 2 Křikava Ivo MD 2 Štoudek Roman MD 2 Dušek Ladislav MSc, Dr, PhD 1
    1 Institute of Biostatistics and Analyses Faculty of Medicine Masaryk University Brno Czech Republic 2 Department of Anesthesiology and Intensive Care Medicine, University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic Corresponding Author: Daniel Schwarz schwarz@iba.muni.cz 07 2013 08 07 2013 15 7 e135 01 03 2013 19 03 2013 05 04 2013 ©Daniel Schwarz, Petr Štourač, Martin Komenda, Hana Harazim, Martina Kosinová, Jakub Gregor, Richard Hůlek, Olga Smékalová, Ivo Křikava, Roman Štoudek, Ladislav Dušek. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 08.07.2013. 2013

    This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in the Journal of Medical Internet Research, is properly cited. The complete bibliographic information, a link to the original publication on http://www.jmir.org/, as well as this copyright and license information must be included.

    Background

    Medical Faculties Network (MEFANET) has established itself as the authority for setting standards for medical educators in the Czech Republic and Slovakia, 2 independent countries with similar languages that once comprised a federation and that still retain the same curricular structure for medical education. One of the basic goals of the network is to advance medical teaching and learning with the use of modern information and communication technologies.

    Objective

    We present the education portal AKUTNE.CZ as an important part of the MEFANET’s content. Our focus is primarily on simulation-based tools for teaching and learning acute medicine issues.

    Methods

    Three fundamental elements of the MEFANET e-publishing system are described: (1) medical disciplines linker, (2) authentication/authorization framework, and (3) multidimensional quality assessment. A new set of tools for technology-enhanced learning have been introduced recently: Sandbox (works in progress), WikiLectures (collaborative content authoring), Moodle-MEFANET (central learning management system), and Serious Games (virtual casuistics and interactive algorithms). The latest development in MEFANET is designed for indexing metadata about simulation-based learning objects, also known as electronic virtual patients or virtual clinical cases. The simulations assume the form of interactive algorithms for teaching and learning acute medicine. An anonymous questionnaire of 10 items was used to explore students’ attitudes and interests in using the interactive algorithms as part of their medical or health care studies. Data collection was conducted over 10 days in February 2013.

    Results

    In total, 25 interactive algorithms in the Czech and English languages have been developed and published on the AKUTNE.CZ education portal to allow the users to test and improve their knowledge and skills in the field of acute medicine. In the feedback survey, 62 participants completed the online questionnaire (13.5%) from the total 460 addressed. Positive attitudes toward the interactive algorithms outnumbered negative trends.

    Conclusions

    The peer-reviewed algorithms were used for conducting problem-based learning sessions in general medicine (first aid, anesthesiology and pain management, emergency medicine) and in nursing (emergency medicine for midwives, obstetric analgesia, and anesthesia for midwifes). The feedback from the survey suggests that the students found the interactive algorithms as effective learning tools, facilitating enhanced knowledge in the field of acute medicine. The interactive algorithms, as a software platform, are open to academic use worldwide. The existing algorithms, in the form of simulation-based learning objects, can be incorporated into any educational website (subject to the approval of the authors).

    medical education patient simulation algorithms students community networks problem-based learning serious games survey
    Introduction

    Medical education is constantly evolving by gradually, but significantly, shifting from traditional methods (eg, textbooks, lectures, bedside teaching) to a more comprehensive approach that also employs modern information and communication technology (ICT) tools (eg, e-learning, interactive algorithms, computer simulations, virtual patients). Such approaches have been demonstrated to enhance and improve the learning skills of medical students and residents in comparison to traditional methods [1-3]. Several ancillary factors in medicine and medical education have also contributed significantly to these trends; in particular, the rapid development of new technologies and the generally preferred shorter hospital stays, which reduces the student’s exposure to a given case or diagnosis. The economic efficiencies of Web-based education and traditional face-to-face education approaches were compared under randomized controlled trial conditions in Maloney et al [4] and it was shown that the Web-based education approach was clearly more efficient from the perspective of the education provider.

    Although most of the modern interactive tools are intended for extending and supplementing the traditional methods rather than replacing them, they have undoubtedly brought a number of advantages, such as equal and easy access for the students to all diagnoses, simulation of a variety of real-life situations, comprehensive interdisciplinary learning, and a higher level of comfort for hospitalized patients. Simulation-based learning also provides the unique opportunity of practicing knowledge application in a manner that mimics real-time patient care without posing a risk to the patient [5,6]. On the other hand, developing simulations and e-learning materials requires investment of the time of skilled professionals (eg, physicians, teachers, programmers); therefore, it is necessary to ensure that the time and resources expended is justified by the educational impact [7]. Furthermore, the developed tools are often accepted uncritically and with emphasis on technological sophistication at the expense of the underlying psychopedagogical theories [1].

    Improved efficiency in the development of digital teaching and learning materials, as well as their higher quality, can be achieved by sharing the educational content and by initiating collaborative multi-institutional authoring teams together with joint efforts in establishing the methods for quality evaluation. The management of multisource content among academic institutions brings the necessity of correct indexing, metadescription, and proper categorization [8], as well as reimbursement [9-11] for the created resources. The idea of the medical faculties in the Czech Republic and Slovakia sharing their educational digital contents surfaced in 2006 for the first time. Soon after, in 2007, all 7 Czech medical faculties as well as all 3 Slovak medical faculties formally joined the new network. In 2012, representatives of the Czech and Slovak health care institutions joined the Medical Faculties Network (MEFANET) education network. The MEFANET project [12] aims to develop cooperation among the medical faculties to further the education of medical and health care disciplines usin