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Introduction: Digital twins of patients are virtual models that can create a digital patient replica to test clinical interventions in silico without exposing real patients to risk. With the increasing availability of electronic health records and sensor-derived patient data, digital twins offer significant potential for applications in the healthcare sector. Methods: This article presents a scalable full-stack architecture for a patient simulation application driven by graph-based models. This patient simulation application enables medical practitioners and trainees to simulate the trajectory of critically ill patients with sepsis. Directed acyclic graphs are utilized to model the complex underlying causal pathways that focus on the physiological interactions and medication effects relevant to the first 6 h of critical illness. To realize the sepsis patient simulation at scale, we propose an application architecture with three core components, a cross-platform frontend application that clinicians and trainees use to run the simulation, a simulation engine hosted in the cloud on a serverless function that performs all of the computations, and a graph database that hosts the graph model utilized by the simulation engine to determine the progression of each simulation. Results: A short case study is presented to demonstrate the viability of the proposed simulation architecture. Discussion: The proposed patient simulation application could help train future generations of healthcare professionals and could be used to facilitate clinicians' bedside decision-making.

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BACKGROUND: Health care providers have a critical opportunity to mitigate the public health problem of suicide. Virtual patient simulations (VPS) allow providers to learn and practice evidence-based suicide prevention practices in a realistic and risk-free environment. The purpose of this study was to test whether receiving VPS training increases the likelihood that providers will engage in effective suicide safer care practices. METHODS: Behavioral health and non-behavioral health providers (N = 19) at a Federally Qualified Health Center who work with patients at risk for suicide received the VPS training on risk assessment, safety planning, and motivation to engage in treatment. Providers' electronic health records were compared 6 months pre- and post-VPS training on their engagement in suicide safer care practices of screening, assessment, safety planning, and adding suicide ideation to the problem list. RESULTS: Most behavioral health providers were already engaging in evidence-based suicide prevention care prior to the VPS training. Findings demonstrated the VPS training may impact the likelihood that non-behavioral health providers engage in suicide safer care practices. CONCLUSION: VPS training in evidence-based suicide prevention practices can optimize and elevate all health care providers' skills in suicide care regardless of role and responsibility, demonstrating the potential to directly impact patient outcomes.

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BACKGROUND: Despite guidelines recommending the use of glucagon-like peptide-1 receptor agonists (GLP-1 RAs) in certain patients with type 2 diabetes (T2D), they are not being prescribed for many of these patients. Web-based continuing medical education (CME) patient simulations have been used to identify clinicians' practice gaps and improve clinical decision-making as measured within a simulation, but the impact of this format on real-world treatment has not been researched. OBJECTIVE: This study aimed to evaluate the effect of a simulation-based CME intervention on real-world use of GLP-1 RAs by endocrinologists and primary care physicians. METHODS: Two evaluation phases of the CME simulation were conducted: phase I, the CME simulation phase, was a paired, pre-post study of 435 physician learners in the United States; and phase II, the real-world phase, was a retrospective, matched case-control study of 157 of the 435 physicians who had claims data available for the study period. RESULTS: Phase I CME results showed a 29 percentage point increase in correct decisions from pre- to postfeedback (178/435, 40.9% to 304/435, 69.9%; P<.001) in selecting treatment that addresses both glycemic control and cardiovascular event protection. Phase II results showed that 39 of 157 (24.8%) physicians in the intervention group increased use of GLP-1 RAs, compared to 20 of 157 (12.7%) in the comparison group. Being in the intervention group predicted GLP-1 RA use after education (odds ratio 4.49; 95% CI 1.45-13.97; P=.001). CONCLUSIONS: A web-based CME simulation focused on secondary prevention of cardiovascular events in a patient with T2D was associated with increased use of evidence-based treatment selection in the real world.

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The main goal of continuing medical education (CME) is to help healthcare providers (HCP) improve their knowledge and levels of competency with an ultimate enhancement of their performance in practice. Despite the long and well-intentional history of CME, the proof of success (based on improved clinical outcomes) is difficult to obtain objectively. In the past several years, the traditional CME world has been disrupted by replacing multiple-choice questions with virtual simulation. We utilised an innovative, next-generation virtual patient simulation (VPS) platform to develop objective measures to assess the success of educational activities that can be applied to the CME. This VPS platform was used at five distinct educational events designed to assess learners' knowledge and competency in the guideline-driven management of Type 2 diabetes, hyperlipidaemia, and hypertension. A total of 432 learners (medical doctors, nurse practitioners, and clinical pharmacists) participated in these educational events of whom 149 went through two consecutive cases with a similar clinical picture and educational goals. Their ability to achieve glycaemic, lipid, and blood pressure control improved significantly as they moved from the first to the second case. The participants improved their test performance in all categories - between 5 and 38%, achieving statistically significant increases in the many goals examined. In conclusion, this study employed the pioneering application of technology to produce, collect and analyse the VPS data to evaluate objectively educational activities. This VPS platform allows not only an objective assessment of the effectiveness of the CME activity but also provides timely and helpful feedback to both learners and providers of a given educational event.

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Background: Healthcare organizations are often committed to preventing suicide among their patients, but they can struggle to adequately train providers and implement strategies grounded in evidence-based suicide prevention practices. Virtual patient simulations (VPS) offer the opportunity for providers at healthcare organizations and educational institutions to learn suicide prevention strategies using a realistic and risk-free environment. The purpose of this study was to gather feedback from leaders in the healthcare field regarding the feasibility and acceptability of VPS for their organizations. Methods: Participants (N=9) included administrators, managers, and educators from a variety of health care settings. They were invited to independently test the VPS and participate in a subsequent focus group to provide feedback. Participants were asked about VPS acceptability, satisfaction, potential fit within the intended context, feasibility of delivery, motivation to use, and likelihood of adoption. Responses were audio recorded and transcribed for coding and thematic analysis. Results: Themes emerged regarding perceived benefits of the VPS, considerations related to cost, barriers to implementation, and suggestions for improvement. Participants reported VPS trainings were acceptable and feasible, filling an important gap in the field especially around suicide safety planning, particularly for newer clinicians and students in training. Participants felt that this type of virtual training was particularly feasible given the recent increase in need for online trainings. Suggested improvements included the need to normalize the trial-and-error nature of the VPS for trainees prior to the start of the training, and to consider shortening the duration of the simulation due to learners not being able to bill for time while training. Conclusions: VPS may help to fill an important training need in the field of suicide prevention. The training suite may be best suited for certain settings, such as educational institutions, and most useful for populations including students and new clinicians. VPS may be particularly feasible for organizations that already utilize remote options for work and training.

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Background: Moral sensitivity is the first step towards ethical decision-making. This sensitivity should form a basic attitude in healthcare team members, particularly nurses, toward providing effective and ethical care. This is highlighted in intensive care units (ICUs) where close attention should be paid to patient rights and moral or ethical decision-making.Objective: The present study aimed at determining and comparing the effect of written simulation and computer simulation of a virtual patient on the development of moral sensitivity of ICU nurses.Research design: Randomized controlled trial with one control arm and two experimental arms.Participants and content: This study involved 204 ICU nurses working in hospitals affiliated to Tehran University of Medical Sciences, Tehran, Iran, from 2019 to 2021 using a random allocation method. The participants were allocated to three groups comprising virtual patient computer simulation, written simulation, and the no simulation control group. After training based on a Patient Rights Charter, five scenarios, with themes reflecting the clauses of the Patient's Rights Charter, were written as a computer program and text for the computer simulation and written simulation groups, respectively. Finally, nurses' moral sensitivity was assessed using the Lützén moral sensitivity questionnaire as pre- and post-tests (immediately and 2 months after the intervention).Ethical considerations: Ethical permission was obtained for the study. All the participants signed the informed consent before the study onset.Results: The study results showed a significant difference in moral sensitivity among the three groups before the intervention (p = 0.003). Immediately after the intervention compared to pre-intervention, the three groups showed no significant differences in this regard (p = 0.056), however a significant difference among the three groups was found 2 months post-intervention (p < 0.001).

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BACKGROUND: Effective provider-patient communication is crucial to the delivery of high-quality care. Communication roadblock such as righting reflex is widely observed among providers and can lead to relational disengagement. In previous work, nurses felt ill-equipped to communicate effectively with HIV-positive patients to support medication adherence. Providing nurses with continuing education opportunities to improve their relational skills is a major target for optimizing the quality of care. Virtual patient simulation is one promising strategy that needs to be evaluated among graduate nurses. This study aimed to assess the acceptability of a virtual patient simulation to improve nurses' relational skills in a continuing education context. METHODS: We conducted a convergent mixed methods study by combining a quantitative pre-experimental, one-group post-test design and a qualitative exploratory study. We used convenience and snowball sampling approaches to select registered nurses (n = 49) working in Quebec, Canada. Participants completed an online sociodemographic questionnaire, consulted the automated virtual patient simulation (informed by motivational interviewing), and filled out an online post-test survey. Descriptive statistics (mean, SD, median, interquartile range) were used to present quantitative findings. From the 27 participants who completed the simulation and post-test survey, five participated in a focus group to explore their learning experience. The discussion transcript was subjected to thematic analysis. At the final stage of the study, we used a comparison strategy for the purpose of integrating the quantitative and qualitative results. RESULTS: Nurses perceived the simulation to be highly acceptable. They rated the global system quality and the technology acceptance with high scores. They reported having enjoyed the simulation and recommended other providers use it. Four qualitative themes were identified: motivations to engage in the simulation-based research; learning in a realistic, immersive, and non-judgmental environment; perceived utility of the simulation; and perceived difficulty in engaging in the simulation-based research. CONCLUSIONS: The simulation contributed to knowledge and skills development on motivational interviewing and enhanced nurses' self-confidence in applying relational skills. Simulation holds the potential to change practice, as nurses become more self-reflective and aware of the impact of their relational skills on patient care. TRIAL REGISTRATION: ISRCTN18243005 , retrospectively registered on July 3 2020.

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As any other aspect of contemporary life, an old and established field of CME undergoes a transformation into a "digital age." Virtual patient simulation (VPS) has shown to be an interactive and efficient way of engaging healthcare professionals (HCP) in continuing medical education. VPS can identify gaps in knowledge and improve competence, using engaging, online tools. The Edocate VPS Platform has been developed by a group of physicians, education experts, and computer specialists. In this communication, we report the experience of several hundreds of HCP using the Edocate VPS application in the fields of type 2 diabetes (T2DM) and hyperlipidemia. The Edocate VPS application, displaying both simple and complex clinical situations, was presented to an international group of HCPs who had the task to perform physical exams, order lab and imaging tests, update the medical record with the right diagnoses, prescribe medications, and perform long-term follow-up through multiple visits. The HCPs received personalized, guideline-based, feedback on their actions. The analytical capabilities of the Edocate VPS platform run very deep and allow in-depth analysis of learners' competence in achieving the best outcomes, while teaching to apply a personalized approach, avoiding side effects of medications, and providing instantaneous access to the most current references in the field. The data collected from the program has shown significant gaps in knowledge and adherence to guidelines in the areas of management of T2DM and hyperlipidemia. Only about 50% of all participants achieved guideline-compatible glycemic control - namely HbA1c below 7%. Furthermore, only 41% of practicing physicians and 23% of family medicine residents achieved levels of LDL below 70 mg/dl in their virtual patients. In conclusion, the data presented in this communication strongly suggests that this novel simulation platform can enable medical organizations to create immersive VPS cases for their primary educational and CME efforts.

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Results of a CME-certified activity completed by a total of 986 cardiologists and 783 haematologists-oncologists (haem-oncs) from around the world were examined to determine whether virtual patient simulation could improve decision-making and performance within the simulation related to patient evaluation, tailoring anticoagulant therapy, and patient management to improve adherence using patient-centred care strategies. Results showed a significant overall impact of education from pre- to post-clinical guidance (CG) on correct decisions made in both cases for cardiologists, with a relative improvement of 22% for Case 1 (45% pre- to 55% post-CG, n = 475, t(474) = 14.12, P<.001, Cohen's d =.46) and 19% for Case 2 (62% pre- to 74% post-CG, n = 245, t(244) = 11.95, P<.001, Cohen's d =.59). Impact also was seen for haem-oncs, with a relative improvement of 27% for Case 1 (45% pre- to 57% post-CG, n = 280, t(279) = 11.91, P <.001, Cohen's d =.60) and 19% for Case 2 (63% pre- to 75% post-CG, n = 147, t(146) = 9.52, P <.001, Cohen's d =.58). Virtual patient simulation improved cardiologists' and haem-oncs management of patients with pulmonary embolism in a simulated environment.

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In this article, technologies that have been widely adopted and used in the field of allied health education in recent years are identified and introduced. These technologies may be distinguished based on education content and approach into the following three categories: online-offline digital education, which uses massive open online courses, CD-ROM, and similar learning tools; mobile learning, which uses mobile phones, tablets, and other devices to connect to the Internet of things; and digital simulation education, which uses virtual reality, virtual patient simulation, serious gaming, and gamification. Preliminary positive findings regarding the effectiveness of using the above technologies have been reported in the literature. Therefore, to better understand the impact of new technology, it is recommended that relevant medical/nursing educators should continue introducing practical courses to evaluate their impact on learning. However, funding limitations and the declining birthrate / population aging are two key threats to education that remain to be effectively addressed and overcome.

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BACKGROUND: Virtual reality (VR) is increasingly used as simulation technology in emergency medicine education and training, in particular for training nontechnical skills. Experimental studies comparing teaching and learning in VR with traditional training media often demonstrate the equivalence or even superiority regarding particular variables of learning or training effectiveness. OBJECTIVE: In the EPICSAVE (Enhanced Paramedic Vocational Training with Serious Games and Virtual Environments) project, a highly immersive room-scaled multi-user 3-dimensional VR simulation environment was developed. In this feasibility study, we wanted to gain initial insights into the training effectiveness and media use factors influencing learning and training in VR. METHODS: The virtual emergency scenario was anaphylaxis grade III with shock, swelling of the upper and lower respiratory tract, as well as skin symptoms in a 5-year-old girl (virtual patient) visiting an indoor family amusement park with her grandfather (virtual agent). A cross-sectional, one-group pretest and posttest design was used to evaluate the training effectiveness and quality of the training execution. The sample included 18 active emergency physicians. RESULTS: The 18 participants rated the VR simulation training positive in terms of training effectiveness and quality of the training execution. A strong, significant correlation (r=.53, P=.01) between experiencing presence and assessing training effectiveness was observed. Perceived limitations in usability and a relatively high extraneous cognitive load reduced this positive effect. CONCLUSIONS: The training within the virtual simulation environment was rated as an effective educational approach. Specific media use factors appear to modulate training effectiveness (ie, improvement through "experience of presence" or reduction through perceived limitations in usability). These factors should be specific targets in the further development of this VR simulation training.

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INTRODUCTION: Standards 2016 state students must be "practice-ready" upon graduation and utilizing health information technology is one skill needed to ensure students are practice-ready. Incorporating academic electronic health records (EHRs) into the didactic pharmacy curriculum is one tool for preparing students to be practice-ready, but it is unclear if this technology is used to facilitate assessment of students' patient care skills. METHODS: A 35-question electronic survey was distributed to each school/college of pharmacy (S/COP) with questions focused on general use of EHRs and characterizing EHRs as a tool to assess students' patient care skills in the didactic curriculum. Aggregate, anonymous data was reported and analyzed using descriptive statistics. RESULTS: Fifty-nine survey responses were suitable for inclusion in the analysis (43.8% response rate). Of those, 37 S/COP (62.7%) used an EHR in the didactic curriculum. Frequently performed and assessed EHR functions were collecting information and documentation, and EHRs were most commonly utilized to assess students' abilities to perform the collect (96.9%) and assess (93.8%) steps of the Pharmacists' Patient Care Process. EHRs were perceived to be most effective in assessing the following Center for the Advancement of Pharmacy Education Educational Outcomes: patient-centered care (93.9%), problem solving (83.9%), and learner (80.6%). CONCLUSIONS: Optimizing the use of EHRs in S/COP is critical. Determining which outcomes are best suited to be assessed utilizing this technology and the optimal method to do so is an appropriate next step.

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Aims: The relative impact of left ventricular (LV) diastolic dysfunction (LVDD) and impaired left atrial (LA) function on cardiovascular haemodynamics in heart failure with preserved ejection fraction (HFpEF) is largely unknown. We performed virtual patient simulations to elucidate the relative effects of these factors on haemodynamics at rest and during exercise. Methods and results: The CircAdapt cardiovascular system model was used to simulate cardiac haemodynamics in wide ranges of impaired LV relaxation function, increased LV passive stiffness, and impaired LA function. Simulations showed that LV ejection fraction (LVEF) was preserved (>50%), despite these changes in LV and LA function. Impairment of LV relaxation function decreased E/A ratio and mildly increased LV filling pressure at rest. Increased LV passive stiffness resulted in increased E/A ratio, LA dilation and markedly elevated LV filling pressure. Impairment of LA function increased E/A ratio and LV filling pressure, explaining inconsistent grading of LVDD using echocardiographic indices. Exercise simulations showed that increased LV passive stiffness exerts a stronger exercise-limiting effect than impaired LV relaxation function does, especially with impaired LA function. Conclusion: The CircAdapt model enabled realistic simulation of virtual HFpEF patients, covering a wide spectrum of LVDD and related limitations of cardiac exercise performance, all with preserved resting LVEF. Simulations suggest that increased LV passive stiffness, more than impaired relaxation function, reduces exercise tolerance, especially when LA function is impaired. In future studies, the CircAdapt model can serve as a valuable platform for patient-specific simulations to identify the disease substrate(s) underlying the individual HFpEF patient's cardiovascular phenotype.

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BACKGROUND: Improving the identification of and intervention with patients at risk for suicide requires innovative training techniques that safely and effectively teach or enhance practitioners' skills. Virtual patient simulations (VPS) can be particularly effective for this purpose because they allow for repetition in skill building as well as a safe space to practice difficult interactions with patients. The purpose of this study was to assess the feasibility and acceptability of a novel VPS that trains practitioners in suicide risk assessment, as well as to examine pre-post changes in suicide-related knowledge through a pilot of the VPS training. METHODS: Practitioners (n=20) were recruited from a Federally Qualified Health Center in the northeastern United States to test the feasibility and acceptability of a VPS suicide risk assessment training. A paired samples t-test was conducted to compare mean differences in practitioners' suicide risk assessment knowledge scores from pre- to post-training, on a scale of 0 to 10. RESULTS: The VPS was feasible to implement, with 18 of 20 participants using the VPS for an average of 21 to 95 minutes, and was acceptable to participants, with an average satisfaction rating of 5.82 out of 7. Participants' knowledge scores improved significantly by an average of 1.86 points from pre- to post-training. CONCLUSIONS: The VPS was feasible and acceptable to this sample of practitioners and significantly increased knowledge from pre- to post-training. As such, VPS holds promise as a technique to develop skills in suicide risk assessment.

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INTRODUCTION: Non-technical skills (NTS) are fundamental requirements for health professional graduates for safe and competent practice. Technology enhanced simulation, including virtual patients (VPs), is suggested to be effective in developing NTS. PURPOSE: The purpose of this paper is to explore what participants learnt about NTS following interactions with the VPs in the case study. DESIGN: Case study methodology was used to explore learning by undergraduate nursing students related to NTS following interactions with VPs. First- (n = 40) and third-year (n = 31) undergraduate nursing students from two universities in Victoria, Australia agreed to participate in focus groups and interviews. These were audio-recorded, transcribed and then underwent framework analysis. A priori codes in the framework used NTS categories including communication, situation awareness, teamwork, decision-making skills, leadership, managing stress and coping with fatigue. FINDINGS: Overall, students in both years and universities reported that interactions with VPs developed knowledge and skills across all categories of NTS to varying degrees. Third-year students suggested that interactions with VPs enabled development of knowledge and skills, as well as practise of selected NTS in the clinical setting. CONCLUSION: Interactions with VPs across the curriculum may assist undergraduate nursing students in developing knowledge, skill and practice of NTS categories including communication, situation awareness, teamwork, decision-making skills and duty, advocacy and empathy.

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INTRODUCTION: Electronic health records (EHRs) are used extensively throughout health systems; this indicates a need for pharmacy student competencies prior to pharmacy practice experiences. The objective was to determine current utility, perceived benefit, and future plans for EHR use in the didactic curriculum of doctor of pharmacy programs in the United States. METHODS: An electronic survey was distributed to members of two special interest groups through the American Association of Colleges of Pharmacy. Content areas in the 14-question survey included current utilization of EHRs in the didactic curriculum, perceived benefit for preparing students for pharmacy practice experiences, and future plans for implementing or improving EHR use. RESULTS: A total of 59 (7.7%) individuals responded to the survey, representing 43 out of 133 schools (32%). Of the respondents currently using EHRs (37%), more than 60% have been using an EHR in the classroom for two years or less while 18.2% reported five or more years of experience. The most common application of EHRs was for clinical cases (77%) followed by pharmaceutical care lab courses (59%), other uses in pharmacotherapeutics (27%), and interprofessional education (23%). Of those not currently using EHRs (63%), the vast majority (84%) plan to integrate EHRs into didactic coursework within the next two years. CONCLUSIONS: EHRs appear to be used by many colleges of pharmacy in courses where clinical cases are being discussed. Further research into the value of EHR usage at earlier stages of professional programs, including within skills labs, objective structured clinical examinations, and other pharmacy coursework, may be helpful given increasing EHR use in healthcare settings.

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