As complexity in medicine increases and there is a need to improve education and reduce the number errors, simulation is being used to provide experiential learning in a risk-free environment. The typical approach is to use simulation wards with mannequin-based training to enhance patient safety through routine practice in high realism scenarios to obtain expert performance. Now this approach is being scaled up at large institutions such as MGH with the Learning Lab Simulation Center. In parallel a range of new game technologies have been developed that simplify the creation new applications at a lower cost. These technologies are beginning to be used in the medical domain. This include immersive environments (e.g. Second Life), multi-platform game development environments (e.g. Unity 3D) or new game devices (e.g. MS Kinect). We have created eAdventure an open source game platform that allows for the creation and maintenance of adventure games and simulations without any programming. We are interested in how this low-cost game technology and especially story-based game-like simulations can be used to improve the acquisition of procedural knowledge in medicine. Our current research focus is on how game-like simulations can be applied to represent, standardize and/or improve medical procedures (including the representation of the common errors or the capture of team tacit knowledge). We study how to use the description of medical procedures combined with representative teaching cases to produce game-like simulations that provide students with the opportunity to enhance knowledge and skill acquisition in a safe environment. We have applied this approach to create several simulations in the medical domain (e.g. teaching basic first aid procedures to high-school students, preparing for the first visit to the operating room, representation of the supra-hospital transplant procedures in Spain, improving application of the WHO Surgical Check-list). We are also researching how learning analytics can be applied to the evaluation of simulations.

1. Baltasar Fernandez-Manjon
balta@fdi.ucm.es
@BaltaFM
Developing low-cost game-like
software simulations for the medical
domain
06/08/2013, Institute of Medical Engineering & Science,
Harvard -Massachusetts Institute of Technology

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Context: about me
 Baltasar Fernández Manjón
 Catedrático de Universidad, Facultad de
Informática
 Universidad Complutense de Madrid
 Director of the e-UCM e-learning research group
 http://www.e-ucm.es/people/balta
 E-mail: balta@fdi.ucm.es
 Now visiting scientist at LCS-MGH
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Context: e-UCM group
 e-UCM research group
 Learning tecnologies
 About 15 researcher
 Serious games
 European projects
 Application to the medical
domain
 www.e-ucm.es
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Medicine: new requirements
 Medicine needs continous education
 Reduce the number of errors
 Knowledge duplicating every 5 years
 Time-limited certification
 Traditionally master-apprentice
 Now moving to mannenquin-based simulation
 Deliverate practice (Ander Ericsson)
 Clear learning objective
 Adequate and increasing level of difficulty
 Repetitive practice with informative feedback

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MGH Learning Laboratory
 MGH has created a Learning Lab to include
simulation in the MGH learning flow
 Regular opportunities for dedicated
clinical practice and feedback in a risk-
free environment
 Fully integrate clinical simulation as a quality and safety
tool in health care practice
 Enhance patient safety through routine practice for
expert performance
 Residents and medical personnel
http://www.massgeneral.org/learninglab/

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MGH Learning Laboratory

7. 6/46Alinier G. A typology of educationally focused medical simulation tools. Medical teacher.
2007;29(8):e243–50. Available at: http://www.ncbi.nlm.nih.gov/pubmed/18236268.

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Simulations: fligh simulator

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Serious games: A Learning Technology on the Rise
 Serious Games
 Game designed for learning or training
 Game-based learning, educational
simulations, etc
 It is being used in different contexts
 Military (America´s Army, www.americasarmy.com)
 Medicine (Re-mission, www.re-mission.net)
 Some of the advantages
 “Learning by doing” principles
 Enhance students’ motivations
 Involve students in their own learning

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Use of games in residency programs in USA (2010)
Akl EA, Gunukula S, Mustafa R, et al. Support for and aspects of use of educational games in family
medicine and internal medicine residency programs in the US: a survey. BMC medical education.
2010;10:26.

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e Trainer SGI Coventry (de Freitas) Resuscitation 81 (2010) 1175–1179

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Different types of simulations
Arnold, J. J., Johnson, L. M., Tucker, S. J., Chesak, S. S., & Dierkhising, R.
A. (2013). Comparison of Three Simulation-Based Teaching
Methodologies for Emergency Response. Clinical Simulation in Nursing,
9(3), e85–e93.
to compare the effects of 3 simulation methodologies (low-fidelity, computer-
based, and full-scale) on the outcomes of emergency response knowledge,
confidence, satisfaction and self-confidence with learning, and performance.
the statistical findings did not support the hypothesis that RNs who
receive full-scale simulation training will score higher in knowledge,
confidence, and performance than those receiving computer-based
simulation or low-fidelity simulation
Note: only 28 participants

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Serious Games
 Characteristics of games
 Backstory or Story line
 Rules and game mechanics
 Graphical enviroment
 Interactivity and reactivity
 Challenge /competition
 Flow – user engaged, focussed, committed
 Clear goals, attainable challenge, feedback
 Gamification
 Use of game characteristics to increase user
engagement

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Serious Games: Open Issues
 At the DESIGN Stage
 Balance between entertainment and
educational value
 Involve instructors in the process to
guarantee a high educational value!
 Choose an appropriate game genre

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Serious Games: Open Issues
 At the PRODUCTION Stage
 The Cost! Developing a whole game is
expensive
 usually between 5k and 5M $
 Reusability is SCARCE
 games as closed products

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Serious games: Open Issues
 At the DEPLOYMENT stage
 Games are an extra burden for the instructor
Games usually need to be installed
Games usually need to be handed out in CDs or
DVDs
Games usually require controlled environments
Games usually demand up-to-date computers
Educators do not always have the preparation to
install and execute the games
There is not always time in the curricula to arrange
play sessions

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Serious Games: Open Issues
 How do instructors evaluate students’
performance?
Plan and elaborate de-briefing sessions, post-
tests, debates, etc.
 Very difficult to prove the effectivity of the serious
games
 Even if some correlation has been found between using
games and fewer errors in practice (e.g. laparoscopic
surgery)

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eAdventure
 eAdventure platform development
 Simplify the creation of educational games and
simulations
 Educationcal characteristics (evaluation,
accesibility, deployment, etc)
 Free, open source
 http://e-adventure.e-ucm.es
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Two applications: an editor to create the
games, and an engine, to run the games
eAventure: A tool to simplify the creation and
maintenance of educational games

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eAdventure’s goals
• Simplify the creation of games
• Reduce of the cost of the
resources needed for creating a
game
• Simplify the use and deployment
of games
Cost reduction

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eAdventure goals
• Involve teaching experts in
the creation of the games
• Include educational
characteristics
Increase the
educational value

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eAdventure
 Increase the educational value, reduce the
development costs
 Game genre: Point-and-click 2D adventure games (like
Myst™ or Monkey Island™)
High educational value
Promotes reflection instead of action
Resolution of complex puzzles
The story is important!

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eAdventure
 Increase the educational value, reduce the
development costs
 Development methodology that involves instructors
Instructors add educational value to the products
Increases game acceptance by the instructors
A good story never becomes a bad game

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<e-Adventure>
 Increase the educational value, reduce the development
costs
 Game patterns (from experience)
Third-person games => Concepts. Subjects like History
First-person photo-based games => Procedural
knowledge. Contexts like medicine, engineering, etc.
Third-person games

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Educational Game Development Methodology

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eAdventure in Medical education:´First attemps
 Central Venous Catheter (CVC)
 MGH
 Simulation to teach the whole procedure (over 90
steps)
 Problem:
Key and high risk procedure
Very expensive and limited time
Professional time
Lab equipment
 Ensure that students known the procedure before
doing a practical exam
 Proof of concept
Work by Carl Blesius, Paul Courier, Pablo Moreno, Baltasar Fdez

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eAdventure in Medical education: evaluation of knowledge
 HazMat Training
 Massachusetts General Hospital
 Staff certification for handling Hazardous Material
(HazMat) shipments
 Problem
Moving face-to-face training to online training
The training includes a game packing evaluation
 Deployed from 2009 to 2012
Reduce certification time & cost
The game is part of the final grade
Done by Carl Blesius, Pablo Moreno

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eAdventure in Medical education: better formalization of knowledge
 Transplants: Evaluation, distribution, and
logistics of organ donation
 National Transplant Organization (Spain)
 Training new staff (management and clinical)
 Problem: pre-existing situation
Tacit knowledge, non-formalized procedures
Not a predefined set of teaching cases
 Other outcomes of the game creation
Better formalization of procedures that can be
tested and refined by the medical personnel
Creation of 10 representative teaching cases
Done by Blanca Borro, Baltasar Fernandez, ONT

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a) Main scene corresponding to a real picture of ONT
central office b) Action of evaluating the organs.
c) Documentation available for the player. The player
is opening the zone distribution document.
d) Character of the simulation representing the
liver transplant coordinator.

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eAdventure in Medical Education
 CPR game
 Centro de Tecnologias Educativas de Aragon (Spain)
 Identify a cardiac arrest and teach how to do a
cardiopulmonary resuscitation
 Oriented to middle and high school students
 Includes how to use a automatic defribilator
 Tested in schools with 340 students
Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar Marco J, Suberviola González JF,
Giménez Valverde A. Video-game instruction in basic life support maneuvers. Emergencias.
2012;24:433-7.
Available at http://first-aid-game.e-ucm.es

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Evaluation
Simultaneous sessions with same time
One with game
Other with 2 emergency medical doctors

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CPR game Results
Pre-test and post-test for evaluating knowlege
game

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Now: Surgical Safety Checklist

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Surgical Safety Checklist

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Surgical Safety Checklist

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Improving evaluation: eAdventure + Learning Analytics
Game Engine
Communication
API
{
type: 'input',
timeStamp: some_timestamp,
device: 'some_device',
action: 'some_action',
target: 'target_id',
data: { key1: value, ...}
}
{
type: 'logic',
timeStamp: some_timestamp,
event: 'some_event',
target: 'some_id',
data: { key1: value, ...}
}
LA Database

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 Raw data can feed several systems
 An LRS
 A Learning Analytics System
eAdventure + Learning Analytics with xAPI
Raw data
LRS
Learning
Analytics
System
Statements
Analyzer
Statements
Analyzer
EXPERIENCE
API
EXPERIENCE
API

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Other experiences with xAPI
 Laboratory of Computer Science MGH
 Integration medical maniquin
simulation data in a LMS

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Conclusions
 Many opportunities of serious games in
the medical domain
 Need to do more evaluation of the effect
of the serious game application in real
settings
 Cost and integration in the learning flow
are identified issues
 New oportunities with Learning Analytics
and new e-learning specifications
 Experience API (xAPI)

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References
•eAdventure. http://e-adventure.e-ucm.es/
•MGH Learning Lab. http://www.massgeneral.org/learninglab/
•First Aid Game. http://first-aid-game.e-ucm.es/
• Marchiori EJ, Ferrer G, Fernández-Manjón B, Povar Marco J, Suberviola González JF,
Giménez Valverde A. Video-game instruction in basic life support maneuvers. Emergencias.
2012;24:433-7
•Pablo Moreno-Ger, Javier Torrente, Julián Bustamante, Carmen Fernández-Galaz, Baltasar
Fernández-Manjón, María Dolores Comas-Rengifo (2010). Application of a low-cost web-based
simulation to improve students’ practical skills in medical education. International Journal of
Medical Informatics 79(6), 459-467 (doi:10.1016/j.ijmedinf.2010.01.017).
•Brian Johnston, Liz Boyle, Ewan MacArthur, Baltasar Fernández-Manjón (2013). The role of
technology and digital gaming in nurse education. Nursing Standard, Vol 27, No 28, pp 35-38,
March
•Ángel del Blanco, Baltasar Fernández-Manjón, Pedro Ruiz, Manuel Giner (2013). Using
videogames facilitates the first visit to the operating theatre. Medical Education. Vol 47, Issue
5, pp. 519-520 (short contribution to the really good stuff section).
•Borro-Escribano B., Martínez-Alpuente I., del Blanco A., Torrente J., Fernández-Manjón B.,
Matesanz R. (in press) Application of Game-Like Simulations in the Spanish National
Transplant Organization. Transplantation Proceedings Journal.