Technical Infrastructure

Guiding questions:

What are the technical requirements for a successful integration of VPs in the curriculum?
What are the benefits of connecting VPs with other e-learning tools?
How to make the technical costs of VPs manageable?

VPs require a technical infrastructure to function. Most of the currently available VPs are accessed using a standard web browser. This does not require much configuration by the learner. However, it is crucial that the VP server is available at all times [Huwendiek 2013]. This means there should be a technical maintenance team employed with a quick response in case problems occur and a help desk for questions. Unfortunately, services like that require substantial and stable funding [Berman 2011, Huwendiek 2008, Radon 2011].

It has been observed that learners tend to complete their VP assignments shortly before the deadlines [Hege 2007]. For instance, Hirumi et al reported 70% of students worked on VPs in the last two days before the task was due [Hirumi 2016]. This uneven distribution of workload may influence the performance of the IT system or even lead to system failure. There are two potential solutions to this problem. One is to divide VP tasks in smaller assignments which are space activated [Hege 2016]. The second is to provide a technical infrastructure that, instead of using one central server, is distributed on several smaller computers forming a cloud of smaller servers that could be turned on or off depending on the number of students . Such solutions are able to endure even very high loads as in MOOC courses [Kononowicz 2015].

Another technical aspect expected by students is the usability of the VPs. The navigation should be intuitive and the graphical layout should help to focus on the tasks in the VP assignment [Boeker 2006]. Issues with user-friendliness can be avoided to a certain degree by constantly paying attention to the stakeholder perspective. This can be achieved by frequent needs assessments, following usability guidelines [Kononowicz 2017] and principles of multimedia learning [Mayer 2010], involving students and teachers in frequent user experience testing [Nunnally 2016] and providing technical help and instructions to students while learning [Nagji 2020].

VPs should not be isolated from other e-learning tools the students use. For instance, it is possible to use one central login/password to access VPs and the learning management system (e.g. Moodle). Next, links to VPs could be part of the learning units in regular courses taught at the university. Furthermore, It is possible to make automatic transfers of scores collected by students in assignments between systems. Another option is that certificates from completed VPs could be stored in e-Portfolio systems. To achieve software integration, there are technical specifications (like Shibboleth, LTI, xAPI) [Kononowicz 2017] implemented by VP system developers and communities (like MedBiquitous) that work to establish or extend data exchange standards in medical education. To access the iCoViP collection check whether your University is part of the EduGain program (many European universities are) to enable your students to login using their standard University credentials. Some of the iCoViP partners add links to iCoViP VPs into their learning management system Moodle using the External Tool function (LTI) which saves a separate login and password as well.

Finally, to make the VPs affordable and in the long term sustainable, it is recommended to share costs by joining consortia of several institutions with one technical infrastructure [Berman 2011]. This decreases the costs substantially. Several national and international projects demonstrated that it is possible – like the CLIPP project [Berman 2009], or MEFANET [Majernik 2016].

Recommendations:
– Make sure you have a technical help desk that reacts in case of disruption in the system operation and supports the students and teachers when questions arise.
– Save students the burden of generating another account to access their VPs by using integration technologies that enable login using their University credentials.
– Pay attention to usability, as it is an important factor in acceptance of VPs in curriculum that requires frequent evaluation and refinements.

Phase of the curriculum	4th year of medical school
Goal in the curriculum	The iCoViP collection was implemented to practice selected VPs in the subject of Occupational Medicine (a voluntary subject in the University of Zaragoza in the 4th year of medical school).
Effective use of resources	The collection was used asynchronously so it was not necessary to have a computer infrastructure or a specific room and all students in Spain have laptops or access to the medical school computers. However, issue of updating content not yet solved.
VP alignment	The collection is used while students are doing their clinical placements having a teacher revising the responses and explaining to students most frequent mistakes.
Prioritization/relevance	For Occupational Medicine, the use of the iCoViP collection was a mandatory assignment needed to pass, but did not add points to the final grade.
Relation to other learning activities	None
Time allocation	One week was given to complete the assignment but more time was available for those who wanted to do the activity remote from home.
Group allocation	Students worked alone at home, when the educator discussed the solution of the VP, it was allocated in class (face-to-face or online).
Presence mode	Asynchronous
Technical Integration	It was integrated into Moodle.
VP use orientation/training	VPs were related to a specialty of medicine, but were randomly assigned to students regardless of where in the specialty they were rotating at the time.
Technical infrastructure	We used the technical infrastructure of the iCoViP project without any additions at the University of Zaragoza.
Learning activities around VPs	The teacher explained each VP and how to resolve them after getting the responses of all the students.
Assessment	Students had to complete the VPs, but there was no grade at the end. Only credit (pass/fail).
Quality assurance, maintenance, and sustainability	Frequent revision of the VPs by medical doctors.

Phase of the curriculum	Year 3 and 4 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning including identifying relevant findings, developing differential diagnoses, deciding about a final diagnosis, ordering tests to rule out / confirm differentials, and suggesting treatment options.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs
VP alignment	VPs were part of the modules (e.g. Abdomen, cardiovascular system, pulmonary system, etc.) in year 3 and 4 of medical school and aligned with the objectives of these modules based on key symptoms. In addition a pool of 41 VPs was available for deliberate practice across key symptoms and diagnoses.
Time allocation	5 VPs / module
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	No specific familiarization, but general introduction at the beginning of year 3.
Learning activities around VPs	Depending on the modules other learning activities were embedded.
Assessment	The topics of the VPs were part of modules assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Year 1 and 2 of medical school
Goal in the curriculum	Students learn basic steps of clinical reasoning such as identifying & prioritizing findings and composing a summary statement. They also can follow the reasoning process of the VP author concerning differential diagnoses, ordered tests, and treatments.
Effective use of resources	Course tutors needed time to familiarize themselves with the VPs and time had to be planned during the synchronous meetings to discuss the VPs.
VP alignment	VPs were part of the longitudinal clinical course and aligned with the other modules in year 1 and 2 (In case of Augsburg this was Contact, Movement, and equilibrium). We aligned the key symptoms of the VPs with these modules, so that students worked in parallel on these VPs and the corresponding module.
Time allocation	15 VPs over two years / 5 VPs per module.
Group allocation	Students could choose whether to work in groups or individually.
Presence mode	Students could decide when and where to work on the VPs during the period of the module.
Technical Integration	VPs were integrated into the school's learning management system Moodle via a SingleSignOn interface.
VP use orientation/training	At the beginning of year 1 students were introduced into clinical reasoning and how they can train this ability with VPs.
Learning activities around VPs	Depending on the key symptoms during the longitudinal clinical course other learning activities were embedded.
Assessment	The topics of the VPs were part of the clinical longitudinal course assessment.
Quality assurance, maintenance, and sustainability	We used the built-in feedback functionality to receive qualitative feedback from students and VPs were part of the regular evaluation activities of the medical school.

Phase of the curriculum	Basic sciences/pre-clinical years: - At Jagiellonian University Medical College in Kraków we have integrated it in the “Introduction to Clinical Sciences” course in 2nd year of medicine. - At University of Porto in the “Propedeutics/Semiology” course in the 3rd year of medicine.
Goal in the curriculum	- To provide the students with an opportunity to challenge their knowledge at home in between classes with an interactive, clinical-oriented task. - To support learning by linking basic science knowledge with clinical reasoning. Students had the opportunity to practice on undiagnosed cases the skill of differentiating common symptoms, such as dyspnea, abdominal pain, headache.
Effective use of resources	Use of iCoViP VPs in native language of the students. No extra cost needed.
VP alignment	- In Kraków we have selected a few VPs (seven) with common diseases (e.g. pneumonia, pancreatitis, pulmonary embolism) with common symptoms. - In Porto, VPs are chosen according to the common symptoms to promote clinical reasoning.
Prioritization/relevance	- In Kraków the completion of all VPs is mandatory. - In Porto, VPs are introduced on a voluntary basis and are available on demand.
Relation to other learning activities	We used the time students had at home between seminars (Kraków: between on-campus based PBL sessions). VPs were spaced-activated (a new VP appeared biweekly synchronized with changing topics of the PBL seminars that focus on different leading symptoms).
Time allocation	Around 30 minutes biweekly, repeated 7 times in a semester.
Group allocation	Students worked alone at home to reflect but could consult the VPs with their peers or instructors in small groups of the face-to-face PBL seminars.
Presence mode	Students worked on the VPs asynchronously and self-directed at home to have time to reflect and consult textbooks.
Technical Integration	VPs were integrated with a course to which all students were enrolled on the official university learning management system Moodle using Learning Tools Interoperability (LTI) interface.
VP use orientation/training	Students were provided with an introductory email with instructions and had additionally the opportunity to technically practice using CASUS in a parallel “Telemedicine” (Medical informatics) course. Instructors received test-codes to practice the VPs at home.
Technical infrastructure	Students used their own computers from home. An email address was provided to a person responsible for technical support.
Learning activities around VPs	Students were asked to complete concept maps for all VPs they solve. Moreover, in Kraków students were provided with links to additional online articles to help them with topics difficult at this stage of education.
Assessment	Students were asked to complete the cases prior to the end of the term. They were not given grades for the activity - just credit. Their answers were randomly inspected to see common mistakes and provide general feedback to all students.
Quality assurance, maintenance, and sustainability	We checked the diagnostic accuracy of individual cases (and detected one case with imprecise diagnosis). Students evaluated the course using the iCoViP case collection evaluation questionnaire.

Technical Infrastructure

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