Program simulates on-the-job education and clinical support for HIV doctors

Clinics in African hotspots will use system

A new electronic, interactive education system provides training and clinical management to clinicians in sub-Saharan Africa and other areas where antiretroviral drugs are now available, but the medical infrastructure has made less progress.

Training systems are needed in sub-Saharan Africa because the PEPFAR, the Global Fund and the Gates Foundation have been good about funding drugs, but have not prioritized funding HIV clinical training in that region, says John Bartlett, MD, chief of the Division of Infectious Diseases at The Johns Hopkins University School of Medicine in Baltimore, MD. Bartlett is also an editorial advisory board member of AIDS Alert.

The computer-based system, named after its development company TheraSim, of Durham, NC, is also available to HIV providers around the world through a three-hour continuing medical education course on Medscape, says Jonathan Estes, vice president for global health at TheraSim.

The HIV/AIDS content was developed by Douglas Blevins, MD, medical director of TheraSim, Bartlett and others.

"Dr. Bartlett wrote the series of cases that TheraSim generates," Estes says. "He's the spearhead behind this content and his book on HIV/AIDS is embedded into this system."

Four-year-old TheraSim has developed electronic training for other disease disorders as well, Estes notes.

"I think what [TheraSim's system] represents is a combination of the problem we have with manpower in training and the lack of funding for training and the opportunity to use new technology," Bartlett says. "It's a really good program for what it attempts to do, and it comes as close to teaching and evaluating clinical competence as anything I've seen."

It's important for HIV clinicians around the world to have access to electronic training because it's very difficult for people in such a fast-moving field to have mentors when they need them, Blevins says.

The ideal situation is to have an HIV provider with experience working in a sub-Saharan country where he or she can assist new HIV clinicians who are not as familiar with disease and treatment, Blevins says.

"But that's pretty much impossible," Blevins says.

"We all need someone to run cases by to help us improve our care, rather than to just read medical literature," Blevins adds. "Getting advice from a peer always is important, and we feel the TheraSim system is one of the approaches that people can use to obtain this advice."

The interactive system provides initial HIV/AIDS training through 20 competencies in which 60 cases are available for review and study, Estes says.

"If someone is very knowledgeable they could go through the 20 cases within 10 hours," Estes says. "If they're really new and have little experience, it could take as long as 20 hours."

When a clinician sits down to take the course, he or she is shown a case study that includes still pictures of a patient, X-rays, lab work, medical histories, interview answers, and any other pertinent information for that particular competency. The cases are based on real people, and the clinician is asked to make a diagnosis or order tests or prescribe according to the evidence presented, Estes explains.

"Each page of our simulator looks like a virtual medical record with the patient's picture, an introduction, history, physical, images, and pictures of everything from a rash to biopsy, X-rays, and information on co-infections with hepatitis B and C," Blevins says. "The next page has to do with past visits the patient has made and medications the patient is on, along with vital signs, demographics."

The third page allows the clinician to order tests, and the results appear instantaneously, Blevins continues.

The program will note that the physician has made a good choice, or it will say, "We've seen no evidence this patient has this condition," Blevins says.

A page with therapies prescribed and other orders, including special diets, hospital admission, and a variety of other things also appears, Blevins says.

When a clinician fails to make the correct decisions with a particular case, he or she is directed to similar cases for that same competency before the program advances to the next competency.

"There's a scoring mechanism that's customizable," Estes says. "Categories are given weight, such as dosing, which is given heavier weight than observation or having the patient see a counselor."

Participants have to achieve an 80 or better score to pass, and with each failed competency they are directed to additional links where answers can be found, he says.

The system has a nice feedback mechanism, Bartlett says.

"By the time the physician finishes the module, you feel the candidate really knows how to deal with clinical issues," Bartlett says. "Now it's still not quite the same as working in a clinic, but it comes awfully close to it, and it's a lot better than book reading because it's so interactive."

Even with lectures, there is the reality that people will stop paying attention unless there's an interactive element, such as a keypad punch in which people select answers to questions presented during a lecture, Bartlett says.

Each version of TheraSim that's sent to a particular country for use is customized to that country's particular epidemic needs, Estes says.

"Each country has different drugs available and different co-morbidities and opportunistic infections that people die from," Estes explains. "For example, TB would be prominent in South Africa, and in Ethiopia, it's malaria and hepatitis."

For the CME version, there are handpicked cases on very specific issues, such as HIV related to a co-morbidity, Estes says.

"There are three competencies, totaling nine cases," he explains. "Physicians are given three credits if they complete it, and we have nine to 12 programs running now."

There have been over 4,500 registered users of the CME program from 115 countries, initiating over 7,000 sessions and completing 4,300, Blevins says.

"The average duration for a case is 21 minutes," Blevins says. "But it will take some physicians five minutes to actively finish a case."

Outcomes showed an average of 32 points improvement on the Internet-based global TheraSim system, using guidelines from the U.S. Department of Health and Human Services, Blevins notes.

"We also studied how satisfied people were using the Web-based cases, and there was a 97 percent satisfaction with the activity, and 98 percent considered the simulation to be valuable," Blevins says.

"One major lesson we learned from listening to participants' questions upon doing the cases in the pilot projects was that we need to engage local experts from specified countries to reflect regional availabilities and realities," Blevins says. "Sometimes you have available a different set of drugs in places that are close together, but aren't alike."

A month after Blevins, David Hadden, and Bartlett presented an abstract about TheraSim's computerized HIV teaching at the 44th Annual Meeting of the Infectious Diseases Society of America, held October 12–15, 2006, in Toronto, Canada, the company had sold systems to sites in Ethiopia, Uganda, and South Africa, Estes says.

Typically, the company works with non-government organizations who want to improve the quality of training for physicians in the field, he notes.

Contracts include a customization of the system for a particular site and may include a clinical performance management (CPM) element in which local physicians can key-in data about their actual patients to receive medical oversight by the program, Estes says.

"It's a decision support piece that has tables, information, best practices, and a reporting feature that summarizes information," Estes explains. "CPM is being implemented first in sub-Saharan Africa and then it's being brought back here."