This article has Open Peer Review reports available.
eMedOffice: A web-based collaborative serious game for teaching optimal design of a medical practice
- Andreas Hannig1Email author,
- Nicole Kuth†2,
- Monika Özman†2,
- Stephan Jonas†1, 3 and
- Cord Spreckelsen†1
© Hannig et al.; licensee BioMed Central Ltd. 2012
Received: 19 November 2011
Accepted: 25 October 2012
Published: 31 October 2012
Preparing medical students for the takeover or the start-up of a medical practice is an important challenge in Germany today. Therefore, this paper presents a computer-aided serious game (eMedOffice) developed and currently in use at the RWTH Aachen University Medical School. The game is part of the attempt to teach medical students the organizational and conceptual basics of the medical practice of a general practitioner in a problem-based learning environment. This paper introduces methods and concepts used to develop the serious game and describes the results of an evaluation of the game's application in curricular courses at the Medical School.
Results of the conducted evaluation gave evidence of a positive learning effect of the serious game. Educational supervisors observed strong collaboration among the players inspired by the competitive gaming aspects. In addition, an increase in willingness to learn and the exploration of new self-invented ideas were observed and valuable proposals for further prospective enhancements were elicited. A statistical analysis of the results of an evaluation provided a clear indication of the positive learning effect of the game. A usability questionnaire survey revealed a very good overall score of 4.07 (5=best, 1=worst).
We consider web-based, collaborative serious games to be a promising means of improving medical education. The insights gained by the implementation of eMedOffice will promote the future development of more effective serious games for integration into curricular courses of the RWTH Aachen University Medical School.
KeywordsComputer-Assisted Instruction/methods Games, Experimental Teaching/methods, Education, Medical Undergraduate/methods User-Computer Interface
The German healthcare system faces a downturn in the number of general practitioners starting or taking over a practice, especially in the rural areas [1, 2]. Financial and administrative incentives have been introduced to improve the situation. In Germany most general practitioners own their medical practice or at least most of their equipment. They act as entrepreneurs and take the full economic risk. Recent reforms in the German healthcare system have granted patients more freedom to choose a general practitioner and, as a result, encourage competition [3, 4]. Nonetheless, medical education is challenged to play its part by preparing medical students to cope with the increasingly risky and cost-intensive venture of a practice takeover or start-up. In the context of economics studies business games have been proven to support training in the skills necessary for starting up an enterprise [5, 6]. Enhanced by computer-based communication and simulations, similar game-based learning interventions have evolved to a new category of serious games. Recently, serious games have been successfully applied to some fields of medical education [7, 8]. The challenge of adequately preparing medical students for future practice start-up provides an excellent opportunity for further developing and testing collaborative aspects of serious games in medical education.
A general-purpose business game (or business simulation) has been defined as a complex man-made environment, where participants are able to gain experiences when acting in a simulated reality [9, 10]. Yet there is open discussion concerning the definition of the term serious game. A relatively broad definition of a serious game is ‘any computerized game whose chief mission is not entertainment and all entertainment games which can be reapplied to a different mission other than entertainment’ . In contrast to teacher-centred learning approaches, which primarily rely on the control and activity of the teacher, serious games are considered as inherently learner-centred and focusing on the needs of learners . Experts in the field of serious games predict a continuous growth in this research area [13, 14]. Recently, research activity in the field of serious games has indeed markedly increased and has especially addressed their application in medical environments . Ritterfeld and colleagues (2009) found that 8% of all existing serious games deal with a health- or medicine-related topic . Medical learners showed a high acceptance of serious games as shown in several studies: The INMEDEA simulator, which presents virtual case studies and adopts an open, nonlinear problem-oriented problem-solving approach situated in a virtual hospital, was judged as a good or very good teaching method by 76% of 70 test candidates . As a second example the Junior Doctor Simulator (JDoc), an interactive, 3D, third-person view prototype focusing on the training of doctor-patient interactions, was considered to provide valuable experiences of patient interactions and routines of a hospital ward to junior doctors . Evaluation results suggest a significant impact of serious games' stimulation of conceptual thinking on the learning outcome . JDOC and INMEDEA teach common procedures of the everyday work of doctors in different contexts and focus on doctor-patient interaction and medical diagnosis. Recent projects have tried to close the gap between computer-supported learning and reality by introducing learning support to mobile devices [20, 21]]. Improved collaboration induced by serious games in the nursing context was stressed some time ago ; in a more recent review of virtual 3-D medical learning environments the collaborative aspect was identified as a major strength associated with several game-oriented medical learning approaches based on virtual worlds . Following the idea of applying a serious game approach to prepare medical students for future practice start-up the ‘Business Game: How to start a Medical Practice’ was set up as a joint project of the Division of General Medicine and the Department for Knowledge-based Systems of the Institute for Medical Informatics of the RWTH Aachen University Medical School. The learning scenario consists of different learning and computer-aided game phases covering an online search, rough and fine-grained planning of funding and the detailed planning of required medical equipment. A special computer-assisted module of the business game is the interactive, collaborative serious game eMedOffice. The game eMedOffice focuses on practical exercises guiding the participants towards strategies for an optimization of the interior design, workflows, equipment, components and furnishing arrangements of a medical practice. The goal of eMedOffice is to provide fun access to the necessary theoretical knowledge to promote relevant practical problem-solving skills of the learners. In this work we present the theoretical approach, technical realization, and evaluation results of eMedOffice that evidence the positive effect of this learning game.
Knowledge acquisition, representation and maintenance
The game has been developed in close cooperation with medical students and the Division of General Medicine of RWTH Aachen University Medical School. In preliminary work, the implemented step-wise structure and learning objectives of the ‘Business Game: How to start a Medical Practice’ (eMedOffice) were acquired. Oriented on a business game used in economic sciences at RWTH Aachen University named EasyStartup, the requirements were analysed in several meetings with students and experts in medical practice design. Using a top-down approach, the game steps were iteratively refined to provide a convenient computer-supported way to achieve the learning objectives in an explorative manner. Acquisition of required special knowledge on how to characterize a medical practice for eMedOffice with sound workflows and efficient design was part of an on-going dissertation project (Rühr 2012, to be published). In particular, it was the main task of the dissertation to find rules usable for scoring and to verify the external validity of the scoring system. We used a pattern language that we tailored to our particular needs to gather and transfer the specific knowledge from the medical domain to an operational format. This acquired domain knowledge was represented and formalized in an ontology. A short and general definition of an ontology is given by Gruber and colleagues: 'An ontology is an explicit specification of a conceptualization’ . The ontology editor Protégé was used for acquisition and maintenance of the semantic model . We developed a transformation for the representation of non-branched workflows to concepts of an ontology that allowed a visual simulation of many common non-branched workflows of general practitioners. By using the A* path-finding algorithm we integrated a simulation of agents on the ground plan .
Conditions for a medical practice with sound workflows and adequate furnishing of a general practice are formalized as ontology restrictions. An evaluation algorithm verifies these restrictions by calculating an appropriate score. Examples of integrated rules formalized as restrictions are ‘All beds must be usable’ and ‘In the briefing room there is a medicine cabinet’. Many rules check the existence of furniture and equipment items in a specific room. Others check useful composition and usability of placed furniture and equipment items. A score is assigned to each of these rules. If a player’s solution meets the rule, the assigned score is added to the player’s total score. The score calculation is done by a conformity check of the restrictions with a student’s solution which is translated to an instance of the ontology-based object model. The result of this conformity check is a list of rules that the current student’s solution complies with and those with which it does not. A scoring algorithm calculates the final score based on the former rules according to a score table. For this calculation, we used a custom language developed for the purpose that is able to address the specific conditions of an ontology.
The learners should realize the fundamental relationship between the needs of patients and staff arising during typical processes in a medical practice on the one hand and the requirements concerning (a) the assignments of functions to rooms and (b) the arrangement of furniture and technical equipment on the other hand. The participants should gain orientation on the usage of rooms, furniture and equipment during the daily routine. Players should develop useful furniture and equipment compositions in the different rooms. In this game players do not learn factual knowledge by heart. Instead players are encouraged to explore self-invented solutions to problems when arranging a medical practice. The game is intended to teach observation and analytical skills as well as planning and deductive skills in the context of furnishing a medical practice by using immediate feedback of simulated patients. Thus, as a primary goal the participants should learn to react to patients’ (and staff's) problems caused by suboptimal arrangement of rooms, furniture items and equipment items. This goal reflects the fact that requirements may change dynamically over time. The participants should adopt a patient- and process-oriented approach to adjusting the organization of a medical practice.
Hardware / software platform
Evaluations of the game used a virtual linux server machine with one gigabyte of RAM and 50 megabytes of free hard disk. For execution on the server side the game depends on common web techniques like a web server and a standard database that supports SQL. Clients of the game use a standard web browser without any requirements for extensions. To play eMedOffice, an active network connection between client and server is required. For a smooth visualization of integrated workflows the client should have at least a 1.0 GHz CPU. Thus, the hardware requirements do not exceed the standards of available computer hardware.
As part of a revised six-year medical curriculum (‘Aachen Model Curriculum Medicine’), the game is embedded into the compulsory elective part (the so-called Individual Qualification Profile - IQP). The game is part of an IQP module addressing family medicine. Students may choose the module between the third and the sixth year. A group of 15 to 25 students regularly takes part in the module each semester.
I am able to name important rooms
I am able to name important furniture
I am able to name important equipment
I am able to estimate the financial outlay for interior furnishing
I know the target rooms for placing furniture correctly
I know how the furniture in specific rooms should be equipped
I have an idea about good arrangements of furniture
Timing chart table
Students arrive at the training room and sit down
Educational supervisor greets students and gives an overview of the agenda
Students fill in the first evaluation sheet self-report (pre)
Educational supervisor collects first evaluation sheets
Educational supervisor gives brief instructions on how to start eMedOffice
Students start web browser, navigate to the correct web address, register and log into eMedOffice
Students read the introduction
Students play eMedOffice
Educational supervisor tells students to stop game play
Students stop playing and discuss eMedOffice results
Students fill in second evaluation sheet: self-report (retro and post)
Students fill in usability questionnaire
Educational supervisor collects second evaluation sheet as well as usability questionnaire and says goodbye to students
Students leave the training room
The game eMedOffice is an interactive, web-based, 2D, bird's eye view simulation of a medical practice prototype. Its purpose is to teach optimization of interior design, including the furnishing as well as equipment components of a medical practice of a general practitioner. It is playable in every standard web browser and hence available anytime at any location where an internet connection is accessible. Constructed as a rich internet application that uses a live-connect technique to communicate with the web server, it offers continuous game play that is not interrupted by interfering web page loads while one is using standard web techniques. First, all participants have to register with a free-to-choose public player’s name. After registration the active game starts. Three successive game phases characterize the active game. During the Introduction Phase the learning objectives, principles and procedures of the serious game are presented. The introduction utilizes many in-game pictures to describe possible situations as an example. Additionally, this phase is supported by an educational adviser who explains the learning objectives orally and answers general questions. The game is played in the following Execution Phase. In this phase players start to assign appropriate room functionalities, placing interior furniture and equipment onto the ground plan. A player can virtually open his/her medical practice at any time. Opening his/her medical practice starts a simulation. During the simulation virtual agents of the doctor, doctor's assistants, patients and other visitors follow common workflows and use the placed furniture and equipment. If an agent cannot fulfil his/her operation because of a missing requirement a speech bubble appears that describes the requirement in the form of first-person statements. In this situation a player can stop the simulation to plan and integrate a solution to the problem. Players are free to choose the number of repetitions of this enhancement procedure. In the final Evaluation Phase a detailed evaluation of the current session is presented. It includes a detailed report of the used furniture and equipment with overall costs and the price of every single item used. Extensive point ranking gives information on which rule accounts for how many points. If a rule did not comply a hint provides possible improvements for the next time. At any time of game play a public player ranking is visible to all players. This ranking shows the relative distance between the players according to their current score. Additionally, the total money spent on interior furnishing and equipment components is presented. The ranking can be projected to a screen to drive competition between the students.
This section presents results concerning the game design. In-game screenshots show the user interface as well as the game design. In the last part of this section we describe the evaluation results.
Game play and design
Comparison of significances and means of groups
Given our experiences in the development and evaluation of eMedOffice, various extensions are possible. One important possible extension is the enhancement of the knowledge base. This includes the formalization of new rules to describe a good working medical practice. More rules would allow the expedient usage of different levels of difficulties and could enable more authentic scoring. Another important aspect is the integration of an internationalisation function that allows players to switch the language of eMedOffice. This is especially important for international courses with many students from foreign countries. Moreover, additional languages could improve the subject-specific foreign languages of all students. An economic circuit could further extend the game to enhance players' commercial and financial understanding. Players could earn virtual money for each successfully treated patient. This earned money could be invested to further enhance the medical practice. In that context it could be an additional motivating aspect if all players competed for the same shared patient pool. Thus, more visits of patients would indicate a ‘better’ medical practice compared with a ‘bad’ one less frequently visited. This would leave more successful players with increasing difficulties and the need to satisfy more varied demands by the patients than less successful players who have more time to evaluate failed workflows. Overall, it could benefit the balance of the game depending on each student’s performance. A shared patient pool could also sensitize players to the growing competition for patients in the real world. Additionally, the evaluation elicited many valuable suggestions from players concerning improvements for the game interaction like an enhanced method to rotate equipment on the ground plan or more detailed information about the placed furniture items.
The project eMedOffice implements a practical approach for a serious game in a medical environment to teach optimization of design in terms of furnishing, equipment components and furniture items in a general medical practice. Designed as a serious game, it is integrated in the curricular courses of medical study at the RWTH Aachen University Medical School. By using motivating aspects like permanently visible public player ranking and fun elements, the game fostered valuable discussions and competitive collaboration among participants. A statistical analysis of the results of an evaluation provides a clear indication of the positive learning effect of the serious game. A usability questionnaire survey reveals a very good overall score of 4.07 (5=best, 1=worst). In conclusion, we are confident that we can develop even more effective serious games in future that can be integrated into curricular courses of the RWTH Aachen University Medical School.
Availability and requirements
Project name: eMedOffice
Project home page: http://sourceforge.net/projects/emedoffice/
Operating system(s): Platform independent
Programming language: PHP
Other requirements: Apache2, mod-php, MySQL
License: GNU GPL
Any restrictions to use by non-academics: GNU GPL
We would like to thank the students and teachers who took part in the study. We also thank the RWTH Aachen University Medical School for providing access to the computers and rooms used in the study.
- Landsberg G: Positionspapier „ärztliche versorgung im ländlichen raum. DStGB - Deutscher Städte- und Gemeinde. 2010, DStGB web site [cited 2011 October 18]. http://www.dstgb.de/dstgb/Kommunalreport/Archiv%202010/%C3%84rztliche%20Versorgung%20im%20l%C3%A4ndlichen%20Raum%20gef%C3%A4hrdet%20-%20Reformans%C3%A4tze%20notwendig/positionspapier_aerztliche_versorgung_1105.pdf.Google Scholar
- Hauschild W, Klose A: Kostenstrukturen bei arzt und zahnarztpraxen 2003. Wirtschaft und Statistik. 2003, 11: 1151-1158. 2006Google Scholar
- Lisac M, Reimers L, Henke KD, Schlette S: Access and choice–competition under the roof of solidarity in German health care: an analysis of health policy reforms since 2004. Health Econ Policy Law. 2010, 5 (1): 31-52. 10.1017/S1744133109990144.View ArticleGoogle Scholar
- Stock SAK, Redaelli M, Lauterbach KW: Disease management and health care reforms in Germany — does more competition lead to less solidarity?. Health Policy. 2007, 80 (1): 86-96. 10.1016/j.healthpol.2006.02.005.View ArticleGoogle Scholar
- Fripp J: A future for business simulations?. Journal of European Industrial Training. 1997, 21 (4): 138-142. 10.1108/03090599710171387.View ArticleGoogle Scholar
- Mayer BW, Dale KM, Fraccastoro K, Moss G: Improving transfer of learning: relationship to methods of using business simulation. Simulation & Gaming. 2010, 42 (1): 64-84. 10.1177/1046878110376795.View ArticleGoogle Scholar
- Hansen MM: Versatile, immersive, creative and dynamic virtual 3-D healthcare learning environments: a review of the literature. J Med Internet Res. 2008, 10 (3): e26-10.2196/jmir.1051.View ArticleGoogle Scholar
- Adams SA: Use of “serious health games” in health care: a review. Stud Health Technol Inform. 2010, 157: 160-166.Google Scholar
- Martin A: The design and evolution of a simulation/game for teaching information systems development. Simulation & Gaming. 2000, 31 (4): 445-463. 10.1177/104687810003100401.View ArticleGoogle Scholar
- Garris R, Ahlers R, Driskell JE: Games, motivation, and learning: a research and practice model. Simulation & Gaming. 2002, 33 (4): 441-467. 10.1177/1046878102238607.View ArticleGoogle Scholar
- Sawyer B, Smith P: Serious games taxonomy. Health San Francisco. 2008, [cited 2011 September 19]. http://www.dmill.com/presentations/serious-games-taxonomy-2008.pdf.Google Scholar
- Stapleton AJ: Serious games: serious opportunities. 2004, Australian Game Developers’ Conference, Academic Summit, Melbourne, 1-6. [cited 2011 October 2]. http://andrewstapleton.com/wp-content/uploads/2006/12/serious_games_agdc2004.pdf.Google Scholar
- Sawyer B: From cells to cell processors: the integration of health and video games. IEEE Comput Graph Appl. 2008, 28 (6): 83-85. 10.1109/MCG.2008.114.View ArticleGoogle Scholar
- Eck RV: Digital game-based learning: It’s Not just the digital natives Who Are restless …. Educause Review. 2006, 41 (2): 1-16. 10.1145/950566.950596.Google Scholar
- Susi T, Johannesson M, Backlund P: Serious games – an overview. 2007, School of Humanities and Informatics, University of Skövde, Sweden, Technical Report HS-IKI-TR-07-001, 2007Google Scholar
- Ritterfeld U, Cody MJ, Vorderer P: Serious games: mechanisms and effects. 2009, Taylor & Francis, New YorkGoogle Scholar
- Horstmann M, Renninger M, Hennenlotter J, Horstmann CC, Stenzl A: Blended E-learning in a Web-based virtual hospital: a useful tool for undergraduate education in urology. Education for Health. 2009, 22 (2): 269.Google Scholar
- Sliney A, Murphy D: JDoc: a serious game for medical learning. First International Conference on Advances in Computer-Human Interaction. 2008, 39: 131-136. 10.1109/ACHI.2008.50.View ArticleGoogle Scholar
- Girardi FM, Nieto FB, Vitória LP, de Borba Vieira PR, Guimaráes JB, Salvador S, Scroferneker ML: T- and B-cell ontogeny: an alternative teaching method: T- and B-cell ontogeny game. Teach Learn Med. 2006, 18 (3): 251-260. 10.1207/s15328015tlm1803_11.View ArticleGoogle Scholar
- Kanstrup AM, Boye N: Theory meets practice in the design of e-support for junior registrar doctors. Artifact. 2007, 1 (3): 190-197. 10.1080/17493460701800231.View ArticleGoogle Scholar
- De Marcos Ortega L, Barchino PR, Jiménez Rodríguez ML, Hilera González JR, Martínez Herráiz JJ, Gutiérrez De Mesa JA, Gutiérrez Martínez JM, Otón Tortosa S: Using m-learning on nursing courses to improve learning. Computers Informatics Nursing CIN. 2011, 29 (5): 311-317. 10.1097/NCN.0b013e3181fcbddb.View ArticleGoogle Scholar
- Crancer J, Maury-Hess S: Games: an alternative to pedagogical instruction. J Nurs Educ. 1980, 19 (3): 45-52.Google Scholar
- Gee JP: What video games have to teach us about learning and literacy. Computers in Entertainment (CIE). 2003, 1 (1): 20-10.1145/950566.950595. October 2003View ArticleGoogle Scholar
- Gee JP: Learning by design: good video games as learning machines. E-learning. 2005, 2 (1): 5-16. 0.2304/elea.2005.2.1.5.View ArticleGoogle Scholar
- Gruber TR: Toward principles for the design of ontologies used for knowledge sharing. International Journal of Human Computer Studies. 1995, 43 (5–6): 907-928. 10.1006/ijhc.1995.1081.View ArticleGoogle Scholar
- Noy N, Sintek M, Decker S: Creating semantic web contents with protege-2000. IEEE Intelligent Systems. 2001, 16 (2): 60-71. 10.1109/5254.920601.View ArticleGoogle Scholar
- Hart PE, Nilsson NJ, Raphael B: A formal basis for the heuristic determination of minimum cost paths. IEEE Transactions on Systems Science and Cybernetics. 1968, 4 (2): 100-107. 10.1109/TSSC.1968.300136.View ArticleGoogle Scholar
- Holzinger A: Beurteilungskriterien für lernsoftware. 2003, [cited 2011 September 20]. http://user.meduni-graz.at/andreas.holzinger/holzinger%20de/papers%20de/Beurteilung_Lernsoftware.pdf.Google Scholar
- Ulrich M: Komplexität anpacken: Mit planspielen erfolgreiches handeln erlernen. 2006, Werner-und-Elisabeth-Kollath-Stiftung, Tagungsband zur 7. Werner-Kollath-Tagung, Universität Giessen, [cited 2011 September 10]. http://www.ucs.ch/service/download/docs/artikelkomplexitaetplanspiele.pdf.Google Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6920/12/104/prepub
This article is published under license to BioMed Central Ltd. 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 is properly cited.