CancerSPACE: An Interactive E-learning Tool Aimed to Improve Cancer Screening Rates
Aimed to Improve Cancer Screening Rates.
Cancer is the second leading cause of death in the United States today. Due to advances in new medical technology, screening devices for many cancers including breast, cervical, and colon cancers, are drastically reducing mortality rates. These technologies are able to detect cancer early, allowing for earlier treatment and a better survival rate. Unfortunately, many people, especially those in low socioeconomic groups, those without health insurance, and minority groups have very low cancer screening rates. As a result of not being screened, these populations face higher rates of cancer. One way to improve cancer screening rates in low income and minority populations is to target the healthcare staff which works with them. CancerSPACE (Simulated Practice and Collaborative Education) is aimed to improve cancer screening education among healthcare professionals in a virtual, interactive, easy to use online simulation presented in a game format. Simulated education, such as this, can be used on an individual basis at times and locations which are convenient for staff members. It also helps the user to retain information, stay engaged with the task at hand, and learn how to apply the information presented into a real clinical environment.
Cancer is the second leading cause of death in the United States (National Center for Health Statistics, 2008). It is currently estimated that 1.48 million new cases of cancer will occur, and about 562 thousand people will die as a result of it in 2009 alone (Surveillance Epidemiology and End Results (SEER), 2009). The overall burden, or weight, of many cancers is not distributed equally. African Americans, the uninsured and underinsured, and those of low socioeconomic statuses and education levels face higher rates of cancer than the US population as a whole (SEER, 2009; Breen, Wagener, Brown, Davis, & Ballard-Barbash, 2001). Looking specifically at African Americans, it can be seen that they have the highest mortality rates of breast, cervical, and colon cancers when being compared to all other ethnic groups, yet they do not have the highest incidence rate for breast or cervical cancer (SEER, 2009). One reason for this disparity is that African Americans have lower screening rates then the general population which is a result of limited access to quality care (Jemal et al., 2008). Screening has been shown as an effective way to reduce mortality from breast, cervical, and colon cancers among all populations, and lack of screening often results in late stage diagnosis and a lower survival rates (Agency for Healthcare Research and Quality (AHRQ), 2002a; AHRQ, 2002b; AHRQ, 2003).
Breast cancer is the most common form of cancer found in women today, resulting in 26% of all female cancer diagnosis and is the cause of 15% of all female cancer deaths (Jemal et al., 2008). Caucasian women face the highest breast cancer incidence rate with 127.8 per 100,000 being diagnosed with breast cancer and 23.9 per 100,000 women dying as a result of diagnosis (SEER, 2009). Again, African American women, while having a lower incidence rate then the general public at 117.7 out of every 100,000 women, still face the highest mortality rates at 33 per 100,000 women (SEER, 2009). There are three commonly used forms of breast cancer screening. They are mammography, clinical breast exam, and breast self exam. Mammography is by far the most accurate at detecting abnormalities in the breast and is recommended to be done once every one to two years beginning at age 40 for most women (Agency for Healthcare Research and Quality (AHRQ), 2002a).
About 11 thousand women are expected to be diagnosed with cervical cancer, and 4 thousand are expected to die from it in 2009 (SEER, 2009). Hispanic women have the highest incidence rate of cervical cancer with 12.7 out of every 100,000 Hispanic women being diagnosed which is significantly higher than the national average of 8.2 per 100,000 women (SEER, 2009). The Hispanic mortality rate is 3.1 per 100,000 (SEER, 2009). Again, it can be seen that while African American women do not have the highest incidence rate at 10.4 out of every 100,000, they do have the highest mortality rate at 4.6 per 100,000 compared to the national mortality rate of 2.5 per 100,000 women (SEER, 2009). There is only one main form of screening for cervical cancer in women and it is known as the Papanicolaou (Pap) test. It is recommended by the USPSTF that women be screened at least every 3 years beginning at age 21 or after the beginning of sexual activity (Agency for Healthcare Research and Quality (AHRQ), 2003).
Finally looking at colorectal cancer, about 147 thousand men and women are expected to be diagnosed and about 50 thousand are expected to die in 2008 (SEER, 2009). Again, African Americans, both male and female, face the highest rates of colorectal cancer mortality at 31.4 and 21.6 per 100,000 respectively (SEER, 2009). Unlike breast and cervical cancer however, African Americans also have the highest incidence rate of colorectal cancer at 69.3 and 53.5 per 100,000 respectively (SEER, 2009). There are two main forms of screening for colorectal cancer which are colonoscopy and fecal occult blood test (FOBT). Colonoscopy is more effective at detecting cancer at an early stage, however it is invasive and can be expensive if not covered by insurance (Strul & Arber, 2001). The FOBT test on the other hand is fairly inexpensive and generally effective at detecting potential abnormalities by looking for blood in the stool (Strul & Arber, 2001). The only disadvantage is that it is a late stage indicator, generally resulting in a later stage at diagnosis (Strul & Arber, 2001).
While the deaths associated with the above mentioned cancers are on the decline in the population as a whole, it is mainly because cancer screening rates for breast, cervical, and colon cancers are on the incline (Jemal et al., 2008). As a result, it is essential to continue working at increasing screening rates for these cancers among all populations of people in the United States. As with many things however, saying is often easier than doing. It is important to look at all factors associated with low screening rates and see what can be done to address each of them. CancerSPACE is targeting practitioners and healthcare staff to educate them about reasons for low screening rates, and how they can address those issues to increase rates in their communities (Stone et al., 2002).
E-Health and simulation technology
E-Health is defined by the World Health Organization (2005) as “the combined use of electronic communication and information technology in the health sector”. This broad definition includes a large array of technology that can be used in various areas of the healthcare. Some of the more prominent tools include the internet, interactive video, personal digital assistants (PDA's), interactive voice response systems, CD/DVD's, e-tablets, and even interactive games (Health e-Technologies Initiative, 2008). These technologies can then be used to address specific issues in healthcare. For instance, interactive games and videos can be used in patient and practitioner education as well as for increasing physical education, while e-tablets and PDA's may be useful when using a digital records system in a hospital (Health e-Technologies Initiative, 2008). The internet has also become essential for accessing evidenced based information and is widely used as a patient to patient, and practitioner to practitioner communication mechanism (Health e-Technologies Initiative, 2008). It is also being used as a new way for patients and practitioners to connect in a quick and easy way. Examples of communications in this realm include social networking cites, blogs, and patient support sites, as well as email and video chat (Parker & Thorson, 2009). With such a vast array of technologies available, and infinite uses for each of them, e-health seems to be taking off in the healthcare industry.
One form of e-health in education, as mentioned above, is through simulations. This technology has been used as the foundation for the development of CancerSPACE which generates simulated scenarios to educate healthcare staff about cancer screening. In general, simulations “place trainees in life-like situations that provide immediate feedback about questions, decisions, and actions” (Issenberg et al., 1999).
So why use simulations in healthcare education? Simulation technology has been shown to be an effective means of teaching health information in various studies across the healthcare industry and has been shown to have specific advantages over more traditional means of teaching (Laschinger et al., 2008; Maran & Glavin, 2003). First, simulations allow for users to look at specific situations, or scenarios, which may arise in a clinical environment and learn how to properly address them and practice environment. The advantage is that if a situation is not handled properly, the user then has the opportunity of encountering the scenario again and again, using new and hopefully better approaches each time (Maran & Glavin, 2003). In addition, the user has the opportunity to carry out clinical errors to see the consequences and learn from them (Maran & Glavin, 2003). In a typical clinical setting students are stopped at the first sign of a mistake, and that mistake is rectified in order not to cause harm to the patient (Ziv, Wolpe, Small, & Glick, 2006). Secondly, simulations can be tailored to the specific needs of medical clinics and individuals which work in them (Maran & Glavin, 2003). Simulations can present specific topics, such as cancer or diabetes or, if characters are used, they can become representative of the population which is seen at that clinic. Tailoring can be also be created for specific users by varying skill levels throughout the simulation and providing feedback based on the individual answers a user provides to a question. Simulated technology in education also has the advantage of increasing the accuracy and retention of information by the user when being compared to more typical and conventional means of education (Maran & Glavin, 2003). Finally, of fundamental importance, is flexibility. Many simulations can be used at a variety of times and a in a variety of locations (Nelson, 2003).
Simulations also provide many distinct advantages from the administrative aspect. Simulations can, in the long term, be cost saving for institutions and clinics. They require staff members to spend less time away from their patients and other obligations, which often translates into needing fewer staff member to cover lost time (Nelson, 2003). Simulations can be paperless, track performance rates, and result in overall higher completion rates due to their flexibility (Nelson, 2003). They additionally do not require the hiring of individuals to teach or educate staff members (Nelson, 2003).
While there are numerous advantages to simulation based e-learning tools, it is also important to look at the potential disadvantages. Simulations can be cost saving, as mentioned above, but if base equipment such as computers are not already available, then a large financial investment may be required (Nelson, 2003). This, depending on the simulation and its intended use may not be beneficial. There is also a learning curve associated with e-learning tools, just as there is with any new technology (Health e-Technologies Initiative, 2008). This can range from installation, to how to use a computer, or may be specific to the simulation itself and can interfere with the intended learning. Simulations also are not meant to be used as a primary learning tool, but rather as a supplement to be used within a broader curriculum (Laschinger et al., 2008).
Simulations in the workforce
Simulations have been developing as an effective and innovative means of education for years and can be seen in an array of disciplines. Today, we see them educating people in a variety of fields such as aviation, military, business, and medical (Boulos, Hetherington, & Wheeler, 2007). Most notably the aviation industry has been able to show the effectiveness of simulations at improving specific skill sets (Issenberg et al., 1999)
Within the medical arena, simulation based activities are created for a variety of specialties and are used in many different ways. They can be seen in schools teaching basic skills to medical and nursing students (Issenberg et al., 1999), in hospitals educating about new complex procedures such as laparoscopic surgery (Issenberg et al., 1999), and even in society at large teaching people how they can keep themselves healthy (Boulos et al., 2007). Some of these simulations are strictly computer based, others use mannequins, and some integrate both to form a more comprehensive program.
Many simulations are created using mannequins, which give students the advantage of being able to practice a procedure multiple times, using the same procedures and skills they would use with a human patient. Harvey, for instance, was one of the first mannequin based simulations and was created in the 1960's (Cooper, & Taqueti, 2008). This is a cardiology patient simulator which can present with one of 27 different cardiac conditions, allowing the student to identify the problem and diagnose the patient (Issenberg et al., 1999). Since then, many more mannequin based simulations have been developed. SimMan® for instance is a more advanced simulation which portrays various symptoms associated with a specific health problem. The job of the student is to identify and treat those symptoms while diagnosing the health problem. The instructor is allowed to program SimMan® with various illnesses to teach students about a specific condition (Laerdal, 2009). Similarly, a few different simulations for laparoscopic surgery have been created. These simulations focus on teaching special techniques which are specific to laparoscopic procedures, helping the user to master the process (Issenberg et al., 1999). One example is the LAP Mentor™, which allows for individual or multiple users to practice the procedure at the same time. There is an array of similar technologies aimed at teaching students various aspects of health (Simbionix, 2009).
Mannequin based simulations, which generally focus on acute care and the advancement of procedural knowledge, have been shown to be effective in many studies. Harvey, for instance, has been studied over the years, and has shown a higher confidence rate and a higher ability to interpret conditions on human patients when being compared to those who weren't educated using Harvey (Cooper, & Taqueti, 2008). More recently, a review study by Laschinger et al. (2008) looked at 23 mannequin based simulation studies to see if they were effective at advancing the knowledge, skills, confidence, and satisfaction of students in health professions. The results showed simulations to be effective at improving high level skills performance and knowledge attainment, however refresher courses were important to incorporate since both knowledge and skills diminish over time (Laschinger et al., 2008). Very positive results were shown for learning satisfaction and confidence. Students prefer to learn in simulation based activities over traditional methods relating to an easier more enjoyable learning experience (Laschinger et al., 2008). This study showed overall positive results, however many of the individual studies within this meta-analysis showed differing results in areas such as knowledge and skills attainment. One possible explanation of this variation is that the studies were all looking at different procedures in different areas of medicine. So, while a simulation may be effective and beneficial in one area, it may not be in another.
Computer based simulation programs are beginning to emerge in the medical arena. One of the first was the UMedic multimedia computer system which was first developed in 1985. While this can be used with Harvey, the above mentioned cardiac patient, it can also be used strictly as a computer simulation (Cooper, & Taqueti, 2008). This simulation provides a patient medical history, bedside findings, diagnosis, laboratory data, and treatment information. It integrates procedural videos, and asks the user multiple choice questions along the way (Boulos, Hetherington, & Wheeler, 2007). More recently, computer based simulations have become more accessible and are often internet based. Second Life, an online virtual environment, has a variety of medical and educational based applications aimed at educating students and the public about various aspects of health. Ohio State University created a “Nutrition Game” allowing its students to experiment and see how ingesting different types of fast foods affect their bodies in the short and long term. The goal of the game is to make healthy food choices at the fast food restaurants resulting in positive health and a high score (Boulos et al., 2007). Another virtual simulation in second life called “The Heart Murmur Sim in Second Life” was created to help medical students properly identify the different sounds of heart murmurs. It was developed by Jeremy Kemp, and uses the sounds from McGill University's Virtual Stethoscope project to imitate the sounds of the heart (Boulos et al., 2007).
Overall, computer based simulation technology, rather than mannequin based, and those geared toward improving chronic care have not been sufficiently studied or evaluated for effectiveness. A study by Qayumi et al. (2004), found that students who used an online patients to practice a patient exam either alone, or in conjunction with a text tool, had higher performance rates when being compared to a group who used only text. The text only group also was shown to be much less satisfied with their educational experience (Qayumi et al., 2004). A second study completed a review of nine published articles focusing on computer based simulations in medical education. It was found that 75% of the studies showed that simulations improved skills and knowledge attainment but acknowledges that the small number of studies and, in some cases, undocumented evaluation tools as potential weaknesses (Ravert, 2002). Looking to chronic care simulations, the authors could find no evidence to either support or refute their possible effectiveness, further showing the need expand research this area.
One of the biggest challenges in simulation technology has been bridging the gap from simulations used to educate in acute care versus simulations which are used in chronic care. There is a sufficient evidentiary base showing the effectiveness of using simulations, however they mainly focus on acute healthcare (Ravert, 2002). It is important to expand this area of study because chronic illnesses are one of the biggest burdens on the healthcare system today, and are only expected to increase.
CancerSPACE was developed in response to a need set forth by the Health Disparities Collaborative, a multi-organizational government group with the goal of reducing health disparities. The collaborative put forth a need for a cancer screening educational tool aimed at Federally Qualified Health Centers (FQHC's). Initial discussions made it clear that the tool had to be easily used and easily disseminated in order to reach its intended audience. For this, an internet based program would be effective. After researching internet based tools, the advantages of using simulations in health education became obvious and seemed as though a good way to go about presenting information to staff members at FQHCs. It would allow important information to be presented in a more interesting and interactive way and would be easily accessible to health professionals. From the beginning stages of development, some key issues were known that needed to be addressed in the simulation. It was important for the simulation to be geared toward adult health professionals, many of whom would be completing this for continuing education. It also needed to be interesting and easy to use. All of these needs seemed as though they could be easily addressed using an interactive simulation.
Using theoretical components as an underlying guide for CancerSPACE was important in the creation. In particular behaviorism and andragogy, or adult learning, were essential to incorporate in the development. Behaviorism is the idea that positive and negative reinforcement can guide learning (Parkay & Hass, 2000). In CancerSPACE, reinforcement is given as a response to the users chosen answer. It forces the user to make choices and face the consequences of their decisions. Additionally, the situations one may encounter in simulated activities may directly mimic those which are seen in the real world. Here, how the user responds to a patient, and how the patient reacts as a result, may be directly comparable to how the situation would play out in the real world.
Since CancerSPACE is geared toward educating adult learners, it became essential to incorporate aspects of adult learning theory into the development process. The most widely used theory of adult learning is called andragogy which was introduced by Knowles in 1968 as a way of distinguishing the difference between the ways adults learn compared to the ways children learn (Merriam, 2001). The fundamental concept is that adults are self-directed learners and are capable of directing, or helping to direct, their own learning. As such, programs which encourage students to be in control of their own learning are fundamental in adult learning success (Merriam, 2001).
CancerSPACE has been through four stages of development and usability testing. Each stage has been educational and informative, resulting in revisions that have created a more immersive environment for the user. After each stage of development, usability testing was completed by a group of 30-60 participants in the healthcare industry. Many of these testing sessions were completed at conferences and included staff members from FQHCs. Testing consisted of verbal/and or written feedback from the user on different simulation components, including questions about material presentation, whether it was easy to understand, and things that could be improved. The testing sessions also used software such as Morae™ which records users and their actions throughout the session. This helped to determine whether users were looking and clicking in the correct places, using the important features which were built in, and were using the game for its intended purpose. It also recorded the amount of time it took for a user to complete various sessions of the simulation as well as whether they answered questions correctly or incorrectly.
Version 1 was developed using basic simulation technology with geometric characters. There was little character interaction and most information was presented to the user in a text format. Usability testing showed that users were not utilizing CancerSPACE in the intended way, and that it was very text heavy, often causing users to skip over many of the important features that had been included. In an effort to improve usability and make it more engaging and interactive, CancerSPACE advanced into Version 2. Here, the geometric characters were removed and replaced with live action video. This turned out to be ineffective in terms of time and cost, and would hinder future production in development and modifications. This hindrance led to use of avatars, which are animated characters who look and appear more lifelike than those characters used in Version 1, yet do not have the limitations of live action video. The avatars were then superimposed over still images of real clinics to create the base of CancerSPACE. During usability testing for Version 2, it was discovered that the avatar characters seemed out of place in the clinic and that the interactions between the characters were unrealistic. This feedback lead to the development of Version 3 which integrated more interactive features, had information presented by the characters rather than in text format, and had the backdrop of virtual opposed to real life, clinical environment. The clinic and characters received great feedback, however the simulation was drawn out, had too much talking, and lost user interest. Finally, Version 4 was created with the characters and environment from Version 3 but incorporating feedback from usability testing. While still in the development stage, a demo of version 4 has been released for public use. The final round of testing was conducted in March of 2009 with a large amount of positive feedback. Some small suggestions were taken into account and have been incorporated into the current version. A completed version of CancerSPACE will be available in September of 2009.
CancerSPACE addresses cancer screening related to breast, cervical, and colon cancers. Within this subject matter, recommendations and appropriate screening intervals as well as different screening modalities for each cancer are addressed. For example, when looking at breast cancer, CancerSPACE would educate about the recommended screening intervals for breast self exam, clinical breast exam, and mammography. In order to have a more comprehensive program, CancerSPACE also looks at and educates about many of the barriers patients face to screening, both from the patient side and the physician side. Once healthcare staff is aware of the barriers they can begin to address them. This tool gives specific, proven interventions which have been shown to be effective in addressing specific barriers. CancerSPACE not only addresses guidelines, barriers and interventions, but it also looks at areas such as clinical processes, using a database, and scaling up care.
Many of the above mentioned topics are taught through the Chronic Care Model. The Chronic Care Model (CCM) is defined as “promoting effective change in provider groups to support evidence-based clinical and quality improvement across a wide variety of healthcare settings” (Improving Chronic Illness Care, 2008). It has six main areas of focus: health system, delivery system design, decision support, clinical information systems, self management support, and the community (Improving Chronic Illness Care, 2008). Each of these six areas focuses on some aspect of how chronic care can be handled and improved in the health care system. The Health Disparities Collaborative adapted the CCM to facilitate cancer screening by adding specific points under each of the six main areas of focus to address cancer screening from a community health center perspective (HRSA Health Disparities Collaborative, 2005). Since this model was adapted to specifically address this cancer screening from the side of community health centers, and looks to comprehensively address the issues from six different perspectives, it seemed appropriate as the bases for CancerSPACE development.
The All Hands Community Health Center is the virtual community health center where CancerSPACE takes place. It is located in a virtual low-income urban community which is a typical location for most federally qualified health centers (FQHCs). The staff members and patients represent a wide array of ethnicities, cultures and ages. As the user, otherwise known as the “Decider”, moves through the game, they are presented with questions, scenarios, and activities in order to diversify the experience and keep the interest of the user. They are given helping tools along with way, such as evidence summaries and performance feedback. The information presented in CancerSPACE can take one of 5 card formats: to-tell-the-truth, text multiple choice, simulations, vignettes, or activities. The varying format is essential in creating an environment which optimizes information retention and utilization. This can be seen in a review study by Issenberg et al. (2005) which described that variation is one of ten important components which should be presented in simulations. Below is a description and image of the five card formats and other important aspects presented to the user throughout the simulation. This is intended to give the reader a better idea of how the simulation works, and how information is presented to the user.
Information can be presented to the user in varying ways. To-tell-the-truth (TTTT) scenarios give the user three statements, two of which are incorrect, and one which is correct. The statements are made by one of three characters, and the job of the user is to decide who has the best information. After the characters make their statements, a multiple choice question pops up asking the user to decide which character was correct. In the scenario presented in Image 1, each character makes a statement about colorectal cancer. Maria and Virginia gave incorrect responses, while Lou gives a correct response. If the user chooses Lou as making the correct statement, then their score will increase.
Text multiple choice (TMC) cards present basic information to the user such as screening guidelines. Each question is asked to the user in a text format. The user then has to choose the correct answer out of the three or four possible answers provided. Image 2 shows an example of how to handle low completion of FOBT screening. Here, the chosen answer is incorrect, which would result in a reduced score.
Simulations allow for an interaction to take place between the user and a virtual patient. These scenarios let the user to learn the best way to speak with and respond to the concerns of patients. During simulations, the patient makes a statement about screening, and the user then has to choose the best response to the statement which was presented. After a response is chosen, the patient will then make another statement. The user again has to choose the most appropriate response. This process is repeated multiple times until the patient chooses to leave the clinic or agrees to have the screening procedure done. After each statement, if the correct response is chosen, the user moves one step closer to having the patient agree to screening. If the incorrect response is chosen the user moves one step away from the patient agreeing to screening, but is given the opportunity to get back on the correct path. If the incorrect response is chosen multiple times, the patient may choose to leave and the user does not earn points. Most simulations focus on patient barriers surrounding screening such as cost, time, an idea of fatalism or a sense of modesty. In the simulation presented in Image 3, the patient, Lou, does not want to complete a fecal occult blood test (FOBT). The role of the user is to listen to and address Lou's concerns in a way which ultimately will result in Lou completing the FOBT.
Vignettes begin with a video showing an interaction between a combination of clinic staff and/or patients. The interaction will often involve a problem or situation which the characters are having. At the end of the video, a multiple choice question is presented asking the user to choose the best of the possible answers offered. Many of these scenarios encourage the user to learn about proper interventions and how to scale up care at their clinic. Image 4 shows an example. Again, the incorrect answer is chosen in this image and would result in a reduced score.
Activities are an important part of CancerSPACE and allow the user to be an active participant in a clinical environment. Image 5 begins with a video describing the process used at the All Hands Clinic for cervical cancer screening. It is the job of the user to map out the process described in the video, and identify which step was missed in the process. By identifying this step, the user is able to improve cancer screening rates at the All Hands Clinic.
Wildcards sporadically show up during the game and can either increase or decrease the total score. These are meant to represent the idea that unexpected things can happen on a day to day basis. For instance, the Wildcard presented in image 6 states: “One of your team members thinks her ideas aren't being considered. This is adversely affecting the member's morale. Your score has been reduced.” Another example of a wildcard states: “Your physician Champion has accepted another position. While your new physician is getting up to speed, your progress temporarily stalls. Your score has been decreased.”
Check the Evidence (CTE) files are available on all cards. Each file gives a summary of the available evidence which supports the correct answer to the question asked. A CTE file is available for the user to see before he/she answers a question. The goal of the CTE files are to encourage the user to check and use substantiated evidence in their clinical decision making both in CancerSPACE as well as in the real world. Image 7 shows how this information is presented.
CancerSPACE offers various types of feedback for the user. After any question is answered, the “mentor” offers appropriate feedback based on the response given. The feedback varies from a “congratulations you chose the correct answer”, to a statement on what the correct answer should have been. There is also feedback offered in image form shown in the middle of the screen, and numerical form shown in the users score. Image 8 shows an example of each type of feedback presented.
A summary screen is presented to the user at the end of each sub-game giving the user information about the subject areas that were addressed as well as their responses, number of points earned, and whether their clinics screening rates improved for cervical, breast and colon cancers. Image 9 shows an example of this. The summary screen also gives a graph indicating how screening rates have improved or worsened over the course of the simulation as a whole.
The Future of CancerSPACE
CancerSPACE has been a learning process for all those involved. It has lead to a better understanding of how people learn, effective ways of presenting information, and an overall understanding of how e-learning tools are produced. With the demo version of CancerSPACE already available, and the final version available in September 2009, the next steps are going to entail dissemination and evaluation. A dissemination plan is currently being developed, and will entail distribution of CancerSPACE to Federally Qualified Health Centers. Before widespread dissemination, it will be distributed to smaller groups of community health centers, and will also be presented to different audiences at health and e-health related conferences. An evaluation phase will be important to complete either during or after distribution. Evaluation will allow the team to determine whether CancerSPACE achieved its goal of creating an e-learning tool which effectively educates healthcare staff about cancer screening. If CancerSPACE is shown to be an effective e-learning tool during evaluation, there is hope that the same simulation engine can be used to create a similar tool to be used as a patient decision or educate on other chronic health conditions. Since the simulation engine, characters, and virtual environment is already created, turning the simulation into a different educational tool only requires changing the content and characters movements. This would require some time and investment, but would be fairly cost effective since the engine is already built.
There is an abundant amount of evidence suggesting that simulations are an effective means of educating students in the healthcare field. However, most of these studies have looked at acute care and mannequin based simulations. With new forms of technology being developed at a faster and faster pace, it is becoming easier, and often time more cost effective, to create tools which can be used to teach new information. Computer based simulations in chronic care is one example. While the technology and the need for this type of tool is both there, there is still a lack of evidence based information to support the effectiveness of these new tools. This is one reason why tools such as CancerSPACE need to be studied. It is important to understand whether these tools are useful in order to help guide future production of e-learning tools, and ensure that those tools which are being created are working toward their intended purpose.