Background.            

Between 26 and 44 percent of the 1.25 million victims of acute coronary syndrome delay in seeking prompt care for this condition. Attempts to reduce delay have focused on pedagogical materials, such as pamphlets and public service announcements that aim to instruct the user by forcing memorization of concepts.  Given the high rate of delay in seeking care, it is clear that these methods are at best only partially effective.  An alternative approach relies on constructivist pedagogy that minimizes rote learning by incorporating the trainee into a realistic, non-threatening scenario in which she discovers for herself the key elements of the material to be learned.  We report here on the development of a prototype system, HEART SENSE, which employs this pedagogical methodology to reduce delay in seeking care for acute coronary syndrome.

System.  

HEART SENSE is a game-based training system for use by lay (non-medical) persons who are either at risk of a first myocardial infarction or are associated with a person who is at such risk.  The system has two goals: to improve the lay public’s early recognition of acute coronary syndrome, and once recognized, to reduce delay in seeking care.  HEART SENSE uses a decision tree-like structure for knowledge representation that guides the user through a series of cognitive states that are clearly identified in a “patient” character.  These states reflect the pathway from unawareness to self-determination, and are in turn reflected emotionally in the patient through a rich set of facial expressions and body postures.  The patient was designed to be identifiable with the user, on the basis of race, age, and sex. In addition to the patient, a “helper” character was included to provide performance feedback to the user through spoken and displayed text as well as emotions through facial expressions and physical movement. The goal of the game is to make as few incorrect decisions as possible, within the context of a “virtual clock;” thus, the best score will be obtained by making correct decisions quickly.

Knowledge Engineering.  

The knowledge contained in HEART SENSE is expressed in four scenarios, which were designed to capture four common situations.  A “typical event” was characterized by symptoms such as crushing retrosternal pain with radiation to the shoulder, diaphoresis, and pallor.  An “atypical event” focused on symptoms of dyspepsia.  A “musculoskeletal event” was preceded by heavy manual labor and was characterized by point and motion-related tenderness. A “musculoskeletal-coronary event” combined the first and third scenarios.  These scenarios were developed by a clinical team that included a cardiologist, a family practitioner, and an emergency medical technician.  Scenarios were reviewed by other clinical personnel and members of the development team to ensure consistency and the ability to map the scenario text to program code. 

Evaluation. 

A prototype of the HEART SENSE system has been developed using one scenario as a proof of concept.  Using this scenario, the software will be used in focus groups consisting of lay persons who correspond to the targeted user group.  Members of the groups will be asked to provide feedback on the system’s interface and the flow and content of the software in general and the scenario specifically.  In addition, HEART SENSE will be evaluated by a panel of experts in cardiology, family practice, and lay medical education.  These evaluations will be used to refine the software for future use in a randomized clinical trial to ascertain its efficacy in reducing delay in seeking care.

Conclusion.  

This project has produced a working prototype of a decision support system to help reduce delay in seeking care for acute coronary syndrome.  This prototype will provide a means to evaluate the appropriateness of a constructivist pedagogy in training the lay public to recognize the symptoms of acute coronary syndrome and to seek care quickly.

Acknowledgement. 

This project was funded by the National Library of Medicine for the National Heart Attack Alert Program of the National Heart, Lung, and Blood Institute.