Clinical Encounter Case Building Engine

Original Project Overview

Pain Tx Challenge is a cross-platform based application (web, iOS, Android) that provides a simulated clinical training experience for health professions students to develop pain management skills. Simulated patients have challenging combinations of pain conditions and addiction issues that are discovered by interacting with a simulated electronic health record. Using the training involves selecting clinical evaluations and interpreting results, making clinical decisions, and experiencing realistic clinical outcomes. Positive patient outcomes are experienced when a patient-centered, evidence-based approach is followed and medical knowledge is correctly applied. New cases can be created by faculty using a convenient xml-form based user interface.

This product will enhance health professional skills essential to pain management: 1) competence in preventing, diagnosing and treating pain, 2) proper use of pain medications that include an addiction or misuse potential. The training is designed to integrate easily into existing curricula. With the support for case creation Tx Challenge can be adapted for teaching other types of cases, as well.


Build a cost-effective and reproducible cross-platform solution (web-based, Android) that fits well into multiple existing systems-based curricula and improves clinical skills related to assessing and assisting patients with pain. The product includes support for the addition of new cases by faculty.


Project Title: iPad EMR Pain Management Simulator: Tablet-based Skills Development

Phase II, NCATS Grant #R44TR000576

Dates: 12/2011 to 5/31/2015

T. Bradley Tanner, MD – Principal Investigator (contact)

Mary P. Metcalf, PhD, MPH, CHES – Principal Investigator

  • Web development is underway and planned for consumer release in Summer 2015.
  • iOS and Android tablet release with XML support for case construction is planned for Winter 2015-2016.

iPad EMR Pain Management Simulator: Tablet-based Skills Development

An estimated 100 million US adults suffer from chronic pain at an estimated cost of $635 billion [1] and, unfortunately, existing pain management training is not adequately preparing health professionals to address this area. To address this gap we propose to create iPad EMR Pain Management Simulator, an iPad-based application to provide a learning and shared experience environment for health professional students to enhance their skills related to pain assessment and control.

The simulated EMR will echo core features of any EMR used in clinical practice and present case simulations. For learners it will provide easy and affordable access to standardized skill-based pain management training. For faculty/educators it will assess: 1) a student's clinical competence and skills in diagnosing and treating patients with pain, while 2) decreasing the chance of opioid misuse and diversion.

For each iPad EMR simulated pain management case, health professional students will collect data, examine the patient, choose the appropriate course of action, outline a treatment plan, and receive feedback. Feedback from choices and decisions made will be based on best practice. The instructor will have control over the clinical components of the application by providing increasing or decreasing clinical information, challenge, feedback, or prompts.

Phase I will develop a prototype and perform basic usability of the potential intervention based on the active involvement of different target audiences: 1) health professional students in medicine and nursing, and 2) educators in medicine and nursing. Phase I will proceed with a carefully planned formative analysis involving needs analysis surveys, semi-structured interviews, guidance from consultants, creation of prototype experiences, and usability assessments.

Phase II will complete the activity and conduct an evaluation using a randomized, cross-over [wait-list control], pretest-posttest design with an estimated 60 participants from medicine and nursing. We will specifically assess if the simulated learning and shared experience environment positively impacts target clinical skills and increases core competencies related to assessment and treatment of pain.

Phase III will market the product actively via existing and novel partnerships with Clinical Tools. We will pursue additional tailoring of the content to specific audiences beyond physicians and nurses such as dentists, P.A.s, physical therapists and others. Our solution will support ongoing assessment of the training to determine areas of weakness which can be refined and improved over time.


Chronic pain is a common problem, affecting an estimated 100 million Americans [1]. Previously ignored, chronic pain has become a significant cause of an epidemic of prescription drug abuse, leading to misuse of opioid painkiller medications, diversion to the public, and overdose deaths.

In 2013, estimates of past-month substance use included 6.5 million people who used prescription drugs non-medically. That same year, approximately 1.9 million people had pain reliever dependence or abuse, up from only 1.5 million in 2002 [2]. Non-heroin opioid admissions rose from 2% of total admissions in 2002 to 10% in 2011 and represented 37% of all opioid admissions in 2012 (a major rise from 14% in 2002) [3]. Out of the 2.8 million recent initiates of illicit drug use in 2013, 1.5 million were initiates of nonmedical use of pain relievers. More than half of the nonmedical prescription drug users obtained the substance from friends or relatives, of whom 4 out of 5 obtained drugs from one doctor [2]. In California, worker's compensation prescriptions of Schedule II opioids increased nearly six-fold between 2002 and 2013 and has remained at an all-time high since 2010 [4].

Lest we fall back into a world where pain is under-treated, we must prepare future health professionals with the skills to intervene in pain without causing undue harm. This product will enhance the education of health care providers via a simulated clinical encounter where they can develop proper pain management and opioid risk assessment and intervention skills including screening (for pain and addiction history), full assessment and diagnosis (again of pain etiology and addiction), treatment interventions, and when necessary referral to a specialist in pain control and/or addiction. Future health professionals who are more proficient in core competencies related to pain management will be better equipped to reduce the suffering and costs of inadequate pain treatment.


1: Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education, and research. Washington, DC: The National Academies Press, 2011.

2: Substance Abuse and Mental Health Services Administration, Results from the 2013 National Survey on Drug Use and Health:Summary of National Findings, 2014. Available at:

3: Substance Abuse and Mental Health Services Administration, Center for Behavioral Health Statistics and Quality. Treatment Episode Data Set (TEDS): 2002-2012. National Admissions to Substance Abuse Treatment Services, 2014. Available at:

4: California Workers' Compensation Institute. Prevalence of Opioids in California Workers’ Comp Holding At Near-Record Highs. LexisNexis® Legal Newsroom. 2014. Available at: Accessed on: 2014-07-30.

An estimated 100 million US adults suffer from severe acute and chronic pain at an estimated cost of up to $635 billion; and misuse of opioids continues at epidemic proportions. These two public health problems interact to create a complex practice challenge for health care providers. Unfortunately, existing pain management training is not adequately preparing health professionals to address this area. To address this training gap we are creating Pain Tx Challenge, a cross platform application that provides a simulated clinical experience covering a spectrum of pain and addiction issues. Health professional students engaging in this learning experience will enhance their skills related to pain assessment and control and safe prescribing of pain medications.

In this new approach to clinical training, health professional students learn while experiencing a simulated clinical experience in a simulated electronic health record wrapper. Training involves progressing through the typical steps of a patient encounter by interacting with the patient's electronic health record (EHR), selecting clinical evaluations and interpreting results, making clinical decisions, and experiencing realistic clinical outcomes. Users “see” patients having a spectrum of pain and addiction conditions and are called on to use and learn evidence-based pain management skills.


To inform product development, formative studies were conducted with students and faculty to determine educational need. Next, after developing the product, we will conduct a pilot study (n=25) with the target audience to evaluate assessment instruments and the study process.

At the end of the pilot, we will make edits to the product, as suggested by the study participants. Next, we will perform a longitudinal study and a report of the effectiveness of the training activity on target professional and clinical skills using a randomized, cross-over design with an estimated 60 participants. A wait list control will be used. Summative analysis will include pre- and post assessment of educational value as well as post- qualitative assessments of the experience. Ratings of clinical skills and standard multiple choice questions will assess competence and performance with target professional and clinical skills. Self ratings will assess attitude and confidence change. We will analyze data, review results and revise as indicated.

Interested faculty will be invited to upload cases using our case creation feature and asked to provide feedback on this component of the product that will be further developed in Phase III development.

Contact us if you would like your students to participate or if you are interested in helping us test our case creation feature!


Students “see” patients in all the stages of a typical patient encounter, including history and physical exam, diagnostic tests, diagnosis, and treatment plan. At each stage, users are presented with challenges resembling the challenges they might face when seeing a patient needing pain management. Feedback is provided immediately after a choice is made and in the form of patient outcomes, later in the simulation.

Types of challenges include:

  • Ordering and interpreting assessments and diagnostic tests
  • Forming a differential diagnoses and final diagnosis
  • Creating a pain management treatment plan
  • Requesting consultations
  • Making referrals
  • Selecting patient education
  • Planning follow-up/monitoring

Feedback includes information as to whether a clinical decision made is correct or incorrect when it is possible to make this determination. Also, they are told if a decision follows evidence based guidelines. A star is awarded for the latter.

Info & Communications

Users have the option of looking up information that might help them in the patient encounter stage they are completing. Users at an earlier stage of their clinical training may need to consult this resource more often than more advanced users.

Users are made aware of the availability of diagnostic test results, consultation responses, and patient outcome information through a communications button at the top of the EHR.


Users are made aware of the availability of diagnostic test results, consultation responses, and patient outcome information through a communications button at the top of the EHR.


Students take a short quiz based on the objectives at the end of each module. Pre- to post-training evaluations are also available to measure changes in knowledge, attitude, self-efficacy, and intended behavior from before starting to use the simulation to after competing all modules.