DIABETES TECHNOLOGY amp THERAPEUTICSVolume 3 Number 4 2001copy Mary Ann Liebert Inc

Use of the AIDA Diabetes Simulation Softwaremdashwww2aidaorgmdashas an Interactive Educational Tool for

Teaching Student Nurses

PATRIZIO TATTI MD1 and ELDON D LEHMANN MBBS BSc2

ABSTRACT

In previous ldquoDiabetes Information Technology amp WebWatchrdquo columns various user experi-ences with an interactive educational virtual diabetes patient simulator called AIDA havebeen documented The simulator is available free of charge from www2aidaorg on the WebIn the 51 years since the program was first made available on the Internet over 125000 peo-ple have visited the AIDA Website and over 27000 copies of the program have been down-loaded gratis User comments that have been received about the program have highlightedsome of the many and varied ways in which a range of people have been applying the dia-betes simulations in their own particular situations and practices Inevitably up to now agreat deal of attention has focused on use of the program by individuals with diabetes andtheir relatives as well as by health-care professionals such as diabetologistsendocrinologistsdiabetes educators and primary care physicians (general practitioners [GPs])

However an important group of health-carers involved in the provision of day-to-day carefor many people with diabetes are nurses The current ldquoDiabetes Information Technology ampWebWatchrdquo column overviews a workshop held in June 2001 in Italy to gain experience withapplication of the AIDA diabetes simulation approach as a teaching tool for student nursesFeedback obtained from participants attending the workshop was generally very positivewith the student nurses reporting the simulation approach to be both of interest and of useFurther workshops involving other health-care students and professionalsmdashin particularmedical students and qualified nursesmdashare planned

655

INTRODUCTION

AIDA is an interactive educational freewarediabetes simulation program available

without charge from www2aidaorg on the

Web The software has been overviewed pre-viously elsewhere in this journal1 Briefly theprogram allows the simulation of clinical dia-betes situations for educational self-learningandor demonstration purposes

1Endocrine and Diabetes Unit Ospedale di Marino Marino Rome Italy2Academic Department of Radiology St Bartholomewrsquos Hospital and Department of Imaging NHLI (Imperial

College of Science Technology and Medicine) Royal Brompton Hospital London United KingdomEDL is a co-developer of the AIDA diabetes simulator

Diabetes Information Technology amp WebWatch

As an extension to our previous experienceusing the software with primary care physi-cians (general practitioners [GPs])2 for the cur-rent study we explored the use of AIDA witha group of student nurses attending the Nurs-ing School of the Hospital of Marino (outsideRome Italy) The aim of the workshop was toteach the student nurses using AIDA and tocollect some feedback from them about howthey perceived the role of the software in nurs-ing student education

MATERIALS AND METHODS

Twenty-four student nurses (aged 22ndash26years 8 males 16 females) in their final year ofstudy prior to graduation were invited to at-tend a lesson using a novel teaching methodThe aim of the lesson was made clear in ad-vance and the participants were informed thatthey would be asked to complete a question-naire concerning their opinions regarding useof the software as a teaching tool All the stu-dents who were asked volunteered to partici-pate and the workshop was held in mid-June2001

Overall the workshopcomputer-based les-son lasted 2 h The participants were seated ina classroom in rows of four people An over-head projector connected to a portable com-puter running the AIDA software was used forthe software presentation The program wasoperated by the teacher himself (PT) The first40 min of the lesson were devoted to an expla-nation of the basic physiology of normal non-diabetic subjects and the pathophysiology ofinsulin-dependent (type 1) diabetes mellituswith the help of a set of slides Some exampleillustrations from the presentation are shownin Figure 1

These illustrations summarize the basic ele-ments of pathophysiology of the postprandialand fasting diabetic state Sp and Sh representperipheral and hepatic insulin sensitivities re-spectively as applied within AIDA3 The fullarrows demonstrate the direction of the mainglucose fluxes the broken arrows represent thedirection of the minor (or temporarily absent)glucose fluxes These illustrations assist in un-derstanding the complex dynamics of glucose

in the human body and as such were felt tohelp exploit the full potential of AIDA whenteaching student nurses

SOFTWARE PRESENTATION

After a break of 5 min the diabetes simula-tion software was presented along with somevery simple clinical examples (translated intoItalian as far as possible)

Two case studies were demonstrated withparticular emphasis on hypoglycemia and theemergency treatment of hypoglycemic episodesaccording to the kinetics of the last insulin in-jection The risk of overcorrecting the blood glu-cose profile was made clear exploiting the po-tential of the AIDA software to demonstratethis

For this a situation was created in which thelsquohyporsquo appeared when the insulin in the bloodwas disappearing to show that a lsquohyporsquo at thattime is less dangerous than a lsquohyporsquo appearingearlier when there is a larger amount of circu-lating insulin A sample simulation taken fromthe lesson is shown in Figure 2

In this example 40 g of carbohydrate in-gested when insulin is disappearing may beconsidered an overcorrection and a more ap-propriate correction might involve the admin-istration of only 10ndash20 g of carbohydrate fol-lowed by cautious observation and review

It was explained to participants that theovercorrection with 40 g of carbohydrate at atime when the insulin level was declining andthe food absorption was starting to increasewould have contributed to the subsequent hy-perglycemia It was pointed out during theworkshop that had the hypoglycemia ap-peared at another time when the insulin wasincreasing then the correction might have beenmore appropriate Incidentally the subject notonly overcorrected but also did not recognizethe need to increase the subsequent insulindose and this also contributed to the lateevening hyperglycemia (Fig 2C)

Another focus of the lesson was on the roleof the liver in glucose metabolism an aspect ofthe disease that seemed to catch most of thestudent nurse participants completely un-aware A frequent comment was ldquoI heard of a

INFORMATION TECHNOLOGY amp WEBWATCH656

role for the liver but only now can I under-stand itrdquo

A third focus of the lesson was on the tim-ing of insulin injections in relation to carbohy-drate ingestion (eg the effect of delaying or

anticipating the injection of a rapidly acting in-sulin preparation)

As with the previous AIDA workshop forGPs2 the participants were divided intogroups and each group had to follow one of

INFORMATION TECHNOLOGY amp WEBWATCH 657

FIG 1 (A) Postprandial state in a nondiabetic subject In this state the hyperinsulinemia elicited by the ingestionof food is shown on the right side The glucose fluxes (arrows) are mainly directed towards the muscle and to a lesserextent towards the liver The extent of the flux is also regulated by the peripheral and hepatic insulin sensitivities(Sp and Sh respectively) In the diabetic subject whenever the blood glucose level is above the renal threshold ofglucose (RTG) glucose spills over into the urine (right lower quadrant) (B) By contrast during the hypoinsulinemiaof the fasting state the fluxes towards the muscle are reduced and the liver glucose flux is turned into a net outputUsing such an illustration it is possible to explain that in this setting the liver is the only input into the system andas such has an exceedingly important role in the hyperglycemia of fasting Sh hepatic insulin sensitivity Sp pe-ripheral insulin sensitivity

INFORMATION TECHNOLOGY amp WEBWATCH658

the simulation parameters during the softwarepresentation (eg the glycosylated hemoglobin[HbA1c] level or the blood glucose profile) Thecases elicited a vivid discussion and were eachsolved by the participants in about 20 min

At the end of the second hour of the lessonthe student nurses completed a simple ques-tionnaire This was based around that previ-ously described2 and was used to reveal theiropinions regarding the software Both openand closed questions were used

RESULTS

The closed questions and the answers givenby the participants are listed in Table 1 Also ofinterest are the participantsrsquo answers to theopen questions (translated from Italian as lit-erally as possible) These are given in Table 2

Connected with this it is interesting to notethat the aim of the simulator was not stated apriori as ldquopatient orientedrdquo but just as an al-ternative way of teaching Nevertheless the

FIG 2 (A) Baseline 24-h simulation from the AIDA simulator for an example patient with insulin-dependent (type1) diabetes mellitus on a four times daily short-acting regular (Humulin R) and intermediate acting (Humulin I) in-sulin regimen Lower panel Insulin and carbohydrate intake with predicted 24-h plasma insulin curve Upper panelPredicted 24-h steady-state blood glucose profile computed on the basis of the insulin and carbohydrate intake Ascan be seen the simulated patient experienced a symptomatic hypoglycemic episode at 1615 h (415 pm) (B) Sim-ulation shown in A in Fluxes mode allowing the different glucose fluxes within the model to be viewed interactivelyUptake grouped peripheral central nervous and red blood cell utilization of glucose nhgb net hepatic glucose bal-ance glucose absorption systemic appearance of glucose from the gut renal excretion loss of glucose via the kid-neys into the urine As can be seen at 1615 h (the time of the symptomatic hypoglycemic episode in Amdashnot markedhere for clarity) glucose absorption from the gut is actually rising Therefore the ingestion of a large quantity of car-bohydrate after the blood glucose test ( ( ) at 1700 h will actually create an overcorrection and a raised blood glu-cose level in the evening (as shown in C) (C) Based on the case scenario example shown in A and Bmdashwith the extraadministration of 40 g of carbohydrate at 1715mdashin an attempt to correct the hypoglycemic episode at 1615 h Cur-rent simulation shown as the bold dark linemdashwith the previous (baseline) simulation from A shown as the lightergray line As can be seen eating 40 g of carbohydrate at this time in fact is expected to cause an overcorrection in theblood glucose profilemdashwith a predicted blood glucose level of 270 mgdL (150 mmolL) at 2000 h (8 pm)

INFORMATION TECHNOLOGY amp WEBWATCH 659

FIG 2 Continued

students seemed to find a practical interest forthe patient in the simulations and correctlyidentified AIDA just as a teaching tool not asa way to give therapy advice or determine in-sulin dose adjustments Overall about 50 ofthe respondents thought that the softwareshould be applied in a patient-oriented man-ner 25 thought it should be used in the nurs-

ing school setting and 25 felt it should be oriented to both patients and students

Of interest also were the features that par-ticipants wanted to see added to future ver-sions of the program (Table 2) Here the great-est concern seemed to be with a local language(Italian) version although many of the otherparticipants thought the software was com-

INFORMATION TECHNOLOGY amp WEBWATCH660

TABLE 1 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO CLOSED QUESTIONS

BASED ON THE STANDARD QUESTIONNAIRE2

No answer(left blank) Do not know

Question Yes n () No n () n () n ()

Do you think AIDA is a promising educational tool 23 (957) mdash 1 (43) mdashDo you think AIDA is useful 23 (957) mdash 1 (43) mdashDo you think you will keep on using AIDA 4 (174) 14 (565) 2 (87) 4 (174)Do you think AIDA is worthy of more widespread 20 (826) 2 (87) 1 (43) 1 (43)0

distributionIf they had computerInternet access would you 1 (43) 20 (826) 2 (87) 1 (43)0

tell friends and colleagues about AIDADo you think AIDA can be in any way dangerous 23 (957) mdash 1 (43) mdashHave you ever come across any tools like AIDA 2 (87) 20 (826) 2 (87) mdash

for diabetes self-education

TABLE 2 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO

OPEN QUESTIONS FROM THE STANDARD QUESTIONNAIRE2

How do you think AIDA can be usedUseful for teaching more so for patients (n 5 8)Clarifies diseases simply Should be used for teaching (n 5 1)Helps evaluate things easily-useful for patients (n 5 1)For teaching to communicate to improve control (n 5 1)Useful to understand the pathophysiology (n 5 1)Helps understanding in the clinical setting (n 5 1)In the office in the wards in the school (n 5 1)Should be a complement to traditional study methods (n 5 1)Should be used with standard lessons (n 5 1)

Which other features would you add to AIDAI do not know AIDA enough (n 5 1)An Italian version (n 5 6)Nothing it is complete (n 5 6)Improve graphics (n 5 2)Graphics should be more easily understandable (n 5 1)A voice to explain the graphs (n 5 3)The case scenarios should include more extreme cases (eg coma) (n 5 1)

Write any free text commentsA fascinating instrument (n 5 1)Useful for teaching and in medical practice (n 5 2)Could avoid dangerous mistakes I would promote a course to use it (n 5 1)Stimulates thinking and discourages automatic learning (n 5 1)Interesting toolmdashneeds a good explanation before use (n 5 1)Interesting toolmdashgood graphic display (n 5 1)Very useful to understand the pathophysiology of the disease (n 5 1)Good teaching method (n 5 2)

Numbers in brackets are the number of respondents who gave each answer

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

role for the liver but only now can I under-stand itrdquo

A third focus of the lesson was on the tim-ing of insulin injections in relation to carbohy-drate ingestion (eg the effect of delaying or

anticipating the injection of a rapidly acting in-sulin preparation)

As with the previous AIDA workshop forGPs2 the participants were divided intogroups and each group had to follow one of

INFORMATION TECHNOLOGY amp WEBWATCH 657

FIG 1 (A) Postprandial state in a nondiabetic subject In this state the hyperinsulinemia elicited by the ingestionof food is shown on the right side The glucose fluxes (arrows) are mainly directed towards the muscle and to a lesserextent towards the liver The extent of the flux is also regulated by the peripheral and hepatic insulin sensitivities(Sp and Sh respectively) In the diabetic subject whenever the blood glucose level is above the renal threshold ofglucose (RTG) glucose spills over into the urine (right lower quadrant) (B) By contrast during the hypoinsulinemiaof the fasting state the fluxes towards the muscle are reduced and the liver glucose flux is turned into a net outputUsing such an illustration it is possible to explain that in this setting the liver is the only input into the system andas such has an exceedingly important role in the hyperglycemia of fasting Sh hepatic insulin sensitivity Sp pe-ripheral insulin sensitivity

INFORMATION TECHNOLOGY amp WEBWATCH658

the simulation parameters during the softwarepresentation (eg the glycosylated hemoglobin[HbA1c] level or the blood glucose profile) Thecases elicited a vivid discussion and were eachsolved by the participants in about 20 min

At the end of the second hour of the lessonthe student nurses completed a simple ques-tionnaire This was based around that previ-ously described2 and was used to reveal theiropinions regarding the software Both openand closed questions were used

RESULTS

The closed questions and the answers givenby the participants are listed in Table 1 Also ofinterest are the participantsrsquo answers to theopen questions (translated from Italian as lit-erally as possible) These are given in Table 2

Connected with this it is interesting to notethat the aim of the simulator was not stated apriori as ldquopatient orientedrdquo but just as an al-ternative way of teaching Nevertheless the

FIG 2 (A) Baseline 24-h simulation from the AIDA simulator for an example patient with insulin-dependent (type1) diabetes mellitus on a four times daily short-acting regular (Humulin R) and intermediate acting (Humulin I) in-sulin regimen Lower panel Insulin and carbohydrate intake with predicted 24-h plasma insulin curve Upper panelPredicted 24-h steady-state blood glucose profile computed on the basis of the insulin and carbohydrate intake Ascan be seen the simulated patient experienced a symptomatic hypoglycemic episode at 1615 h (415 pm) (B) Sim-ulation shown in A in Fluxes mode allowing the different glucose fluxes within the model to be viewed interactivelyUptake grouped peripheral central nervous and red blood cell utilization of glucose nhgb net hepatic glucose bal-ance glucose absorption systemic appearance of glucose from the gut renal excretion loss of glucose via the kid-neys into the urine As can be seen at 1615 h (the time of the symptomatic hypoglycemic episode in Amdashnot markedhere for clarity) glucose absorption from the gut is actually rising Therefore the ingestion of a large quantity of car-bohydrate after the blood glucose test ( ( ) at 1700 h will actually create an overcorrection and a raised blood glu-cose level in the evening (as shown in C) (C) Based on the case scenario example shown in A and Bmdashwith the extraadministration of 40 g of carbohydrate at 1715mdashin an attempt to correct the hypoglycemic episode at 1615 h Cur-rent simulation shown as the bold dark linemdashwith the previous (baseline) simulation from A shown as the lightergray line As can be seen eating 40 g of carbohydrate at this time in fact is expected to cause an overcorrection in theblood glucose profilemdashwith a predicted blood glucose level of 270 mgdL (150 mmolL) at 2000 h (8 pm)

INFORMATION TECHNOLOGY amp WEBWATCH 659

FIG 2 Continued

students seemed to find a practical interest forthe patient in the simulations and correctlyidentified AIDA just as a teaching tool not asa way to give therapy advice or determine in-sulin dose adjustments Overall about 50 ofthe respondents thought that the softwareshould be applied in a patient-oriented man-ner 25 thought it should be used in the nurs-

ing school setting and 25 felt it should be oriented to both patients and students

Of interest also were the features that par-ticipants wanted to see added to future ver-sions of the program (Table 2) Here the great-est concern seemed to be with a local language(Italian) version although many of the otherparticipants thought the software was com-

INFORMATION TECHNOLOGY amp WEBWATCH660

TABLE 1 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO CLOSED QUESTIONS

BASED ON THE STANDARD QUESTIONNAIRE2

No answer(left blank) Do not know

Question Yes n () No n () n () n ()

Do you think AIDA is a promising educational tool 23 (957) mdash 1 (43) mdashDo you think AIDA is useful 23 (957) mdash 1 (43) mdashDo you think you will keep on using AIDA 4 (174) 14 (565) 2 (87) 4 (174)Do you think AIDA is worthy of more widespread 20 (826) 2 (87) 1 (43) 1 (43)0

distributionIf they had computerInternet access would you 1 (43) 20 (826) 2 (87) 1 (43)0

tell friends and colleagues about AIDADo you think AIDA can be in any way dangerous 23 (957) mdash 1 (43) mdashHave you ever come across any tools like AIDA 2 (87) 20 (826) 2 (87) mdash

for diabetes self-education

TABLE 2 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO

OPEN QUESTIONS FROM THE STANDARD QUESTIONNAIRE2

How do you think AIDA can be usedUseful for teaching more so for patients (n 5 8)Clarifies diseases simply Should be used for teaching (n 5 1)Helps evaluate things easily-useful for patients (n 5 1)For teaching to communicate to improve control (n 5 1)Useful to understand the pathophysiology (n 5 1)Helps understanding in the clinical setting (n 5 1)In the office in the wards in the school (n 5 1)Should be a complement to traditional study methods (n 5 1)Should be used with standard lessons (n 5 1)

Which other features would you add to AIDAI do not know AIDA enough (n 5 1)An Italian version (n 5 6)Nothing it is complete (n 5 6)Improve graphics (n 5 2)Graphics should be more easily understandable (n 5 1)A voice to explain the graphs (n 5 3)The case scenarios should include more extreme cases (eg coma) (n 5 1)

Write any free text commentsA fascinating instrument (n 5 1)Useful for teaching and in medical practice (n 5 2)Could avoid dangerous mistakes I would promote a course to use it (n 5 1)Stimulates thinking and discourages automatic learning (n 5 1)Interesting toolmdashneeds a good explanation before use (n 5 1)Interesting toolmdashgood graphic display (n 5 1)Very useful to understand the pathophysiology of the disease (n 5 1)Good teaching method (n 5 2)

Numbers in brackets are the number of respondents who gave each answer

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

INFORMATION TECHNOLOGY amp WEBWATCH658

the simulation parameters during the softwarepresentation (eg the glycosylated hemoglobin[HbA1c] level or the blood glucose profile) Thecases elicited a vivid discussion and were eachsolved by the participants in about 20 min

At the end of the second hour of the lessonthe student nurses completed a simple ques-tionnaire This was based around that previ-ously described2 and was used to reveal theiropinions regarding the software Both openand closed questions were used

RESULTS

The closed questions and the answers givenby the participants are listed in Table 1 Also ofinterest are the participantsrsquo answers to theopen questions (translated from Italian as lit-erally as possible) These are given in Table 2

Connected with this it is interesting to notethat the aim of the simulator was not stated apriori as ldquopatient orientedrdquo but just as an al-ternative way of teaching Nevertheless the

FIG 2 (A) Baseline 24-h simulation from the AIDA simulator for an example patient with insulin-dependent (type1) diabetes mellitus on a four times daily short-acting regular (Humulin R) and intermediate acting (Humulin I) in-sulin regimen Lower panel Insulin and carbohydrate intake with predicted 24-h plasma insulin curve Upper panelPredicted 24-h steady-state blood glucose profile computed on the basis of the insulin and carbohydrate intake Ascan be seen the simulated patient experienced a symptomatic hypoglycemic episode at 1615 h (415 pm) (B) Sim-ulation shown in A in Fluxes mode allowing the different glucose fluxes within the model to be viewed interactivelyUptake grouped peripheral central nervous and red blood cell utilization of glucose nhgb net hepatic glucose bal-ance glucose absorption systemic appearance of glucose from the gut renal excretion loss of glucose via the kid-neys into the urine As can be seen at 1615 h (the time of the symptomatic hypoglycemic episode in Amdashnot markedhere for clarity) glucose absorption from the gut is actually rising Therefore the ingestion of a large quantity of car-bohydrate after the blood glucose test ( ( ) at 1700 h will actually create an overcorrection and a raised blood glu-cose level in the evening (as shown in C) (C) Based on the case scenario example shown in A and Bmdashwith the extraadministration of 40 g of carbohydrate at 1715mdashin an attempt to correct the hypoglycemic episode at 1615 h Cur-rent simulation shown as the bold dark linemdashwith the previous (baseline) simulation from A shown as the lightergray line As can be seen eating 40 g of carbohydrate at this time in fact is expected to cause an overcorrection in theblood glucose profilemdashwith a predicted blood glucose level of 270 mgdL (150 mmolL) at 2000 h (8 pm)

INFORMATION TECHNOLOGY amp WEBWATCH 659

FIG 2 Continued

students seemed to find a practical interest forthe patient in the simulations and correctlyidentified AIDA just as a teaching tool not asa way to give therapy advice or determine in-sulin dose adjustments Overall about 50 ofthe respondents thought that the softwareshould be applied in a patient-oriented man-ner 25 thought it should be used in the nurs-

ing school setting and 25 felt it should be oriented to both patients and students

Of interest also were the features that par-ticipants wanted to see added to future ver-sions of the program (Table 2) Here the great-est concern seemed to be with a local language(Italian) version although many of the otherparticipants thought the software was com-

INFORMATION TECHNOLOGY amp WEBWATCH660

TABLE 1 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO CLOSED QUESTIONS

BASED ON THE STANDARD QUESTIONNAIRE2

No answer(left blank) Do not know

Question Yes n () No n () n () n ()

Do you think AIDA is a promising educational tool 23 (957) mdash 1 (43) mdashDo you think AIDA is useful 23 (957) mdash 1 (43) mdashDo you think you will keep on using AIDA 4 (174) 14 (565) 2 (87) 4 (174)Do you think AIDA is worthy of more widespread 20 (826) 2 (87) 1 (43) 1 (43)0

distributionIf they had computerInternet access would you 1 (43) 20 (826) 2 (87) 1 (43)0

tell friends and colleagues about AIDADo you think AIDA can be in any way dangerous 23 (957) mdash 1 (43) mdashHave you ever come across any tools like AIDA 2 (87) 20 (826) 2 (87) mdash

for diabetes self-education

TABLE 2 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO

OPEN QUESTIONS FROM THE STANDARD QUESTIONNAIRE2

How do you think AIDA can be usedUseful for teaching more so for patients (n 5 8)Clarifies diseases simply Should be used for teaching (n 5 1)Helps evaluate things easily-useful for patients (n 5 1)For teaching to communicate to improve control (n 5 1)Useful to understand the pathophysiology (n 5 1)Helps understanding in the clinical setting (n 5 1)In the office in the wards in the school (n 5 1)Should be a complement to traditional study methods (n 5 1)Should be used with standard lessons (n 5 1)

Which other features would you add to AIDAI do not know AIDA enough (n 5 1)An Italian version (n 5 6)Nothing it is complete (n 5 6)Improve graphics (n 5 2)Graphics should be more easily understandable (n 5 1)A voice to explain the graphs (n 5 3)The case scenarios should include more extreme cases (eg coma) (n 5 1)

Write any free text commentsA fascinating instrument (n 5 1)Useful for teaching and in medical practice (n 5 2)Could avoid dangerous mistakes I would promote a course to use it (n 5 1)Stimulates thinking and discourages automatic learning (n 5 1)Interesting toolmdashneeds a good explanation before use (n 5 1)Interesting toolmdashgood graphic display (n 5 1)Very useful to understand the pathophysiology of the disease (n 5 1)Good teaching method (n 5 2)

Numbers in brackets are the number of respondents who gave each answer

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

INFORMATION TECHNOLOGY amp WEBWATCH 659

FIG 2 Continued

students seemed to find a practical interest forthe patient in the simulations and correctlyidentified AIDA just as a teaching tool not asa way to give therapy advice or determine in-sulin dose adjustments Overall about 50 ofthe respondents thought that the softwareshould be applied in a patient-oriented man-ner 25 thought it should be used in the nurs-

ing school setting and 25 felt it should be oriented to both patients and students

Of interest also were the features that par-ticipants wanted to see added to future ver-sions of the program (Table 2) Here the great-est concern seemed to be with a local language(Italian) version although many of the otherparticipants thought the software was com-

INFORMATION TECHNOLOGY amp WEBWATCH660

TABLE 1 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO CLOSED QUESTIONS

BASED ON THE STANDARD QUESTIONNAIRE2

No answer(left blank) Do not know

Question Yes n () No n () n () n ()

Do you think AIDA is a promising educational tool 23 (957) mdash 1 (43) mdashDo you think AIDA is useful 23 (957) mdash 1 (43) mdashDo you think you will keep on using AIDA 4 (174) 14 (565) 2 (87) 4 (174)Do you think AIDA is worthy of more widespread 20 (826) 2 (87) 1 (43) 1 (43)0

distributionIf they had computerInternet access would you 1 (43) 20 (826) 2 (87) 1 (43)0

tell friends and colleagues about AIDADo you think AIDA can be in any way dangerous 23 (957) mdash 1 (43) mdashHave you ever come across any tools like AIDA 2 (87) 20 (826) 2 (87) mdash

for diabetes self-education

TABLE 2 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO

OPEN QUESTIONS FROM THE STANDARD QUESTIONNAIRE2

How do you think AIDA can be usedUseful for teaching more so for patients (n 5 8)Clarifies diseases simply Should be used for teaching (n 5 1)Helps evaluate things easily-useful for patients (n 5 1)For teaching to communicate to improve control (n 5 1)Useful to understand the pathophysiology (n 5 1)Helps understanding in the clinical setting (n 5 1)In the office in the wards in the school (n 5 1)Should be a complement to traditional study methods (n 5 1)Should be used with standard lessons (n 5 1)

Which other features would you add to AIDAI do not know AIDA enough (n 5 1)An Italian version (n 5 6)Nothing it is complete (n 5 6)Improve graphics (n 5 2)Graphics should be more easily understandable (n 5 1)A voice to explain the graphs (n 5 3)The case scenarios should include more extreme cases (eg coma) (n 5 1)

Write any free text commentsA fascinating instrument (n 5 1)Useful for teaching and in medical practice (n 5 2)Could avoid dangerous mistakes I would promote a course to use it (n 5 1)Stimulates thinking and discourages automatic learning (n 5 1)Interesting toolmdashneeds a good explanation before use (n 5 1)Interesting toolmdashgood graphic display (n 5 1)Very useful to understand the pathophysiology of the disease (n 5 1)Good teaching method (n 5 2)

Numbers in brackets are the number of respondents who gave each answer

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

students seemed to find a practical interest forthe patient in the simulations and correctlyidentified AIDA just as a teaching tool not asa way to give therapy advice or determine in-sulin dose adjustments Overall about 50 ofthe respondents thought that the softwareshould be applied in a patient-oriented man-ner 25 thought it should be used in the nurs-

ing school setting and 25 felt it should be oriented to both patients and students

Of interest also were the features that par-ticipants wanted to see added to future ver-sions of the program (Table 2) Here the great-est concern seemed to be with a local language(Italian) version although many of the otherparticipants thought the software was com-

INFORMATION TECHNOLOGY amp WEBWATCH660

TABLE 1 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO CLOSED QUESTIONS

BASED ON THE STANDARD QUESTIONNAIRE2

No answer(left blank) Do not know

Question Yes n () No n () n () n ()

Do you think AIDA is a promising educational tool 23 (957) mdash 1 (43) mdashDo you think AIDA is useful 23 (957) mdash 1 (43) mdashDo you think you will keep on using AIDA 4 (174) 14 (565) 2 (87) 4 (174)Do you think AIDA is worthy of more widespread 20 (826) 2 (87) 1 (43) 1 (43)0

distributionIf they had computerInternet access would you 1 (43) 20 (826) 2 (87) 1 (43)0

tell friends and colleagues about AIDADo you think AIDA can be in any way dangerous 23 (957) mdash 1 (43) mdashHave you ever come across any tools like AIDA 2 (87) 20 (826) 2 (87) mdash

for diabetes self-education

TABLE 2 RESPONSES OF THE STUDENT NURSE PARTICIPANTS TO

OPEN QUESTIONS FROM THE STANDARD QUESTIONNAIRE2

How do you think AIDA can be usedUseful for teaching more so for patients (n 5 8)Clarifies diseases simply Should be used for teaching (n 5 1)Helps evaluate things easily-useful for patients (n 5 1)For teaching to communicate to improve control (n 5 1)Useful to understand the pathophysiology (n 5 1)Helps understanding in the clinical setting (n 5 1)In the office in the wards in the school (n 5 1)Should be a complement to traditional study methods (n 5 1)Should be used with standard lessons (n 5 1)

Which other features would you add to AIDAI do not know AIDA enough (n 5 1)An Italian version (n 5 6)Nothing it is complete (n 5 6)Improve graphics (n 5 2)Graphics should be more easily understandable (n 5 1)A voice to explain the graphs (n 5 3)The case scenarios should include more extreme cases (eg coma) (n 5 1)

Write any free text commentsA fascinating instrument (n 5 1)Useful for teaching and in medical practice (n 5 2)Could avoid dangerous mistakes I would promote a course to use it (n 5 1)Stimulates thinking and discourages automatic learning (n 5 1)Interesting toolmdashneeds a good explanation before use (n 5 1)Interesting toolmdashgood graphic display (n 5 1)Very useful to understand the pathophysiology of the disease (n 5 1)Good teaching method (n 5 2)

Numbers in brackets are the number of respondents who gave each answer

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

plete Some though found the output a little dif-ficult to understand and wanted improvementsto the graphics

The responses to the final question givingparticipants an opportunity to write free textcomments are self-explanatory (Table 2)mdashalthough it is interesting to see how differentand wide ranging the feedback is

DISCUSSION

This is only the second workshop to be heldusing AIDA and we are still gaining experi-ence about how best to apply the software inan interactive meeting setting It is clearly im-portant that the computer be operated by some-one experienced with the software Also aquestionnaire has been adopted to formalizeobtaining feedback from the participants2 Thismay need slight modification and translatingdepending on the emphasisparticipants andcountry where the workshop is held (and thelanguage used for the lessons) but neverthe-less having a semistandardized questionnaire2

should aid the running and evaluation of fu-ture workshops

Notwithstanding the potential concernsraised by one closed question (Table 1) the an-swers to the open questions (Table 2) were in-formative and generally very encouraging Inaddition the interest of the entire audienceseems to have been highmdashwith all participantsreturning for the software presentation afterthe mid-workshop break

It is our growing experience that in a work-shop setting the AIDA simulation softwaremay be most useful if introduced by some in-formation about the general pathophysiologyof diabetes We are finding that basic physio-logical informationmdashalthough clearly knownto diabetologistsendocrinologists and otherexpertsmdashmay not be so well understood bystudents and nonexpert GPs We plan to in-clude a basic pathophysiology introduction inall future diabetes simulation workshopslessons and also will be seekingmdashin duecoursemdashto place this information on the Inter-net at the AIDA Website (www2aidaorg)

Overall judging by the responses to thequestionnaires (Tables 1 and 2) AIDA seems to

be an interesting and attractive tool for studentnurses This observation is also consistent withpreviously documented experience using theprogram with patients4ndash6 GPs2 and otherhealth-carers 7

In the current study the majority of partici-pants (n 5 23 96) reported finding AIDApromising as an educational tool and thoughtthe software was useful (Table 1) Over half ofthose who attended the workshoplesson (n 514 57) expected to carry on using AIDA witha large number of attendees (n 5 20 83)thinking that AIDA was worthy of more wide-spread distribution However interestinglymost of those questioned (n 5 20 83) did notplan to tell friends or colleagues about the pro-gram Also the majority of participants (n 5 2396) expressed reservations that the softwaremight be perceived as dangerous (Table 1) Thequestionnaire did not permit the thought pro-cesses underlying this perceived concern to beexploredmdashalthough it is interesting that theseviews were not expressed in any of the free textcomments (Table 2)

Nevertheless this issue does warrant furtherinvestigation and analysis in future lessonsworkshops However it is interesting to notethat in a larger survey of 200 AIDA users (in-cluding patients students and health-care pro-fessionals) who were able to use the softwareon their own for as long as they required whenasked the same question the majority (73) didnot regard AIDA as in any way dangerouswith 10 answering ldquodo not knowrdquo and only17 believing that the software might be ofsome danger (Dr ED Lehmann unpublishedobservations)

Obviously any program or educational toolcan be misused and this is one of the reasonsfor the clear caveatswarnings provided at thestart of the software (Fig 3A) to make usersaware that the simulator is not intended for in-dividual patient blood glucose prediction or forinsulin-dosage adjustmenttherapy planning(Fig 3B) Furthermore to reinforce this pointit is actually explicitly stated in the caveats atthe start of the program that ldquoit could be dan-gerous for insulin-dependent diabetic patientsto follow the lsquoadvicersquo given or act on the resultsof the simulated datardquo (Fig 3B)

However it is our preliminary experience

INFORMATION TECHNOLOGY amp WEBWATCH 661

INFORMATION TECHNOLOGY amp WEBWATCH662

FIG 3 (A) Opening caveatwarning screen for the AIDA diabetes simulation software It is not possible to run theAIDA simulator without viewing this screen and pressing a key to move onto the next screen (B) Second caveatwarn-ing screen for the AIDA diabetes simulation software It is not possible to run the AIDA simulator without viewingthis screen and pressing a key to move onto the next display

that if applied properly with a short course oflessons8 the program may actually help to im-prove HbA1c levels and reduce the number ofhypoglycemic episodes9 This initial experienceis based on a small pilot study just involving24 patients with diabetes so clearly substantialproof of efficacy will need to await the resultsof larger-scale studies

In this respect it is important to make clearthat workshops such as the current one or thatinvolving GPs2 do not provide any proof of ef-fectiveness in improving overall outcome in di-abetes nor in enhancing the quality of life Ran-domized-controlled trials (RCTs) are requiredfor this

Connected with this we have developed astandardized RCT protocol that can be used toevaluate the utility of such diabetes simulationsoftware for educational use with patients8 Ashighlighted above preliminary pilot study re-sults from teaching sessions with 24 diabeticpatients have established the feasibility of thisapproach9 Further information about this canbe found at www2aidaorgevaluate on theWeb

CONCLUSION

This workshop appears to have been a suc-cess and popular with the participating studentnurses Furthermore it appears that the use ofAIDA as a teaching tool for student nurses is anew avenue that could be explored to capital-ize on the potential utility of the software Fur-ther workshops involving other health-carestudents and professionals in particular med-ical students and qualified nurses are planned

With the idea of further diabetes workshopsmaking use of AIDA for teaching students pa-tients and fellow health-care professionalsmdashand the plan to run RCTs to evaluate the edu-cational efficacy of such simulation software insmall group diabetes teaching sessionsmdashthe is-sue of how to train teachersdemonstrators touse AIDA becomes of increasing importance

In a future issue of the journal this topic willbe considered providing some recommenda-tions and guidelines for fellow health-care pro-fessionals who wish to teach using AIDA

SYSTEM AVAILABILITY

The latest release of AIDA (v43a) can bedownloaded without charge from www2aidaorg on the Internet The program runs onIBM PC or compatible 8038680486Pentium-based machines and requires approximately 3Mb of hard disk storage space The softwarecan also be used on Apple Macintosh comput-ers running PC emulators such as Virtual PCor SoftWindows A fully Internet-based versionof AIDA called AIDA online is also availablefor use free-of-charge at www2aidaorgon-line on the Web This allows AIDArsquos diabetessimulations to be run from any computer any-where provided it has an Internet connectionand a graphical display

An interactive educational DiabetesInsulinTutorial that has been integrated with AIDAonline can also be accessed without charge atwww2aidaorgtutorial on the Web This al-lows visitors to dynamically simulate some ofwhat they have learnt in the tutorial about bal-ancing insulin and diet in diabetes using AIDAonline

People who wish to be automatically in-formed about future updates and enhance-ments to the AIDAAIDA online diabetes soft-ware range can subscribe (for free) to the AIDAdiabetes simulator announcement list by send-ing a blank e-mail note to subscribe2aidaorg

Any readers who might be interested in col-laborating by teaching in their clinics usingAIDA or by applying a standardized random-ized controlled trial protocol8 in an evaluationof AIDA in clinician- specialist nursendash or ed-ucator-led patient teaching sessions are invitedto contact one of the authors Further informa-tion about the evaluation of AIDA for patientuse can be found at www2aidaorgevaluateon the Web

FURTHER TOPICS

If you would like to suggest further topics or Websites for future ldquoDiabetes InformationTechnology amp WebWatchrdquo columns please e-mail informationmdashwith a brief description ofthe sitesuggestionmdashto Dr ED Lehmann

INFORMATION TECHNOLOGY amp WEBWATCH 663

that if applied properly with a short course oflessons8 the program may actually help to im-prove HbA1c levels and reduce the number ofhypoglycemic episodes9 This initial experienceis based on a small pilot study just involving24 patients with diabetes so clearly substantialproof of efficacy will need to await the resultsof larger-scale studies

In this respect it is important to make clearthat workshops such as the current one or thatinvolving GPs2 do not provide any proof of ef-fectiveness in improving overall outcome in di-abetes nor in enhancing the quality of life Ran-domized-controlled trials (RCTs) are requiredfor this

Connected with this we have developed astandardized RCT protocol that can be used toevaluate the utility of such diabetes simulationsoftware for educational use with patients8 Ashighlighted above preliminary pilot study re-sults from teaching sessions with 24 diabeticpatients have established the feasibility of thisapproach9 Further information about this canbe found at www2aidaorgevaluate on theWeb

CONCLUSION

This workshop appears to have been a suc-cess and popular with the participating studentnurses Furthermore it appears that the use ofAIDA as a teaching tool for student nurses is anew avenue that could be explored to capital-ize on the potential utility of the software Fur-ther workshops involving other health-carestudents and professionals in particular med-ical students and qualified nurses are planned

With the idea of further diabetes workshopsmaking use of AIDA for teaching students pa-tients and fellow health-care professionalsmdashand the plan to run RCTs to evaluate the edu-cational efficacy of such simulation software insmall group diabetes teaching sessionsmdashthe is-sue of how to train teachersdemonstrators touse AIDA becomes of increasing importance

In a future issue of the journal this topic willbe considered providing some recommenda-tions and guidelines for fellow health-care pro-fessionals who wish to teach using AIDA

SYSTEM AVAILABILITY

The latest release of AIDA (v43a) can bedownloaded without charge from www2aidaorg on the Internet The program runs onIBM PC or compatible 8038680486Pentium-based machines and requires approximately 3Mb of hard disk storage space The softwarecan also be used on Apple Macintosh comput-ers running PC emulators such as Virtual PCor SoftWindows A fully Internet-based versionof AIDA called AIDA online is also availablefor use free-of-charge at www2aidaorgon-line on the Web This allows AIDArsquos diabetessimulations to be run from any computer any-where provided it has an Internet connectionand a graphical display

An interactive educational DiabetesInsulinTutorial that has been integrated with AIDAonline can also be accessed without charge atwww2aidaorgtutorial on the Web This al-lows visitors to dynamically simulate some ofwhat they have learnt in the tutorial about bal-ancing insulin and diet in diabetes using AIDAonline

People who wish to be automatically in-formed about future updates and enhance-ments to the AIDAAIDA online diabetes soft-ware range can subscribe (for free) to the AIDAdiabetes simulator announcement list by send-ing a blank e-mail note to subscribe2aidaorg

Any readers who might be interested in col-laborating by teaching in their clinics usingAIDA or by applying a standardized random-ized controlled trial protocol8 in an evaluationof AIDA in clinician- specialist nursendash or ed-ucator-led patient teaching sessions are invitedto contact one of the authors Further informa-tion about the evaluation of AIDA for patientuse can be found at www2aidaorgevaluateon the Web

FURTHER TOPICS

If you would like to suggest further topics or Websites for future ldquoDiabetes InformationTechnology amp WebWatchrdquo columns please e-mail informationmdashwith a brief description ofthe sitesuggestionmdashto Dr ED Lehmann

INFORMATION TECHNOLOGY amp WEBWATCH 663

info-www2aidaorg (please write ldquoDiabetesWebWatchrdquo in the subject line) You can alsofax information to (503) 218-0828 quoting Diabetes Information Technology amp Web-Watch

REFERENCES

1 Lehmann ED Experience with the Internet release ofAIDA v4mdashan interactive educational diabetes simula-tor Diabetes Technol Ther 1999141ndash54

2 Tatti P Lehmann ED Utility of the AIDA diabetes sim-ulator as an interactive educational teaching tool forgeneral practitioners (primary care physicians) Dia-betes Technol Ther 20013133ndash140

3 Lehmann ED Deutsch T A physiological model of glucosendashinsulin interaction in type I diabetes mellitusJ Biomed Eng 199214235ndash242

4 Lehmann ED User experience with the AIDA interac-tive educational virtual diabetes patient simulator Di-abetes Technol Ther 20002165ndash171

5 Lehmann ED Spontaneous comments from users ofthe AIDA interactive educational diabetes simulatorDiabetes Educ 200026633ndash643

6 Lehmann ED Short user comments (ldquosound bitesrdquo) re-

garding usage of AIDA v4mdashhttpwww2aidaorgmdashan interactive educational diabetes simulator DiabetesTechnol Ther 20002663ndash666

7 Lehmann ED Preliminary experience with the Inter-net release of AIDAmdashan interactive educational dia-betes simulator Comput Methods Programs Biomed199856109ndash132

8 Tatti P Lehmann ED A randomised-controlled clini-cal trial methodology for evaluating the teaching util-ity of interactive educational diabetes simulators Dia-betes Nutr Metab 2001141ndash17

9 Tatti P Lehmann ED Preliminary results from a ran-domised controlled clinical trial for evaluating theteaching utility of an interactive educational diabetessimulator (AIDA) [Abstract] Diabetes 200150(Suppl2)A25

Address reprint requests toEldon D Lehmann MBBS BScAcademic Department of Radiology

St Bartholomewrsquos HospitalLondon EC1A 7BE UK

E-mail info-www2aidaorg

Web www2aidaorglehmann

INFORMATION TECHNOLOGY amp WEBWATCH664