A quick-start guide to the NEJM Healer virtual-patient encounter

This guide helps new NEJM Healer users quickly learn how to use the application while working through a case. Consider accessing this document before and during your first encounter. 

You will need to have the application in full screen on some devices to access all of the functionality.

ENCOUNTER Overview

Each encounter has four stages of data acquisition:

• Triage 
• History 
• Physical examination 
• Diagnostic test results 

At each stage, you will:

• Acquire pertinent data 
• Write a problem representation 
• Build and rank a differential 

NOTE: NEJM Healer will save your problem representations and assess your differentials from each stage. Therefore, each stage is equally assessed.

Next, you will build illness scripts using expert-selected data and diseases.

Then, you will confirm your lead diagnosis, create a management plan, and submit the case to receive detailed feedback. 

ASSESSMENT OVERVIEW

After submitting the case, you will be informed of the diagnosis and will have the opportunity to self-assess your problem representations and management plan compared to those of the expert.

You will receive feedback and be given a score relative to expert reasoning on the following skills: 

• Data-Acquisition Thoroughness: How many data thought to be pertinent by the expert did you also acquire? 
• Data-Acquisition Efficiency: How many of the data you acquired were considered pertinent by the expert? 
• Final Lead Dx: Did you identify the lead hypothesis in the case at the end of the diagnostic stage?  
• Revised Lead Dx: Did you identify the lead hypothesis after receiving initial feedback and completing the Dx Pause? 
• Differential Diagnosis: How concordant was your differential with the expert’s at each stage and throughout the encounter? 
• Illness Script Concordance: How concordant were the three illness scripts you built with those of the expert? 

Step 1 – Triage

• Acquire pertinent data in the “General” and “Chief Concern” sections by checking the box to the right of each datum. Selecting a datum adds it to the Diagnosis Pad on the right. 
• Select the “Findings” tab of the pad at any time to see the list of pertinent data you have selected so far. 

• Add a problem representation to the text box in the Diagnosis Pad on the right.
  
  Sometimes called the “one-liner,” the problem representation is a sentence that defines the problem you need to solve and justifies your differential.
  
  A triage problem representation might read: A 51-year-old male presents with acute dyspnea at rest and hypoxemia without fever.
  

• Build your differential. Add a disease by typing it into the “Enter your diagnoses” box on the Diagnosis Pad.  
• Be as specific as possible. For example, if you have enough data to suggest an acute coronary syndrome (ACS) but don’t have an ECG yet to call an ST-segment elevation myocardial infarction (STEMI), then choose ACS. Choosing STEMI will only get you a partial score. 
• Rank your differential from most likely to least likely by dragging the diseases to reorder them.
  
  Remember: You will be assessed stage-by-stage on how well your differential matches the expert’s.
  
  
• The system will lock in your differential and your problem representation as you move to the next stage of the clinical encounter.  

Step 2 – History

• Select the relevant data in Medical History, Family History, and Social History in the left column.  
• In the middle column under Review of Systems, use the dropdown menu to go through each of the sections and select more relevant data.  
• As you gather data, expand the problem representation. 
  
  Such a summary statement might read: A 51-year-old male smoker presents with acute dyspnea at rest, weight gain, lower extremity swelling, and hypoxemia without fever and cough.
  
  
• Update and rank your differential. 

Step 3 – Physical Exam

• Work through the Organ Systems on the left to perform your virtual exam.
• Using your differential diagnosis to guide your inquiry, be selective in choosing the exams you perform. 
• Update your problem representation and your ranked differential.

Step 4 – Diagnostics  

• Check the most important test results from the patient’s chart to justify and update your differential. 
  
  NOTE: You are browsing pre-existing test results in the chart, and not ordering these tests. 
  
  
• Update your problem representation, which at this point should summarize your perspective of the case.
  
  Such a summary statement might read: A 51-year-old male smoker presents in mild respiratory distress with acute dyspnea at rest, hypoxemia, signs of volume overload, audible S3/S4, a displaced point of maximal impulse, and poor perfusion to the extremities; normal troponin; and cardiomegaly on chest imaging. 

Step 5 – Finalize and Reflect

• Make any final changes to your differential.
• Indicate how confident you are that you’ve identified the most likely lead hypothesis (the top disease on your differential).
• Self-assess your cognitive load by indicating how mentally demanding you found the case to be.

Step 6 – Receive Initial Feedback

• Receive feedback on your data acquisition:
  • Data acquisition thoroughness: How many of the data thought to be pertinent by experts did you also acquire? 
  • Data acquisition efficiency: How many of the data you acquired were considered pertinent by experts? Were you able to zero-in on the data that the experts thought was important, or did you select many extraneous data? 
• See how the top 3 diseases on your differential overlapped with the expert’s top 3.
  
  NOTE: The expert’s top 3 are presented alphabetically and are not necessarily indicative of their prioritized differential.

Step 7 – The Diagnostic Pause

• Build illness scripts using expert-selected data and diseases.
• Supporting findings (green data) and Refuting findings (red data) are presented separately.
  • Light green data make a disease somewhat more likely.
  • Dark green data make a disease extremely likely.
  • Light red data make a disease somewhat less likely.
  • Dark red data make a disease extremely unlikely.
• First, drag and drop green findings into the most appropriate segment of the Venn diagram.
• Second, drag and drop red findings into the most appropriate segment of the Venn diagram.

• As you do so, a table opens to the left of the findings to show you which findings are aligned with which diseases.  
• You can also interact with the table instead of the Venn diagram. 
• You can change your work by moving a finding to a different segment or by clicking on the minus sign next to the finding. 
• Once all findings are placed, move on to the management tab or click submit.

Step 8 – Management

• First, based on your Venn, select which of the expert’s top 3 diseases you now believe is the most likely diagnosis. 
• Then, create a management plan by suggesting additional diagnostic tests as well as any treatments, referrals, patient counseling, and patient disposition in the field provided.  

Note: You’ll self-assess by comparing your plan with the expert’s once you submit the case. The expert might not have content in each area, so you may indicate N/A if you think that, for example, counseling or referral, don’t apply.

Step 9 – Case Assessment 

• Once you’ve submitted your case for review, you will see the diagnosis for the case and you’ll be asked to complete a self-assessment, comparing your problem representations and management plan with the expert’s. 
• Submit to view your Performance Summary and Feedback. Click through each tab to understand your performance and receive focused, detailed feedback to help you improve.