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BackgroundMassive open online courses (MOOCs) have been criticized for focusing on presentation of short video clip lectures and asking theoretical multiple-choice questions. A potential way of vitalizing these educational activities in the health sciences is to introduce virtual patients. Experiences from such extensions in MOOCs have not previously been reported in the literature.ObjectiveThis study analyzes technical challenges and solutions for offering virtual patients in health-related MOOCs and describes patterns of virtual patient use in one such course. Our aims are to reduce the technical uncertainty related to these extensions, point to aspects that could be optimized for a better learner experience, and raise prospective research questions by describing indicators of virtual patient use on a massive scale.MethodsThe Behavioral Medicine MOOC was offered by Karolinska Institutet, a medical university, on the EdX platform in the autumn of 2014. Course content was enhanced by two virtual patient scenarios presented in the OpenLabyrinth system and hosted on the VPH-Share cloud infrastructure. We analyzed web server and session logs and a participant satisfaction survey. Navigation pathways were summarized using a visual analytics tool developed for the purpose of this study.ResultsThe number of course enrollments reached 19,236. At the official closing date, 2317 participants (12.1% of total enrollment) had declared completing the first virtual patient assignment and 1640 (8.5%) participants confirmed completion of the second virtual patient assignment. Peak activity involved 359 user sessions per day. The OpenLabyrinth system, deployed on four virtual servers, coped well with the workload. Participant survey respondents (n=479) regarded the activity as a helpful exercise in the course (83.1%). Technical challenges reported involved poor or restricted access to videos in certain areas of the world and occasional problems with lost sessions. The visual analyses of user pathways display the parts of virtual patient scenarios that elicited less interest and may have been perceived as nonchallenging options. Analyzing the user navigation pathways allowed us to detect indications of both surface and deep approaches to the content material among the MOOC participants.ConclusionsThis study reported on first inclusion of virtual patients in a MOOC. It adds to the body of knowledge by demonstrating how a biomedical cloud provider service can ensure technical capacity and flexible design of a virtual patient platform on a massive scale. The study also presents a new way of analyzing the use of branched virtual patients by visualization of user navigation pathways. Suggestions are offered on improvements to the design of virtual patients in MOOCs.