Global Health Informatics Education (Studies in Health Technology and Informatics)

GLOBAL HEALTH INFORMATICS EDUCATION Studies in Health Technology and Informatics This book series was started in 1990 ...

Author: E. Hovenga | J. Mantas

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GLOBAL HEALTH INFORMATICS EDUCATION

Studies in Health Technology and Informatics This book series was started in 1990 to promote research conducted under the auspices of the EC programmes Advanced Informatics in Medicine (AIM) and Biomedical and Health Research (BHR), bioengineering branch. A driving aspect of international health informatics is that telecommunication technology, rehabilitative technology, intelligent home technology and many other components are moving together and form one integrated world of information and communication media. The complete series has been accepted in Medline. In the future, the SHTI series will be available online. Series Editors: Dr. J.P. Christensen, Prof. G. de Moor, Prof. A. Hasman, Prof. L. Hunter, Dr. I. Iakovidis, Dr. Z. Kolitsi, Dr. Olivier Le Dour, Dr. Andreas Lymberis, Dr. Peter Niederer, Prof. A. Pedotti, Prof. O. Rienhoff, Prof. F.H. Roger-France, Dr. N. Rossing, Prof. N. Saranummi, Dr. E.R. Siegel and Dr. Petra Wilson

Volume 109 Recently published in this series Vol. 108. Vol. 107. Vol. 106. Vol. 105. Vol. 104. Vol. 103. Vol. 102. Vol. 101.

Vol. 100. Vol. 99. Vol. 98.

Vol. 97. Vol. 96. Vol. 95.

A. Lymberis and D. de Rossi (Eds.), Wearable eHealth Systems for Personalised Health Management – State of the Art and Future Challenges M. Fieschi, E. Coiera and Y.-C.J. Li (Eds.), MEDINFO 2004 – Proceedings of the 11th World Congress on Medical Informatics G. Demiris (Ed.), e-Health: Current Status and Future Trends M. Duplaga, K. Zieliński and D. Ingram (Eds.), Transformation of Healthcare with Information Technologies R. Latifi (Ed.), Establishing Telemedicine in Developing Countries: From Inception to Implementation L. Bos, S. Laxminarayan and A. Marsh (Eds.), Medical and Care Compunetics 1 D.M. Pisanelli (Ed.), Ontologies in Medicine K. Kaiser, S. Miksch and S.W. Tu (Eds.), Computer-based Support for Clinical Guidelines and Protocols – Proceedings of the Symposium on Computerized Guidelines and Protocols (CGP 2004) I. Iakovidis, P. Wilson and J.C. Healy (Eds.), E-Health – Current Situation and Examples of Implemented and Beneficial E-Health Applications G. Riva, C. Botella, P. Légeron and G. Optale (Eds.), Cybertherapy – Internet and Virtual Reality as Assessment and Rehabilitation Tools for Clinical Psychology and Neuroscience J.D. Westwood, R.S. Haluck, H.M. Hoffman, G.T. Mogel, R. Phillips and R.A. Robb (Eds.), Medicine Meets Virtual Reality 12 – Building a Better You: The Next Tools for Medical Education, Diagnosis, and Care M. Nerlich and U. Schaechinger (Eds.), Integration of Health Telematics into Medical Practice B. Blobel and P. Pharow (Eds.), Advanced Health Telematics and Telemedicine – The Magdeburg Expert Summit Textbook R. Baud, M. Fieschi, P. Le Beux and P. Ruch (Eds.), The New Navigators: from Professionals to Patients – Proceedings of MIE2003

ISSN 0926-9630

Global Health Informatics Education

Edited by

E.J.S. Hovenga School of Information Systems, Faculty of Informatics and Communication, Central Queensland University, Rockhampton, Qld MC 4702, Australia

and

J. Mantas Health Informatics Laboratory, Faculty of Nursing, National and Kapodistrian University of Athens, 11527 Athens, Greece

Amsterdam • Berlin • Oxford • Tokyo • Washington, DC

© 2004, The authors mentioned in the table of contents All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 1 58603 454 5 Library of Congress Control Number: 2004111546

Publisher IOS Press Nieuwe Hemweg 6B 1013 BG Amsterdam The Netherlands fax: +31 20 620 3419 e-mail: [email protected] Distributor in the UK and Ireland IOS Press/Lavis Marketing 73 Lime Walk Headington Oxford OX3 7AD England fax: +44 1865 750079

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS

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Foreword “Throughout the world, health care professionals often lack knowledge of the possibilities and limitations of systematically processing data, information and knowledge and of the resulting impact on quality decision-making. They are often asked to use information technologies of which they have limited appreciation, in order to enhance their practices through better use of information resources. However, for systematically processing data, information and knowledge in medicine and in health care, health care professionals who are well-trained in medical informatics or health informatics are needed. It will only be through improved education of health care professionals and through an increase in the number of well-trained workers in health and medical informatics that this lack of knowledge and associated skills can begin to be reversed. Health and medical informatics education is of particular importance at the beginning of the 21st century for the following reasons …: 1 progress in information processing and information and communication technology is changing our societies; 2 the amount of health and medical knowledge is increasing at such a phenomenal rate that we cannot hope to keep up with it, or store, organise and retrieve existing and new knowledge in a timely fashion without using a new information processing methodology and information technologies; 3 there are significant economic benefits to be obtained from the use of information and communication technology to support medicine and health care; 4 similarly the quality of health care is enhanced by the systematic application of information processing and information and communication technology; 5 it is expected, that these developments will continue, probably at least at the same pace as can be observed today; 6 health care professionals who are well-educated in health or medical informatics are needed to systematically process information in medicine and in health care, and for the appropriate and responsible application of information and communication technology; 7 through an increase in scope and the provision of high quality education in the field of health and medical informatics, well-educated health care professionals world-wide are expected to raise the quality and efficiency of health care.” These were the first paragraphs of the recommendations of the International Medical Informatics Association (IMIA) on health and medical informatics education1. Although we can recognise further progress in educating health care professionals in this field and although a considerable number of educational programs for health informatics / medical informatics specialists have been set up, there is still a need to enhance these educational activities world wide, considering global developments as well as new curricular concepts and technological opportunities. IMIA and in particular its working group on health and medical informatics education (www.IMIA.org) is the leading international society stimulating such educational activities in various ways. As part of these activities, the past and the current chairperson of IMIA’s 1

Recommendations of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics. Methods Inf Med 2000; 39: 267-77. See also http://www.imia.org.

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working group on health and medical informatics education, Professor Evelyn Hovenga, Central Queensland University, Rockhampton, Australia, and Professor John Mantas, National and Kapodistrian University of Athens, Greece, have now edited this book on global health informatics education. Their know-how and experience as well as that of the numerous authors of this book will especially be helpful for educators in the field of health/medical informatics. With the knowledge contained in this book, let us try to further improve education and with it, finally, the quality and efficiency of care. Prof. Dr. Reinhold Haux Rector of UMIT - the University for Health Sciences, Medical Informatics and Technology, Innsbruck, Austria IMIA Vice-President for Services

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Preface Health and medical informatics education has received attention since the 1970s when the education working group was established and led by Dr Roger Salamon and Dr Francois Gremy to address this important issue for the International Medical Informatics Association (IMIA). Seven IMIA sponsored working conferences have been held over the years in France (Lyon and another in Chamonix), Canada, Czechoslovakia, Germany, Australia and the USA (Portland). All proceedings have been published. These have raised awareness of the importance of introducing informatics into medical and health professional curricula and to prepare specialists in medical informatics. There is agreement that health and medical informatics can be regarded as a separate discipline with the need for specialised curricula although the scientific underpinnings of the field are not well articulated in our textbooks or by our professional societies. Establishing a virtual health informatics university to provide global collaborative health informatics education and research was first discussed by a number of IMIA Health and Medical Education Working Group members at the conference held in Newcastle, Australia in 1997. Since then this idea has been nurtured and various possible organisational models explored. The decision that only institutional academic IMIA members are able to be collaborators in this initiative has resulted in a steady increase in members over recent years. IMIA currently has 29 academic institutional members from 12 countries. In 2003 the IMIA working group held a meeting in Portland, USA exploring how we could teach globally, learn locally. A selection of papers presented at this meeting was published as a special issue of the International Journal of Medical Informatics in March 2004. This book is a continuation of our efforts to develop a suitable implementation plan that requires us to fully understand educational differences so that we can better plan for global collaboration. We are witnessing a paradigm shift in higher education as a result of technological advances, adoption of on-line learning and a greater participation in e-commerce by higher education providers. Given the dearth of academics with high level expertise in health informatics in many countries, we need to explore how best to use our scarce resources to have the greatest possible impact regarding the preparation of health professionals such that they can make the best possible use of available informatics technologies to support health service delivery. Electronic or e-learning is being adopted by many. It may include the use of Intranet, email, CD-ROM, DVD, video and audio (tele-) conferencing or electronic discussion groups via the web. Many of these methods are used as delivery methods for distance education to supplement print based materials. Once e-learning is adopted on a large scale there is a need to focus on organisational infrastructure changes required to accommodate these new ways of providing educational services as the adoption of such technologies requires a greater investment of academic effort together with a variety of specialist support staff. Borderless education was examined from a business perspective during 2000 with an update in 2001 for Australia’s Government. In European Union under the initiatives of ehealth and e-government similar approaches were commencing to be developed. This canvassed the emergence of corporate, for-profit and virtual universities. Two versions of ‘virtual’ universities were identified, an organisation providing an advisory service but essentially acting as a clearing house and an online ‘total service’ provider. The ‘clearing house’ concept has essentially been adopted by the IMIA education group in the first instance.

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We have yet to adopt international standards regarding educational terms and their definitions. The current global educational diversity makes the identification, assessment, ranking, accreditation of courses and awards as well as the provision of credit transfers between educational providers difficult, time consuming and challenging. The IMIA education working group is exploring the potential to develop a coordinated educational framework to suit the health and medical informatics discipline. This book is another step in this direction.

The Editors, Professor E.J.S. Hovenga Professor J. Mantas

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Acknowledgements The Editors would like to thank the IMIA President, the Board, and the General Assembly for accepting the proposal to publish the book and for their generous support. We would like to thank the authors for their enthusiastic acceptance of our invitation to contribute and for their suggestions. We thank especially Professor Dr. Reinhold Haux and Professor Arie Hasman for their constructive insights towards the coverage of all aspects of the theme of the book. Finally, we would like to thank Dr. Joseph Liaskos and Miss Martha Charalambidou from the University of Athens for their work to compile and prepare the documents in accordance to the publishers’ instructions. Last but not least we thank IOS Press for their effort to publish the book on time for distribution at Medinfo 2004, San Francisco.

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Contents Foreword

v

Preface

vii

Acknowledgements

ix

Section 1. Governance 1.1 Virtual University Governance E.J.S. Hovenga

3

1.2 Comparative Educational Systems J. Mantas

8

1.3 Academic Standards, Credit Transfers and Associated Issues E.J.S. Hovenga

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1.4 Student and Teacher Exchanges – Criteria for Access J. Roberts

28

1.5 Gaining Support from Health Disciplines and Other Stakeholders J. Murphy

36

Section 2. Curricula and Degree Structures (Outcomes and Recognition) 2.1 A Health Informatics Educational Framework E.J.S. Hovenga

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2.2 Curricula in Medical Informatics A. Hasman and R. Haux

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2.3 Competencies and Credentialing: Nursing Informatics V.K. Saba, D.J. Skiba and C. Bickford

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2.4 Health Informatics Needs Regulation and Registration to Add Value Recognition J. Roberts and G. Hayes

90

2.5 Educational Standards – Terminologies Used R. Engelbrecht, J. Ingenerf and J. Reiner

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2.6 Future Trends in Health Informatics J. Mantas

114

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Section 3. Delivery and Evaluation Methods (Pedagogy and Andragogy) 3.1 Current and Future Trends in Teaching and Learning E.J.S. Hovenga and L. Bricknell

131

3.2 Cognitive Theories and the Design of E-Learning Environments B. Gillani and C. O’Guinn

143

3.3 Self Directed and Lifelong Learning S. Alexander, G. Kernohan and P. McCullagh

152

3.4 Managing Large Online Classes Across Multiple Locations K. Egea and A.C.L. Zelmer

167

3.5 Evolutionary Epistemology and Dynamical Virtual Learning Networks U. Giani

182

3.6 The Role of Evaluation in Web-Based Education K. Saranto, J. Lammintakanen and K. Häyrinen

203

3.7 Student Support Infrastructure C. Nohr

213

International Medical Informatics Association (IMIA) Working Group on Health and Medical Informatics Education WG1

224

Recommendations of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics

226

Authors

244

Glossary

246

Subject Index

273

Author Index

275

Section 1 Governance


Global Health Informatics Education E.J.S. Hovenga and J. Mantas (Eds.) IOS Press, 2004

3

1.1. Virtual University Governance Evelyn J.S. HOVENGA Faculty of Informatics and Communication, Central Queensland University, Rockhampton MC4702 Australia

Abstract. There is a need to establish collaboration alliances or partnerships if we are to provide global Health Informatics educatics education. Agreements need to make provision for the existing diversity between country educational systems as well as variations in funding, legislation and political systems and a number of other issues including intellectual property and copyright. Four virtual University governance models were identified, 1) evolution of existing universities, 2) newly created organisations collectively delivering one type of program eg MBA, 3) a consortium of partners using a common portal and 4) a commercial enterprise. Collectively IMIA academic members need to be in a good position to respond to the global changes in higher education and minimise the risk of failure when establishing a virtual University to collectively deliver Health Informatics education. Others have undertaken a similar path in the past, some successful others not so, we need to learn from these experiences.

1. Introduction The provision of global education requires collaboration, alliances or partnerships between any number of organisations. Educational providers within formal consortia may all be not for profit, or for profit or there may a mix of not for profit and commercial organisations. Governance concerns intellectual ownership of educational content vs an open source model, competition policies and formal agreements detailing individual organisational responsibility arrangements to meet agreed objectives of global strategic alliances between health and informatics education providers and possibly industry partners. This arrangements include statements regarding national copyright issues, adoption of technology standards, cost/funding and administrative structures. Educational provider partners must also comply with national Government policies regarding overseas students. This may influence delivery methods to be adopted, acceptable cost/funding arrangements and educational opportunities. Issues associated with the establishment of alliances adopting any one of many governance options are summarised in table 1. To date only the Massachusets Institute of Technology (MIT) has been in a position to make all its courses available free as opensource courseware via the web [1]. Their approach differentiates between content availability and teaching and learning. The latter requires student administration, provision of academic student support and the awarding of degrees. Their arrangement facilitates academics from elsewhere to make use of the MIT material in the knowledge that many students will continue to value being an on campus MIT student resulting in an MIT degree.

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E.J.S. Hovenga / Virtual University Governance

Table 1. Governance Options and Issues. Governance Options Global Strategic Alliances between health and informatics education providers and possibly industry partners.

Issues o o o o o o o o o o o o

Organisational and program accreditation Intellectual ownership of educational content vs an open source model Competition policies National and organisational copyright issues Adoption of technology standards Variations in National educational standards, degree structures, definitions and managing credit transfers Program/course accreditation Health Informatics competency requirements, credentialing Professional recognition of a health informatician Professional, corporate and/or vacational education Cost/funding, administrative and governance structures Compliance with national Government policies regarding overseas students

2. Changes in Higher Education We are currently witnessing significant changes in higher education around the world due to globalisating, an increasing reliance on information and communication technologies including the Internet, government funding decreases and an increasing need to provide lifelong learning. These changes are resulting in a large competitive international higher education market with a high student mobility factor, changes in student demographics towards a larger number of adult learners, an increasing demand for continuing professional education, the need to improve and demonstrate quality whilst reducing costs, changing academic roles and the need to develop e-learning competencies[2]. These changes are providing new challenges and require adaptable and flexible leadership styles. Mason [3] states that ‘the impact of technology on the whole institution is of such magnitude that the leaders of the university cannot delegate decisions about technology strategy to the information officer. For most universities the senior team needs to own the IT issues and to integrate them into the strategic vision for the university’ (p.11). We are also witnessing an increase in the establishment of virtual universities. This is expected to erode the traditional student base of universities in both developing and developed countries’ although this is likely to be off set by the changes in student demographics and the associated lifelong/adult learning market. Virtual universities tend to be [4]: evolutions of existing universities where virtual or on-line education is offered by one or more departments, newly created organisations operating as a virtual university to deliver one or specific programs such as an MBA or offering programs from many discipline areas on a State or Country basis, or a consortium of partners constituted to develop and/or offer virtual education via a common portal, or a commercial enterprise, including corporate universities, media and publishing enterprises, offering on line education. Some of these are Government sponsored, others are not. Whatever model we choose to adopt will depend on funds available, the level of commitment from all stakeholders and their willingness to provide input, strong leadership, carefull attention to the initial estab-


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lishment arrangements and to mechanisms needed to maintain and continue the relationships between all players. In addition there needs to be a willingness and ability to change various existing in-house arrangements or patterns of behaviour or modes of educational delivery as required.

3. A Global Health Informatics University There are a number of options for the IMIA health and medical informatics education working group to consider. To date our discussions have tended to favour the formation of a loose consortium consisting of IMIA institutional academic members and the provision of a common web based portal. Academic membership is available to any academic and/or research facility that include health and medical informatics and associated fields of interest in their curriculum or research program. This provides one level of quality ensurance in that only reputable and accredited organisations are accepted for membership. At this stage only links to these member websites are provided via the IMIA homepage, we need to explore how to progress. This book is one step towards achieving this goal. All stakeholders need to be well informed of the issues so that we can move on and reach agreement about a common vision, objectives and values. 3.1. Examples of Possible Governance Models We can learn from other past experiences so as not to repeat mistakes. Mason [3] noted that many ‘early adopters’ have ceased to exist. Nevertheless it is predicted that the increasing adoption of on-line learning will continue. The United Kingdom’s electronic university (UKeU) was a company established in 2001 to deliver degrees and degree level learning accredited by UK universities online and worldwide. It is backed and very substantially funded by the UK Government working in partnership with respected UK academic institutions and leading technological companies. UKeU was to seek out the best courses in subject areas with high customer demand and then work with their academic partners to develop these courses specifically for online delivery. They have invested to create an interactive eLearning platform in partnership with Sun Microsystems and adopted Fujitsu’s operational and service support. Central Queensland University and no doubt many others have developed this type of infrastructure over many years on a shoestring by comparison. However funding isn’t all we need, in 2004 it was reported that [4] : “The Higher Education Funding Council for England has decided to discontinue a virtual university set up in 2001 due to low numbers of students enrolled. U.K. eUniversities Worldwide (UKeU) had hoped to draw 5,600 students in its first year, but three years later, the program only has 900 students enrolled. The British government had allocated $111 million for the program, of which about $63 million has been spent. Other anticipated sources of funding, including partnerships with businesses, never materialized at acceptable levels. According to members of the funding council, the crash of the dot-com economy at about the same time as the founding of UKeU led to the lack of interest from most corporations. Others believe that UKeU was flawed in its design, relying on faculty without adequate experience in online education, and that developers of the program spent their resources building an educational platform rather than using tools available on the market”

Another model no longer in operation was the Fathom knowledge network consisting on 14 member institutions and course partners. It began in 1998 as a Columbia university initia-

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Table 2. A Few Examples of Virtual University Models. Canadian Virtual University ®(CVU)

A partnership of universities across Canada, committed to delivering universitylevel programs that can be completed from anywhere in the country or beyond. http://www.cvu-uvc.ca/english.html

Cardean University®

An academic consortium with five elite institutions offering only a MBA degree to corporate customers, given degree-granting authorization in Illinois. http://www.cardean.edu/cgibin/cardean1/view/about_storyCardean.jsp?visitor=guest

Finnish Virtual University

Develops procedures and co-operative networks in virtual education, with the aim to make them a natural element in the Finnish higher education system. The activities aim to identify and remove obstacles to co-operation, and to promote the educational use of information and communication technologies and electronic access to services. www.virtuaaliyliopisto.fi/index.php?language=eng

Idaho Electronic Campus

Links to more than 1600 courses from the State's seven publicly funded colleges and universities. A growing number of entire programs can be completed online. http://www.idahoe-campus.state.id.us/about/about.html

tive and was established as a for profit company. Fathom offered on line education from top research institutions by providing a focus and an infrastructure to faciliate its partners to share production resources, technology platforms, and market intelligence. It provide free sample lectures as a means of attracting students prepared to pay for the course. Fathom simply provided the portal so could seen as a marketing partner to the members. None of the members provided full degree programs online yet it was noted in hindsight that “people will pay handsomely for Internet education, but only if it leads to degrees, or credentials, or certificates that have professional standing” [5]. Kirschner observed that traditional universities spend lots to create online learning programs yet almost nothing is spent to market these. Fathom’s capital requirements, carried exclusively by Columbia university, were serious and a new administration no longer supported this as a signature project resulting in members recapturing their content to pursue their own individual plans. A number of Virtual Universities are listed at a UNESCO website [6], some of which are listed as examples in table 2 below.

4. Conclusion We are now witnessing a paradigm shift in higher education as a result of technological advances, adoption of on line learning and a greater participation in e-commerce by higher education providers. Given the dearth of academics with high level expertise in health informatics in many countries, we need to explore how best to use our scarce resources to have the greatest possible impact regarding the preparation of health professionals such that they can make the best possible use of available informatics technologies to support health service delivery. Academic IMIA members need to reach consensus about how best to establish a global health informatics virtual university model to enable global educational delivery and contribute to global capacity building. In addition to resolving the governance issue it is also necessary to establish how best to deal with country educational system diversity, establish and maintain academic standards, manage credit transfers, student and teacher exchanges, and gain support from the health disciplines and other stakeholders. These topics are discussed in greater detail in the following chapters.


7

References [1] Massachusetts Institute of Technology (MIT) Open Course Ware, http://ocw.mit.edu/index.html accessed 24 June 2004. [2] Hovenga E 2004 Changing Academic Roles: New Approaches to Teaching and Learning, paper presented at EuroMISE 2004 conference in Prague accepted for publication in a special issue of Methods of Information in Medicine. [3] Mason R 2003 The university – current challenges and opportunities in: The Virtual University, D’Antoni S Editor, International Institute for Educational Planning, UNESCO http://www.unesco.org/iiep/virtualuniversity/files/chap2.pdf accessed 24 June 2004 [4] D’Antonio S 2003 The Virtual University Models and messages: Lessons from case studies, D’Antoni S Editor, International Institute for Educational Planning, UNESCO http://www.unesco.org/iiep/virtualuniversity/home.php# accessed 24 June 2004 [4] U.K. Officials End Virtual University, Chronicle of Higher Education, 6 May 2004 (sub. req'd) http://chronicle.com/prm/daily/2004/05/2004050606n.htm accessed 9 May 2004 [5] Ann Kirschner on Marketing and Distribution of Online Learning, Ubiquity, Volume 5, Issue 17, June 23-29, 2004, http://www.acm.org/ubiquity/ accessed 24 June 2004. [6] United Nations Educational, Scientific and Cutural Organisation (UNESCO), International Institute for Educational Planning, http://www.unesco.org/iiep/virtualuniversity/links.php

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1.2. Comparative Educational Systems J. MANTAS Health Informatics Laboratory, Faculty of Nursing, University of Athens, 123 Papadiamantopoulou Street, 11527 Athens, Greece Abstract. During recent years Europe has been engaged in an educational reform that tends to change the whole educational system concerning higher education. The main issues of this reform are related to the free movement of labour and students across the member states. Hence, the need of comparative educational systems, levels, and degrees. The European Union and its executive bodies the European Council and European Commission have issued a series of declarations that are amalgamated in this chapter. The ideas behind these declarations formulate the framework of comparative educational systems that can have a significant impact on the global health informatics education.

1. Introduction The European process, thanks to the extraordinary achievements of the last few years, has become an increasingly concrete and relevant reality for the Union and its citizens. Enlargement prospects together with deepening relations with other European countries provide even wider dimensions to that reality. Meanwhile, we are witnessing a growing awareness in large parts of the political and academic world and in public opinion of the need to establish a more complete and far-reaching Europe, in particular building upon and strengthening its intellectual, cultural, social and scientific and technological dimensions. A Europe of Knowledge is now widely recognised as an irreplaceable factor for social and human growth and as an indispensable component to consolidate and enrich the European citizenship, capable of giving its citizens the necessary competences to face the challenges of the new millennium, together with an awareness of shared values and belonging to a common social and cultural space. The course has been set in the right direction and with meaningful purpose. The achievement of greater compatibility and comparability of the systems of higher education nevertheless requires continual momentum in order to be fully accomplished. We need to support it through promoting concrete measures to achieve tangible forward steps. While affirming our support to the general principles laid down in the Sorbonne declaration, we engage in co-ordinating our policies to reach in the short term, and in any case within the first decade of the third millennium, the following objectives, which we consider to be of primary relevance in order to establish the European area of higher education and to promote the European system of higher education world-wide: 1. Adoption of a system of easily readable and comparable degrees, also through the implementation of the Diploma Supplement, in order to promote European citizens employability and the international competitiveness of the European higher education system 2. Adoption of a system essentially based on two main cycles, undergraduate and graduate. Access to the second cycle shall require successful completion of first cy-

J. Mantas / Comparative Educational Systems

9

cle studies, lasting a minimum of three years. The degree awarded after the first cycle shall also be relevant to the European labour market as an appropriate level of qualification. The second cycle should lead to the master and/or doctorate degree as in many European countries. 3. Establishment of a system of credits - such as in the ECTS system - as a proper means of promoting the most widespread student mobility. Credits could also be acquired in non-higher education contexts, including lifelong learning, provided they are recognised by receiving Universities concerned. 4. Promotion of mobility by overcoming obstacles to the effective exercise of free movement with particular attention to: •

for students, access to study and training opportunities and to related services • for teachers, researchers and administrative staff, recognition and valorisation of periods spent in a European context researching, teaching and training, without prejudicing their statutory rights. 5. Promotion of European co-operation in quality assurance with a view to developing comparable criteria and methodologies. 6. Promotion of the necessary European dimensions in higher education, particularly with regards to curricular development, inter-institutional co-operation, mobility schemes and integrated programmes of study, training and research.

2. Declarations On 19 June 1999, one year after the Sorbonne Declaration, Ministers responsible for higher education from 29 European countries signed the Bologna Declaration. They agreed on important joint objectives for the development of a coherent and cohesive European Higher Education Area by 2010. In the first follow-up conference held in Prague on 19 May 2001, they increased the number of the objectives and reaffirmed their commitment to establish the European Higher Education Area by 2010. On 19 September 2003, Ministers responsible for higher education from 33 European countries met in Berlin in order to review the progress achieved and to set priorities and new objectives for the coming years, with a view to speeding up the realisation of the European Higher Education Area. They agreed on the following considerations, principles and priorities: Ministers reaffirm the importance of the social dimension of the Bologna Process. The need to increase competitiveness must be balanced with the objective of improving the social characteristics of the European Higher Education Area, aiming at strengthening social and gender cohesion and reducing social inequalities both at national and at European level. In that context, Ministers reaffirm their position that higher education is a public good and a public responsibility. They emphasize that in international academic cooperation and exchanges, academic values should prevail. Ministers take into due consideration the conclusions of the European Councils in Lisbon (2000) and Barcelona (2002) aimed at making Europe „the most competitive and dynamic knowledge-based economy in the world, capable of sustainable economic growth with more and better jobs and greater social cohesion“ and calling for further action and closer co-operation in the context of the Bologna Process. Ministers take note of the Progress Report commissioned by the Follow-up Group on the development of the Bologna Process between Prague and Berlin. They also take note of the Trends-III Report prepared by the European University Association (EUA), as well as of the results of the seminars, which were organised as part of the work programme be-

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tween Prague and Berlin by several member States and Higher Education Institutions, organisations and students. Ministers further note the National Reports, which are evidence of the considerable progress being made in the application of the principles of the Bologna Process. Finally, they take note of the messages from the European Commission and the Council of Europe and acknowledge their support for the implementation of the Process. Ministers agree that efforts shall be undertaken in order to secure closer links overall between the higher education and research systems in their respective countries. The emerging European Higher Education Area will benefit from synergies with the European Research Area, thus strengthening the basis of the Europe of Knowledge. The aim is to preserve Europe's cultural richness and linguistic diversity, based on its heritage of diversified traditions, and to foster its potential of innovation and social and economic development through enhanced co-operation among European Higher Education Institutions. Ministers recognise the fundamental role in the development of the European Higher Education Area played by Higher Education Institutions and student organisations. They take note of the message from the European University Association (EUA) arising from the Graz Convention of Higher Education Institutions, the contributions from the European Association of Institutions in Higher Education (EURASHE) and the communications from ESIB - the National Unions of Students in Europe. Ministers welcome the interest shown by other regions of the world in the development of the European Higher Education Area, and welcome in particular the presence of representatives from European countries not yet party to the Bologna Process as well as from the Follow-up Committee of the European Union, Latin America and Caribbean (EULAC) Common Space for Higher Education as guests at this conference.

3. Progress Ministers welcome the various initiatives undertaken since the Prague Higher Education Summit to move towards more comparability and compatibility, to make higher education systems more transparent and to enhance the quality of European higher education at institutional and national levels. They appreciate the co-operation and commitment of all partners - Higher Education Institutions, students and other stakeholders - to this effect. Ministers emphasise the importance of all elements of the Bologna Process for establishing the European Higher Education Area and stress the need to intensify the efforts at institutional, national and European level. However, to give the Process further momentum, they commit themselves to intermediate priorities for the next two years. They will strengthen their efforts to promote effective quality assurance systems, to step up effective use of the system based on two cycles and to improve the recognition system of degrees and periods of studies. a. Quality Assurance The quality of higher education has proven to be at the heart of the setting up of a European Higher Education Area. Ministers commit themselves to supporting further development of quality assurance at institutional, national and European level. They stress the need to develop mutually shared criteria and methodologies on quality assurance. They also stress that consistent with the principle of institutional autonomy, the primary responsibility for quality assurance in higher education lies with each institution itself and this provides the basis for real accountability of the academic system within the national quality framework.


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Therefore, they agree that by 2005 national quality assurance systems should include: - A definition of the responsibilities of the bodies and institutions involved. - Evaluation of programmes or institutions, including internal assessment, external re view, participation of students and the publication of results. - A system of accreditation, certification or comparable procedures. International participation, co-operation and networking. At the European level, Ministers call upon European Network for Quality Assurance in Higher Education (ENQA) through its members, in cooperation with the EUA (European Universities Association), EURASHE (European Association of Institutions in Higher Education) and ESIB (the National Unions of Students in Europe), to develop an agreed set of standards, procedures and guidelines on quality assurance, to explore ways of ensuring an adequate peer review system for quality assurance and/or accreditation agencies or bodies, and to report back through the Follow-up Group to Ministers in 2005. Due account will be taken of the expertise of other quality assurance associations and networks. b. Degree structure: Adoption of a system essentially based on two main cycles Ministers were pleased to note that, following their commitment in the Bologna Declaration to the two-cycle system, a comprehensive restructuring of the European landscape of higher education is now under way. All Ministers commit themselves to having started the implementation of the two-cycle system by 2005. Ministers underlined the importance of consolidating the progress made, and of improving understanding and acceptance of the new qualifications through reinforcing dialogue within institutions and between institutions and employers. Ministers encouraged the member States to elaborate a framework of comparable and compatible qualifications for their higher education systems, which should seek to describe qualifications in terms of workload, level, learning outcomes, competences and profile. They also undertake to elaborate an overarching framework of qualifications for the European Higher Education Area. Within such frameworks, degrees should have different defined outcomes. First and second cycle degrees should have different orientations and various profiles in order to accommodate a diversity of individual, academic and labour market needs. First cycle degrees should give access, in the sense of the Lisbon Recognition Convention, to second cycle programmes. Second cycle degrees should give access to doctoral studies. Ministers invite the Follow-up Group to explore whether and how shorter higher education may be linked to the first cycle of a qualifications framework for the European Higher Education Area. Ministers stressed their commitment to making higher education equally accessible to all, on the basis of capacity, by every appropriate means. c. Promotion of mobility Mobility of students and academic and administrative staff is the basis for establishing a European Higher Education Area. Ministers emphasise its importance for academic and cultural as well as political, social and economic spheres. They note with satisfaction that since their last meeting, mobility figures have increased, thanks also to the substantial support of the European Union programmes, and agree to undertake the necessary steps to improve the quality and coverage of statistical data on student mobility. They reaffirmed their intention to make every effort to remove all obstacles to mobility within the European Higher Education Area. With a view to promoting student mobility, Ministers will take the necessary steps to enable the portability of national loans and grants.

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d. Establishment of a system of credits Ministers stressed the important role played by the European Credit Transfer System (ECTS) in facilitating student mobility and international curriculum development. They note that ECTS is increasingly becoming a generalised basis for the national credit systems. They encourage further progress with the goal that the ECTS becomes not only a transfer but also an accumulation system, to be applied consistently as it develops within the emerging European Higher Education Area. e. Recognition of degrees: Adoption of a system of easily readable and comparable degrees Ministers underlined the importance of the Lisbon Recognition Convention, which should be ratified by all countries participating in the Bologna Process, and call on the ENIC (European Network of Information Centres) and NARIC (National Academic Recognition Information Centres) networks along with the competent National Authorities to further the implementation of the Convention. They set the objective that every student graduating as from 2005 should receive the Diploma Supplement automatically and free of charge. It should be issued in a widely spoken European language. They appealed to institutions and employers to make full use of the Diploma Supplement, so as to take advantage of the improved transparency and flexibility of the higher education degree systems, for fostering employability and facilitating academic recognition for further studies. f. Higher education institutions and students Ministers welcome the commitment of Higher Education Institutions and students to the Bologna Process and recognise that it is ultimately the active participation of all partners in the Process that will ensure its long-term success. Aware of the contribution strong institutions can make to economic and societal development Ministers accept that institutions need to be empowered to take decisions on their internal organisation and administration. Ministers further call upon institutions to ensure that the reforms become fully integrated into core institutional functions and processes. Ministers noted the constructive participation of student organisations in the Bologna Process and underline the necessity to include the students continuously and at an early stage in further activities. Students are full partners in higher education governance. Ministers noted that national legal measures for ensuring student participation are largely in place throughout the European Higher Education Area. They also call on institutions and student organisations to identify ways of increasing actual student involvement in higher education governance. Ministers stressed the need for appropriate studying and living conditions for the students, so that they can successfully complete their studies within an appropriate period of time without obstacles related to their social and economic background. They also stress the need for more comparable data on the social and economic situation of students. g. Promotion of the European dimension in higher education Ministers noted that, following their call in Prague, additional modules, courses and curricula with European content, orientation or organisation are being developed. They noted that initiatives have been taken by Higher Education Institutions in various European countries to pool their academic resources and cultural traditions in order to promote the development of integrated study programmes and joint degrees at first, second and third level.


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Moreover, they stressed the necessity of ensuring a substantial period of study abroad in joint degree programmes as well as proper provision for linguistic diversity and language learning, so that students may achieve their full potential for European identity, citizenship and employability. Ministers agreed to engage at the national level to remove legal obstacles to the establishment and recognition of such degrees and to actively support the development and adequate quality assurance of integrated curricula leading to joint degrees. h. Promoting the attractiveness of the European Higher Education Area Ministers agreed that the attractiveness and openness of the European higher education should be reinforced. They confirmed their readiness to further develop scholarship programmes for students from third countries. Ministers declared that transnational exchanges in higher education should be governed on the basis of academic quality and academic values, and agree to work in all appropriate fora to that end. In all appropriate circumstances such fora should include social and economic partners. They encouraged the co-operation with regions in other parts of the world by opening Bologna seminars and conferences to representatives of these regions. i. Lifelong learning Ministers underlined the important contribution of higher education in making lifelong learning a reality. They are taking steps to align their national policies to realise this goal and urge Higher Education Institutions and all concerned to enhance the possibilities for lifelong learning at higher education level including the recognition of prior learning. They emphasise that such action must be an integral part of higher education activity. Ministers furthermore called those working on qualifications frameworks for the European Higher Education Area to encompass the wide range of flexible learning paths, opportunities and techniques and to make appropriate use of the ECTS credits. They stressed the need to improve opportunities for all citizens, in accordance with their aspirations and abilities, to follow the lifelong learning paths into and within higher education.

4. Additional Actions a. European Higher Education Area and European Research Area - two pillars of the knowledge based society Conscious of the need to promote closer links between the EHEA (European Higher Education Area) and the ERA (European Research Area) in a Europe of Knowledge, and of the importance of research as an integral part of higher education across Europe, Ministers considered it necessary to go beyond the present focus on two main cycles of higher education to include the doctoral level as the third cycle in the Bologna Process. They emphasised the importance of research and research training and the promotion of interdisciplinarity in maintaining and improving the quality of higher education and in enhancing the competitiveness of European higher education more generally. Ministers called for increased mobility at the doctoral and postdoctoral levels and encourage the institutions concerned to increase their co-operation in doctoral studies and the training of young researchers. Ministers will make the necessary effort to make European Higher Education Institutions an even more attractive and efficient partner. Therefore Ministers ask Higher Educa-

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tion Institutions to increase the role and relevance of research to technological, social and cultural evolution and to the needs of society. Ministers understood that there are obstacles inhibiting the achievement of these goals and these cannot be resolved by Higher Education Institutions alone. It requires strong support, including financial, and appropriate decisions from national Governments and European Bodies. Finally, Ministers stated that networks at doctoral level should be given support to stimulate the development of excellence and to become one of the hallmarks of the European Higher Education Area. b. Stocktaking With a view to the goals set for 2010, it is expected that measures will be introduced to take stock of progress achieved in the Bologna Process. A mid-term stocktaking exercise would provide reliable information on how the Process is actually advancing and would offer the possibility to take corrective measures, if appropriate. Ministers charged the Follow-up Group with organising a stocktaking process in time for their summit in 2005 and undertaking to prepare detailed reports on the progress and implementation of the intermediate priorities set for the next two years: - quality assurance - two-cycle system - recognition of degrees and periods of studies Participating countries will, furthermore, be prepared to allow access to the necessary information for research on higher education relating to the objectives of the Bologna Process. Access to data banks on ongoing research and research results shall be facilitated.

5. Further Follow-up a. New members Ministers considered it necessary to adapt the clause in the Prague Communiquι on applications for membership as follows: Countries party to the European Cultural Convention shall be eligible for membership of the European Higher Education Area provided that they at the same time declare their willingness to pursue and implement the objectives of the Bologna Process in their own systems of higher education. Their applications should contain information on how they will implement the principles and objectives of the declaration. Ministers decided to accept the requests for membership of Albania, Andorra, Bosnia and Herzegovina, Holy See, Russia, Serbia and Montenegro, “the former Yugoslav Republic of Macedonia“ and to welcome these states as new members thus expanding the process to 40 European Countries. Ministers recognised that membership of the Bologna Process implies substantial change and reform for all signatory countries. They agreed to support the new signatory countries in those changes and reforms, incorporating them within the mutual discussions and assistance, which the Bologna Process involves. b. Follow-up structure Ministers entrusted the implementation of all the issues covered in the Communique, the overall steering of the Bologna Process and the preparation of the next ministerial meeting to a Follow-up Group, which shall be composed of the representatives of all members of the Bologna Process and the European Commission, with the Council of Europe, the EUA


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(European Universities Association), EURASHE (European Association of Institutions in Higher Education), ESIB (the National Unions of Students in Europe) and UNESCOCEPES (the European Centre for Higher Education - Centre Européen pour l'Enseignement Supérieur) as consultative members. This group, which should be convened at least twice a year, shall be chaired by the EU Presidency, with the host country of the next Ministerial Conference as vice-chair. A Board also chaired by the EU Presidency shall oversee the work between the meetings of the Follow-up Group. The Board will be composed of the chair, the next host country as vice-chair, the preceding and the following EU Presidencies, three participating countries elected by the Follow-up Group for one year, the European Commission and, as consultative members, the Council of Europe, the EUA, EURASHE and ESIB. The Follow-up Group as well as the Board may convene ad hoc working groups as they deem necessary. The overall follow-up work will be supported by a Secretariat, which the country hosting the next Ministerial Conference will provide. In its first meeting after the Berlin Conference, the Follow-up Group is asked to further define the responsibilities of the Board and the tasks of the Secretariat. Ministers asked the Follow-up Group to co-ordinate activities for progress of the Bologna Process as indicated in the themes and actions covered by this Communiqué and report on them in time for the next ministerial meeting in 2005. The next conference will be held in the city of Bergen (Norway) in May 2005.

6. Opposition Such an enormous change in the Higher Education in Europe could not go without opposition. The opposition usually emanates from political reasons that are coming from the fears of a globalised economy that will put first in the agenda the society driven by the economy and not vice versa. This influences also the approaches that are taken in Education. The University transformation is feared that will become a process of developing trained labour to the needs or requirements of the big enterprises destroying the process of developing graduates as intellectuals, leaders in the society. This opposition has been mounted in certain countries, has influenced students and becomes a real obstacle to the implementation of the above mentioned declarations that are seen as an instrument of alienation of the universities from their original scope.

Conclusions The Educational Systems to be comparable need to be transformed across countries and boundaries. In the Higher Education area this transformation in Europe has already started with a consensus process among ministers of education and by issuing a series of declarations to facilitate the process. Even if these declarations are not obligatory most of the countries are conforming to the ideas, suggestions, and recommendations of these declarations. Opposition is encountered in a number of countries by students and teachers due to a lack of communication between authorities and the educational community, not understandable by the people of the implementation of the policies and sometimes because of hidden agendas. In Health Sciences the transformation becomes important as the degrees issued by Universities are also professional passports to the graduates enabling them to cross countries and find job in another member state. Special discussion on the health care professional degrees is required and should be pursued further.

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Barcelona European Council (2002), Presidency Conclusions, 15-16 March 2002 Bologna Declaration (European Ministers of Education) 1999, The Bologna Declaration of 19 June 1999. Joint Declaration of the European Ministers of Education, Bologna 19 June 1999 Brown, Chris 2001, Understanding International Relations (New York: Palgrave) Cox, Robert and Jacobson, Harold 1973, The Anatomy of Influence. Decision-making in International Organisations (London: Yale University Press) Conference of Ministers responsible for Higher Education 2003, Realising the European Higher Education Area. Communiqué of the Conference of Ministers responsible for Higher Education Berlin 19 September 2003 Desai, Meghnad 1995, ‘Global Governance’, Desai, Meghnad and Redfern, Paul (eds.), Global Governance. Ethics and economics of the world order (New York: Pinter), pp. 6-21 DiMaggio, Paul J, and Powell, Walter W. 1991, ‘Introduction’, in Powell, Walter W. and Di-Maggio, Paul, J. (eds.), The New Institutionalism in Organizational Analysis (Chicago, IL: University of Chicago Press), pp. 1-39 European Commission 1993 COM (93) 700, Growth, competitiveness, employment. The challenges and ways forward into the 21st century. White paper. Brussels European Commission 1995, Teaching and Learning. Towards the Learning Society. White Paper on education and training. Brussels European Commision 2000, COM(2000) 6 Towards a European Research Area. Communication from the Commission (Brussels: Commission of the European Communities), pp. 2-39 European Commision 2001, COM(2001) 678 final Making a European Area of Lifelong Learning a Reality. Communication from the Commission (Brussels: Commission of the European Communities), pp. 2-40 European Commision 2003, COM(2003) 685 final Education and Training 2010. The Success of the Lisbon Strategy hinges on urgent reforms. Communication form the Commission (Brussels: Commission of the European Communities), pp. 3-28 European Commision 2003, COM(2003) 58 final The role of the universities in the Europe of knowledge. Communication from the Commission (Brussels: Commission of the European Communities), pp. 2-23 Finnemore, M. and Sikkink, K. 1998, ‘International Norm Dynamics and Political Change’, International Organization 52:4, 887-917 Groom, A.J.R. and Powell, Dominic 1994, ‘From World Politics to Global Governance: A theme in Need of a focus’, in Groom, A.J.R. and Light, Margot (eds.), Contemporary International Relations (London: Pinter) Haas, Peter 1992, ‘Introduction. Epistemic communities and international policy coordiantion’, International Organization 46:1, 1-35 Hewson, Martin and Sinclair, Timothy J. 1999, ‘The Emergence of Global Governance Theory’, in Hewson, Martin and Sinclair, Timothy J. (eds.), Approaches to Global Governance Theory (Albany: State University of New York Press), pp. 3-22 James N. Rosenau and Ernst-Otto Czempiel, Governance without Government: Order and Change in World Politics (Cambridge: Cambridge University Press, 1992). Kooiman, Jan 1993, Modern Governance (London) Lisbon European Council (2000), Presidency Conclusions, 223 1nd 24 March 2000 Prague Declaration (European Ministers in Charge of Higher Education) 2001, Towards a European Higher Education Area. Communiqué of the meeting of the European Ministers in Charge of Higher Education, Prague 19 May 2001 Reinalda, Rob and Verbeek, Bertjan 1998, ‘Autonomous Policy Making by International Organizations: Purpose, Outline and Results’, in Reinalda, Rob and Verbeek, Bertjan (eds.), Autonomous Policy Making by International Organizations (London: Routledge), 1-8 Rhodes, R.A.W. 1997, Understanding Governance (Buckingham: Open University Press) Rosenau, James N. 1992, ‘Governance, Order, and Change in World Politics’, in Rosenau, James N. and Czempiel, Ernst-Otto, Governance without Government: Order and Change in World Politics (Cambridge: Cambridge University Press), pp. 1-29 Sorbonne Declaration (Ministers in Charge of Germany, Italy and United Kingdom), Joint Declaration on harmonisation of the architecture of the European higher education system. Paris, 25 May 1998 Wessels, Wolfgang 2003, (Open) Methods of Self Coordination. New Modes of Governance as a typical step in the Evolution of the EU System? Preliminary Working Paper (www.govecor.org)


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27. Young, Oran 1994, International Governance. Protecting the Environment in a Stateless Society (Ithaca: Cornell University Press) 28. Zgaga, Pavel 2003, Bologna Process. Between Prague and Berlin. Report to the Ministerns of Education of the signatory countries

Useful links 1. 2.

3.

4. 5. 6. 7.

Documents relating to the Bologna Process http://www.bologna-berlin2003.de/en/main_documents/index.htm Realising the European Higher Education Area, Communiqué of the Conference of Ministers responsible for Higher Education held in Berlin, 19 September 2003 http://www.bologna-berlin2003.de/pdf/Communique1.pdf European Credit Transfer System http://europa.eu.int/comm/education/programmes/socrates/ects_en.html see also http://www.tu-dresden.de/aaa/eng/auslandstud/bewerbung_ohne/ects.php#was Erasmus http://europa.eu.int/comm/education/programmes/socrates/erasmus/erasmus_en.htm ESIB – the National Unions of Students in Europe survey http://www.esib.org/frankfurt/survey/ebss.pdf European University Association (EUA) http://www.eua.be/eua/ Trends 2003: Progress towards the European HigherEducation Area http://www.eua.be/eua/jsp/en/client/

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1.3. Academic Standards, Credit Transfers and Associated Issues Evelyn J.S. HOVENGA Faculty of Informatics and Communication, Central Queensland University, Rockhampton Qld MC4702, Australia Abstract. Various policies govern the way academic standards are managed and maintained. This includes organisational and program accreditation. Who decides what makes a program acceptable from a discipline and educational perspective? Should IMIA be developing accreditation guidelines for external program accreditation? Also the extent to which individual students are able to gain recognition for study undertaken elsewhere and thus reduce the length of the degree program undertaken varies by higher education provider. For example CQU provides credits based on study undertaken at the same level and where the content is similar as well as in line with overall program learning objectives for up to 50% of the total requirements. Internationally there are a number of governmental and not for profit private organisation providing an infrastructure to assist with the identification of legitimate educational certificates/degrees obtained overseas. In addition overseas skills recognition is undertaken by each University. This chapter examines these from a number of different international perspectives.

Introduction Higher education is big business, is increasingly ‘commercialised’ encouraging competitiveness in a global society. In these circumstances we need to ensure that academic values and standards are retained and protected. National educational system and qualifications variations challenge us to assist student mobility between the many educational providers globally. Individual higher education providers such as Universities need to adopt policies that indicate how prior learning is best recognised to enable students to be admitted as well as possibly receive credit towards a new qualification to be obtained. This may need to be tailored to national directions. Moodie [1] reports that in 2000 only 5 percent of those enrolled in US universities were internal students whereas Australia enrolled 14 percent that year. This has increased significantly to 34 percent in 2002 (13% onshore + 21% off shore), thus contributing significantly to national export income; education is the eighth largest export industry. As Australia has one of the largest number of international students in the English speaking world behind the United States of America and the United Kingdom, it’s Government Department of Education, Science and Training (DEST) has adopted a national education industry supporting role. DEST has produced Country Education Profiles for over 90 countries. These are published and may be purchased through the JS McMillan printing group. An ongoing country education profile update program is in place [2]. Guidelines on the assessment of educational awards from these countries are also provided by DEST. More recently DEST has established the AEI – International Education Network underpins Australia’s foreign rela-

E.J.S. Hovenga / Academic Standards, Credit Transfers and Associated Issues

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tions and world trade, and builds Australian exports in education, training and scientific services [3]. The European Commission has recognised that there is a need to encourage international cooperation by promoting European higher education to enhance quality in higher education and promote intercultural understanding. Such cooperative links are supported through a range of trans-national education programmes with the USA, Canada, in Latin America, many Asian countries, Japan and Australia. This is in addition to various national initiatives. The Commission’s 2002 Erasmus Mundus initiative supporting inter-university European Union Masters Courses is being extended to 2008 [4]. 1. Maintaining Academic Standards Higher education consists of meeting a variety of educational needs supporting life long learning, continuing education consisting of skills updating and professional development and degree based courses. Such educational services are provided by both the private and public sectors in varying proportions within individual countries. The global market for higher education has attracted many players. Private providers are mostly located in the United States of America and Southeast Asia. Governments, the European Commission as well as private, non-profit national or international organisations such as the European based Academic Cooperation Association (ACA) and the United States based Council for Higher Education Accreditation (CHEA) have provided strong infrastructures supporting student mobility, education provider cooperation and maintaining educational or academic standards. CHEA states that the United States federal government, through the US Department of Education, conducts governmental recognition reviews. Also that accreditation in higher education consists of self- and peer review for improvement of academic quality and public accountability of institutions and programs [5]. In addition every individual higher education provider needs to establish and apply its own policies to maintain the desired level of quality. There is a need to be transparent in a global educational market. When making a decision about credit transfer one needs to be able to establish that the qualification itself is legitimate and obtained from a nationally recognised and/or accredited bona fide higher education provider and that it is was obtained by the person applying for credit recognition. Next one needs sufficient information about the qualification to establish if it is equivalent to one offered locally in terms of educational outcomes achieved or if it is appropriate, that is does it fit with the overall degree program objectives or is it a suitable entry qualification to be recognised for credit transfer. Such scrutiny can be very time consuming, costly and often difficult for individual higher education providers to implement successfully. Credits given also provide a competitive aspect in a global market as students will prefer to enrol at organisations that recognise prior learning. Table 1 lists a number of strategies that may be employed for credit transfer purposes whilst maintaining professionally acceptable academic standards. The Bologna process adopted by Ministers of Education representing 31 European countries in 2001 was the first step of an ongoing process towards the convergence of European higher education. Its primary aim was to facilitate inter-institutional cooperation, and student mobility within Europe, enhance the quality of higher education, and to increase its competitiveness globally. Its starting point was to agree upon a shared structure for bachelor and master degrees and to establish a common framework for quality assurance and accreditation. The European Credit Transfer System, an international credit framework, was adopted as the standard against which all courses are evaluated on the basis of student workload required to achieve program objectives and a number of additional activities have been and continue to be undertaken to construct and describe qualifications

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Table 1. Strategies Used to Maintain Academic Standards. Strategies National adoption of a consistent education framework or profile Organisational accreditation or national recognition of education provider Program accreditation /approval processes

Organisational policies and processes regarding recognition of prior learning and the number of credit transfers accepted within any one degree program and under what conditions or circumstances

Related conditions - needs to be readily accessible by evaluator credit transfer between education providers within a country is easier to achieve than across national borders. - verifies a bona fide education provider - requires accreditation standards or recognition criteria. -

within the organisation as peer review to assure educational standards are met - by professional organisations to ensure the curriculum enables the desired educational outcomes to be achieved by graduates. Requires a recognised professional body of knowledge and program accreditation standards - there needs to be an overall organisational policy such as: o no more than 50% of credits obtained at another education provider will be recognised or o no undergraduate course results will be credited to a post graduate degree program - implementation will vary for specific degree programs based on curriculum requirements

and qualification structures. Other areas considered central to the creation of the European Higher Education Area are program profiles/specifications, learning outcomes, competencies and subject benchmark statements [6] [7]. The quality assurance framework adopted in Australia aims to promote international best practice in higher education as well as ensure the integrity of the industry. The education of overseas students is heavily regulated by the Australian government department of education, science and training through the Education Services for Overseas Students (ESOS) Act 2000 with further amendments adopted in 2002 and associated legislation. All universities need to be established under State and Territory legislation and if they wish to provide education and training to overseas students they must comply with the Federal legislative requirements for registration on the Commonwealth Register of Institutions and Courses for Overseas Students (CRICOS) and its code of practice [8]. Other regulatory requirements are for overseas students to demonstrate English language proficiency by an International English Language Testing System (IELTS) score to correspond with the desired score as published by the Education sector or individual education provider. This score also needs to be accepted by the Australian Department of Immigration and Multicultural Affairs for student visa purposes [9]. An Australian Qualifications Framework (AQF) has been adopted as a national system of learning pathways indicating how different qualifications and types of educational institutions are linked [10]. The AEIInternational Education Network together with the National Office of Overseas Skills Recognition (NOOSR) collect, documents and uses around 90 different country education profiles. It provides guidelines on the assessment of educational awards from these countries and offers an educational assessment service, providing written assessments of overseas higher education, post secondary or technical level qualifications. This enables a comparison to be made between overseas and Australian educational qualifications [11]. Internal higher education provider organisational mechanisms are also in place for ensuring academic standards and most have implemented quality assurance processes. In addition to these governmental initiatives towards establishing and maintaining academic standards and values, some educational degree programs need to meet accreditation standards set by anyone of a number of professional organisations. For example the Austra-


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lian Computer Society (ACS) lists all ACS accredited Information, Communication and Technology university programs (courses) offered [12]. Many professional organisations publish their body of knowledge which forms the basis for their program accreditation guidelines that ensure that such programs produce graduates with the required skills, knowledge and professional behaviours. IMIA has developed a scientific map and endorsed educational requirements. These essentially document the Health Informatics body of knowledge and may be incorporated in a professional program accreditation process. The Australian College of Health Informatics has done this cooperatively with the Australian Computer Society who will manage the accreditation process on a cost recovery basis using their well established infrastructure for this purpose. Program accreditation is voluntary.

2. What do we mean by ‘credits’? The term ‘credit’ is used in a variety of ways reflecting differences in meaning. In other words it is one term used to describe a number of different concepts. Credits are usually part of a qualifications framework, used systematically to describe an educational program by attaching credits to its components. They may be a measure of a nominal student workload, a time based quantitative measure assigned to individual courses or a measure to describe the volume of outcomes. Credits are a way of determining academic qualifications obtained. They are used to determine eligibility of entry to a particular degree program or to formally transfer ‘credits’ to a degree program as recognition of prior learning so that an individual student does not need to repeat this in the new program. One ‘standard’ interpretation of credit is that adopted by the European Commission. In this case one credit is equivalent to 24 to 30 working hours and 60 credits are deemed to be equivalent to a full-time student workload during one academic year consisting of 36/40 weeks. Student workload is defined as “the notional time an average learner might expect to complete the required learning outcomes.” This refers to the time a student spends to attend classes, undertake independent study and prepare for and undertake various assessment activities including exams. Learning outcomes are defined as “sets of competencies, expressing what the student will know, understand or be able to do after completion of a process of learning, short or long”[13]. Australian Universities have not adopted a standard definition or measure of student effort. This makes it more difficult and time consuming to administer applications for credit transfer. A United States Education System survey was undertaken in 2001[14]. This revealed that the average course workload was roughly 16 credit hours per semester (5-6 classess taken simultaneously). A full time student usually undertakes a minimum of 12 credit hours of courses per semester and the maximum allowed is usually 20 unless special permission is granted. A typical U.S. college course (class) is worth 3 credit hours, meet for 3 contact hours per week ( meeting 1, 2 or 3 times per week) over a 15 week semester or 45 contact hours per semester. However a 3 hour laboratory session is likely to only be worth one additional credit hour.

3. Recognition of prior learning Trans-national or borderless or cross-border education requires the formal and public adoption of a mechanism to appropriately recognise prior learning or study undertaken previously in courses provided by suitably credentialed education providers, as well as the recognition of knowledge and skills obtained through work and life experience. Such recognition is necessary to assess if the entry requirements of a program or course have been met

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by any potential student, or for the purpose of determining eligibility for a scholarship, awards, an academic honour, extracurricular activities of for credit transfer in the form of an exemption from equivalent course requirements. In some instances a ‘grade point average (GPA)’, a measure of achievement in a program, may be used to reflect program entry qualifications in terms of level of achievement. For example a 5 stage letter grade system, where the highest grade is worth 4 points, an above average grade equals 3 points, an average passing grade is 2 points and a minimum passing grade is worth 1 point is often used to calculate a student’s GPA per semester or term. But again we have the issue of not having a national or international recognised standard measure of achievement as definitions of the highest grade vary and the previous example may be modified to reflect variations in credit hours associated with individual courses (subjects). The GPA term and concept is used by many. One key benefit of the recognition of prior learning is that there is no need for a student to repeat anything previously learned elsewhere. This reduces both cost and the length of time required to complete a degree program. This concept is also referred to as obtaining ‘advanced standing and/or status’ and is highly regarded by many. It is about facilitating student mobility between educational institutions anywhere in the world. Consequently those educational institutions offering international education need to process many individual applications for credit transfer by foreign students. Indeed formal articulation between specific programs is a feature used for marketing purposes by many. For example one Australian University has many credit transfer arrangements with colleges, polytechnics, other higher education institutions and universities, which provide advanced standing in undergraduate and postgraduate programs (eg. Polytechnic Diploma holders in Singapore can gain up to 16 exemptions from some undergraduate programs) [15]. Higher education providers usually have an organisational policy indicating the maximum amount of credits that can be allocated to any new program. This tends to range from none or one course to as much as 60 percent of the total degree program. There are three types of credit transfer: • • •

specified credit – exemption from a specific course (subject or unit) that is part of a degree program. block credit – exemption for a complete section or component such as a term or semester or a year of study of a degree program. unspecified credit – in place of an elective course within a program where the previous study undertaken differs from the current program requirements.

The recognition of prior learning for the purpose of assessing if program entry requirements have been met require an appreciation of the qualification obtained in terms of the country’s qualifications framework as well as an assessment or knowledge of the legitimacy and accreditation status of the educational provider who issued the original qualification. This issue along with the attraction of large numbers of foreign students to Australian higher education institutions has resulted in the Australian government’s establishment of the AEI – International Education Network administered by the Department of Education, Science and Training (DEST) to develop and support the Australian international education and training industry through a wide range of activities, products and services [3]. One of the activities undertaken in conjunction with the National Office of Overseas Skills Recognition (NOOSR) was the development of Country Education Profiles describing education systems of over 90 countries. This office also provides written assessments of overseas qualifications for individuals, enabling a comparison to be made with Australian educational qualifications. This national infrastructure has positively contributed to Australia’s ability to meet foreign students’ educational demands.


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The European Bologna process is very much about the creation of a similar structural framework to support the European Higher Education sector. Its current primary objective is about the establishment of a European qualifications framework to provide explicit reference points using learning outcomes and competencies, levels and level indicators, subject benchmarks and qualification descriptors. Adam [7] indicates that these devices provide more precision and accuracy facilitating transparency and comparison. Similarly the United States Council for Higher Education Accreditation initiated its work on accreditation and transfer of credit in 1998 and issued a ‘Transfer Framework’, an advisory document for accrediting organisations and institutions, in 2002. However late 2003 McKeon introduced the HR 3311 bill (Higher Education Act) to congress. This bill is centred on tuition cost controls but includes five new federal controls on transfer of credit [16]. It was reported that these proposals, sighted by most higher education institutions and associations, were considered as ‘so extreme as to chill the dialogue…’. Canada has an Association of Universities and Colleges representing 93 public and private not-for-profit universities and university degree level colleges across the country. They actively support ‘cross-border’ higher education but a framework for credit transfer does not appear to be part of this vision. Their latest 2004 draft statement on this topic prepared in conjunction with the International association of Universities (IAU), the American Council on Education (ACE) and the Council on Higher Education Accreditation (CHEA) outlines principles to underpin institutional initiatives in cross-border education [17]. It addresses higher education institutions and their non-governmental associations worldwide as well as national governments and intergovernmental organisations and is being circulated to higher education membership associations worldwide for comment by September 2004. This draft statement includes a number of recommendations for Governments and for higher education institutions. Credit transfer is not mentioned anywhere in this document, although one of the recommendations refers to ‘recognition issues’. Clearly many countries are responding to the internationalisation of higher education in a variety of ways. However it is disturbing that no-one is mentioning the need for the development and adoption of an international standard to facilitate student mobility with the greatest of ease. The lack of a standard international glossary of terms defining all relevant educational concepts associated with the recognition of prior learning, makes optimum student mobility difficult to achieve and costly to administer. 4. Credit Transfer Administration Every higher education institution willing to open its doors to students from locations outside their immediate sphere of influence or student market, needs to develop, publish and implement the administrative process adopted for recognition of prior learning and credit transfer. Such information tends to reflect the organisation’s current student market. Many only provide guidance for credit transfer between organisations within the same State or province, or country. Others have procedures in place to provide credit transfers to students from anywhere. For example Central Queensland University (CQU) lists the requirements from 48 specific countries to serve as a guide for potential students to establish academic eligibility for entry into CQU programs [18]. Over 40 percent of all CQU’s students are international. The administration of credit transfers is time consuming and resource intensive as in most cases every application is unique. The greater the number of students from far and wide locations, the greater the administrative burden associated with this activity. A number of different variables need to be considered. Frequently it is difficult to obtain accurate and sufficient information about previous studies undertaken, or about the awarding organisation to enable an informed decision to be made. This burden is a great impediment to stu-

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Table 2. Variables considered for recognition of prior learning and credit transfer. Variables National Education Qualifications Framework (Country Education Profile) Awarding Education Institution Program/course successfully completed

Recognition Criteria - overview of ‘levels’ of educational qualifications and their relationships - legitimacy and accreditation status of awarding institution - level and content to determine local equivalency (requires the exchange of pertinent information such as course syllabi, outlines, learning outcomes or competencies, curriculum guide)

Credit points Certified copy of Student results

Articulation agreements

- student workload per program/course successfully completed - grades obtained and/or Grade Point Average (GPA) - learning must have been assessed by a valid and reliable method and have been subject to appropriate quality assurance. - agreements between institutions pertaining to specific programs

dent mobility for many. Although a number of efforts are underway to simplify this process, there is an urgent need to standardise many educational concepts on an international basis. The European Commission has begun this process via the Bologna agreement. Scotland has its Scottish Credit and Qualifications Framework providing a national vocabulary describe learning opportunities, clarify relationships between qualifications, entry and exit points as well as identify routes for progression within and across education and training sectors and increase opportunities for credit transfers. This single credit based framework is well documented and accepted, it is at the forefront of European and international developments. It includes qualifications across the academic and vocational sectors [19]. Australia’s qualifications framework is a national system of learning pathways covering 12 different qualifications across the entire education sector but it does not have an agreed standard terminology to describe key educational concepts such as credit points or grade point average. One common data set of U.S Higher Education Terminology has been developed in collaboration with publishers and the U.S. education community [20]. The goal of the latter initiative was to improve the quality and accuracy of information provided to suit student articulation between State based community colleges and institutions offering four year bachelor’s degree programs (higher education) and to reduce the reporting burden. The Education Commission of the States (U.S) reported that many States have written transfer and articulation policy into legislation through statutes, bills or resolutions, many also have adopted cooperative agreements, provide incentives and rewards, have developed Statewide articulation guides, adopted common core courses with some also adopting a common course numbering system. These administrative guidelines and processes primarily facilitate articulation not ad hoc credit transfers. Terminology issues are many. For example some Universities offer courses up to four times per year. As a consequence semesters or terms vary in length to accommodate these arrangements. Class contact hours or the student workload per course will vary to match the length of term or semester. Other Universities have a long summer break thus a full year study workload will vary between these organisations. Then there is the issue of various definitions associated with one label to describe a concept, for example a course for some means a program to others. Consequently interpretation for credit transfer or degree comparison purposes is inconsistent and an administrative nightmare. This is being dealt with in a variety of ways. For example the American Council on Education (ACE) offers a credit assessment service for individuals. This is used to provide portable and secure lifetime documentation of a person’s ACE evaluated college credits and


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continuing education units (CEUs) via transcripts. The equivalence of formal training programs to traditional courses taught by accredited colleges is determined. The ACE’s College Credit Recommendations service has operated since 1974. It has a network of cooperating colleges that agree to consider a person’s ACE college credit recommendations [21]. Various individual higher education providers have established programs that enable prior learning assessments to take place, others have developed or acquired a database to either automatically decide credit transfers or to guide such decision making. All of these methods rely on information about a limited number of educational institutions usually within one country or State and thus isn’t well suited to meet the needs of global education. Some form of international credit equivalence is highly desirable and increasingly becoming more urgent.

5. Future Directions It has been widely recognised that with the adoption of a globalisation of higher education, also referred to as transnational or borderless education, various conventions associated with higher education need to change. Paulsen [22] has identified six trends, an increase in on-line education, the need for system integration and standardisation, significant financial barriers to online education, the desire for flexible or mobile learning, a steady and significant increase in bandwidth capacity and the need to consider education as a component of trade agreements. Accreditation and credit transfers in a global market place requires the widespread adoption of comparative educational frameworks, system integration and standardisation to make this process more consistent and less labour intensive. The Organisation for Economic Co-operation and Development (OECD) has embarked on a major project initiative titled “The Internationalisation of Tertiary Education in conjunction with the United Nations Educational, Scientific and Cultural Organisation (UNESCO) in 2003. This deals with the major trends and issues related to this topic with a strong focus on the trade in educational services. The OECD’s Centre for Educational Research and Innovation (CERI) is managing this project. One of their activities is to develop guidelines on quality provision of cross-border higher education promoting the design of national mechanisms of quality assurance, accreditation, and recognition of qualifications and enhancing consumer/student protection. They have four main policy objectives for these guidelines, these are reproduced in the list below: [23] 1. ‘Students/learners protection’ from the risks of misinformation, low-quality provision and qualifications of limited validity. 2. Qualifications should be readable and transparent in order to increase their international validity and portability. Reliable and user-friendly information sources should facilitate this. 3. Recognition procedures should be transparent, coherent, fair and reliable and impose as little burden as possible to mobile professionals. 4. National quality assurance and accreditation agencies need to intensify their international cooperation in order to increase mutual understanding. Their first drafting experience took place in Paris, France in April 2004 with 120 participants from 64 countries. This was followed by a meeting of experts to seek consensus between countries on the possible creation of an international database of recognised higher education institutions. A list of recognised higher education institutions was noted as being available on the web for at least 53 countries. Further meetings are scheduled to be held in Tokyo and Sydney in October. A number of additional publications documenting key developments, trends and policy issues are imminent at the time of writing.

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6. Conclusions We are witnessing major changes in higher education. The provision of higher educational services is now a very significant component of a global market and as such being considered within trade agreements. Major exporters are the United States, the United Kingdom, Australia, New Zealand, Italy and Canada. Australia is the third most popular English speaking destination for international students. Similarly the European Commission has taken a number of initiatives to facilitate student mobility. Underpinning the success of global education is the need to maintain academic standards and facilitate a consistent mechanism to recognise prior learning and professional qualifications. Changes are needed to make such processes less cumbersome. This has been recognised by the OECD and UNESCO resulting in major new and ongoing initiatives involving many countries. More than twenty recognised educational organizations are institutional members of IMIA with a strong interest to participate in the provision of global education. Collectively we are in a good position to capitalise on these trends. We need to be able to provide global and collaborative health informatics education and research. This may be achieved via a ‘virtual’ health informatics university either as an organisation providing an advisory service but essentially acting as a clearing house or an online ‘total service’ provider. The ‘clearing house’ concept has essentially been adopted by the IMIA education group. A web based portal to facilitate this is currently under development to provide the means for each academic member to register all international educational offerings into a database that has a web based search capacity for potential students. However this development has been held up due to the lack of an overarching global infrastructure or framework, including the non adoption of a standard terminology to define many essential educational concepts such as credit recognition. We have not adopted international standards regarding educational terms and their definitions. All of this diversity makes the identification, assessment, ranking, accreditation of courses and awards as well as the provision of credit transfers between educational providers difficult, time consuming and challenging. The OECD/UNESCO work is expected to make a significant contribution to resolving these issues. Meanwhile it is recommended that the IMIA Education working group explores the possibility of reaching a consensus to enable the establishment of the ‘virtual’ health informatics university vision to be realised.

References [1] [2] [3] [4] [5] [6]

[7]

[8]

Moodie G The big business of higher education, Australian Review of Public affairs-digest, 12 December 2003, http://www.econ.usyd.edu.au/drawingboard/digest/0312/moodie.html acccessed 10 May 2004 Australian Government Department of Education, Science and Training – Country Education Profiles and Updates – AEI-NOOSR http://www.dest.gov.au/noosr/cep/index.htm accessed 8 May 2004 Australian Government – AEI – International Education Network. http://aei.dest.gov.au/general/ about/About.htm accessed 10 may 2004 European Commission – Cooperation with third countries http://www.europa.eu.int/comm/education/ policies/cooperation/cooperation_en.html accessed 9 May 2004 Council for Higher Education Accreditation (CHEA), Washington DC. http://www.chea.org/pdf/chea_glance_2003.pdf accessed 10 May 2004 ESIB – European Student Handbook on Transnational Education 2003 The National Unions of Students in Europe (ESIB), http://www.esib.org/projects/tne/TNEhandbook/TNEhandbook.pdf accessed 8 May 2004 Adam S 2003 Danish Bologna Seminar 27-28 March 2003 Qualification Structures in European Higher Education. Project funded by the European Commission. University of Westminster. http://www.vtu.dk/fsk/div/bologna/BasicReportforSeminar.pdf accessed 8 May 2004 Australian Government Department of Education, Science and Training. Education Services for Overseas Students (ESOS). http://www.dest.gov.au/esos/ accessed 10 May 2004


[9] [10] [11]

[12] [13] [14]

[15] [16] [17]

[18] [19]

[20] [21] [22]

[23]

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International English Language Testing System, IELTS Australia. http://www.ielts.org/ and the Study in Australia website – Entry requirements http://studyinaustralia.gov.au accessed 8 May 2004. Study in Australia government website – Australian Qualifications Framework http://studyinaustralia.gov.au/sia/en/whyAustralia/AQF.htm accessed 8 May 2004 Australian Government Department of Education, Science and Training – AEI-NOOSR Assessment Services, http://www.dest.gov.au/noosr/recog.htm#NOOSR%20Assessment%20Services accessed 8 May 2004. Australian Computer Society, http://acs.org.au accessed 10 may 2004 ECTS – European Credit Transfer System, http://europa.eu.int/comm/education/programmes/socrates/ects_en_html accessed 7 May 2004 Department of Translation Studies, University of Tampere, 2001 U.S. Education System Survey – Grades and Credits in U.S. Higher Education. http://www.uta.fi/FAST/US5/REF/gpa.html accessed 11 May 2004 Central Queensland University (CQU - International) http://www.international.cqu.edu.au/entry/academic_req.htm accessed 1 June 2004 Council for Higher Education Accreditation – Update Number 6, January 23, 2004 http://www.chea.org/Government/HEAupdate/CHEA_HEA012304.htm accessed 8 May 2004 Sharing Quality Higher Education Across Border: A Statement on Behalf of Higher Education Institutions Worldwide, Association of Universities and Colleges of Canada May 2004, http://www.aucc.ca/index_e.html accessed 1 June 2004 Central Queensland University – CQU International, Academic Requirements http://www.international.cqu.edu.au/entry/academic_req.htm#country accessed 1 June 2004 Scottish Credit and Qualifications Framework (SCQF) Joint Advisory Committee (JAC), An Introduction to The Scottish Credit and Qualifications Framework 2nd Ed. October 2003 http://www.ltscotland.org.uk/nq/cqframework.asp accessed 11 May 2004. Common Data Set Initiative – A collaborative effort between publishers and the educational community. http://www.commondataset.org , accessed 11 May 2004 American Council on Education (ACE), College Credit Recommendation Service. http://acenet.edu/clll/corporate/what-we-do.cfm accessed 6 June 2004 Paulsen M.F 2003 Online Education Trends – an extract from his book Online Education and Learning Management Systems – Global E-learning in a Scandinavian Perspective (www.studymentor.com) – http://www.tes.mi.it/biteweb2/Ipswich/BiTE_Morten.pdf accessed 6 June 2004 UNESCO/OECD guidelines on “Quality provision in cross-border higher education”, http://www.oecd.org/documentprint/0,2744,en_2649_34549_29343796_1_1_1_1,00.html accessed 6 June 2004

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1.4. Student and Teacher Exchanges – Criteria for Access Jean ROBERTS School of Health and Post-Graduate Medicine, University of Central Lancashire Harrington Building, UCLAN, Preston, PR1 2HE, United Kingdom

Abstract. Student and teacher exchanges between countries and within the domain of informatics to support health are considered. The availability of guidance appears to be institution-wide not country-specific. It is also not related to the discipline within which the exchange will occur. Concerns and issues are considered here in order for potential participants to prepare better for such exchanges. The observations made will be of interest to the administration of the organisations within which exchanges may occur. The investigation of this topic was delphic and pragmatic rather then exhaustive. The author bears no liability for situations that occur in specific locations, but would be pleased to hear of your experiences by email [email protected]

Introduction There has been a dynamism in academic exchanges for many years, even in an immature profession like Health Informatics (HI). In each case, ad hoc arrangements may need to be made or the home and/or receiving institutions may have protocols and guidance already in place. There are various levels at which sanction is needed for exchange of an inward or outward nature; including at university or governmental levels. There are also many reasons for an exchange – from the personal to the corporate, and they will be explored in this chapter. In order to determine any pattern of process or guidance, the author undertook a simple delphic survey amongst members of the International Medical Informatics Association Education Working Group (IMIA) [1] supported by web-based research. One of the primary difficulties of encouraging mobility is recognition for the profession and confirmation of ‘fitness to practice’. The UK is seeking to address this through its registration body UKCHIP ([2]. It is about gaining the right recognition for the domain from other parts of the academic institution, from subsequent employers and from those in specialist sub-domains. Specialist areas could include the imaging specialists, those in signal processing or a defined clinical functional area. If we cannot describe ourselves collectively then how are we going to make a case to another organisation. Being able to brand the image of Health Informatics will help to mature the profession and encourage interworking and exchanges. Defining the scope of the generic area is challenging [3,4]. It will be useful to anyone anticipating an exchange to consider the following descriptions that may assist the understanding of those making funding and administrative decisions.

J. Roberts / Student and Teacher Exchanges – Criteria for Access

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Table 1. Questions relating to ACADEMIC STAFF (inward and outward).

1. Does your institution have documented policies for international applicants for (temporary/visiting) academic staff posts in health informatics or related disciplines. 2. Where are these documents available publicly (or can you send me copies) 3. Have you had visiting academic staff on exchange or from outside your country in HI or related disciplines in the last five years. 4. How difficult was the administrative process for getting them into post (on a scale of (1) – an easy, routine, robust process to (5) – an extremely challenging process, almost impossible) 5. Can you tell me what you feel is the most difficult barrier to international academic appointments (both inward to your country and outward). 6. Do you have regular visiting academic staff exchanges and appointments from other countries 7. Are your international visiting academic staff identified predominantly by personal invitation or competitive advertisement?

DOMAIN : Health informatics is concerned with the systematic processing of data, information and knowledge in medicine and healthcare. The domain covers computational and informational aspects of processes and structures, applicable to any clinical or managerial discipline within the health sector whether on a tele (remote) basis or not. Health informatics is delivered by operational health practitioners, academic researchers and educators, scientists and technologists in operational, commercial and academic domains (medinfo2001, IMIA) SCOPE : the knowledge, skills and tools that enable information to be collected, managed, used and shared to support the delivery of healthcare and to promote health [and wellbeing] (UKCHIP, 2003) STUDY AREA : nature and principles of information and its applications within all aspects of healthcare delivery and promotion (PROTTI, D 2000) 1. Determining current practice 1.1. The survey A short survey covering both staff (Table 1) and student (Table 2) placements was developed to determine what current practice and future aspirations were regarding academic exchanges. The survey instrument contains the following questions and was ratified by pilot testing by UK academic leads who may have such international interchanges. This was circulated via personal networks and the IMIA and European Federation of Medical Informatics (EFMI) Education Working Groups. Given that the survey was circulated in the period immediately before the ‘examination season’ the author was pleased with the responses. 1.2. Range of Responses Included in the provider survey group were representatives of health informatics ‘departments’ in new and established academic universities. There were departments that were well-established either as ‘spin-offs’ or specialist units within Computer Science or Health Faculties in addition to emerging innovations Units in new universities and Higher Education Colleges.

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Table 2. Questions relating to STUDENT exchanges (inward and outward).

1. Are there publicly available guidance notes for students wishing to study (health informatics or related subjects) in your institution. Can you give me details of these, please. 2. How many students do you typically take on your (health informatics or related) courses in a year from outside your country; and what proportion is that of your typical student intake to these courses. 3. What is the greatest challenge to getting international students onto your courses. 4. What major barriers, from your national perspective, are there to students from your country wanting to study abroad. 5. If your students wanted to study (part of or further) health informatics or related courses in another country, are there formal processes in your institution / country that they will need to go through. Please give details of where any useful guidance may be found.

Even in established institutions, there were some where the lack of maturity of their HI group precluded them from seeking international visiting staff or students from abroad. Other responses were from the specific unit or referred the author to institutional guidance. In addition, organisations and agencies that were known to provide resources to facilitate exchange were approached. As the domain of support for international activity may change over time it is always worth a general Internet search to identify current organisations involved. 1.3. International Partnership Master classes have been undertaken by six higher education institutions as part of a now well established International Partnership since 1999. Partners have agreed to collaborate by supporting and encouraging the exchange of talented students, teachers and the sharing of courseware to prepare their students for leading positions in the health industry [5].

2. Status of Exchange 2.1. Visiting status For academic staff, awarding ‘Visiting’ status to the individual can frequently facilitate the exchange. The position may have been formally advertised in the hardcopy trade press and on websites; or frequently may be the subject of personal invitation to work on a specific task that has academic recognition and credentials. Students on visits to certain countries even within the European Union (EU) may also need to register as ‘visiting’ staff for insurance purposes whether working on specific research or assignments or purely in study. Realistically, many appointments are made of trusted colleagues who are well-known to the receiving organisation beforehand rather than being totally open competition. 2.2. Credit Transfer Many academic institutions have arrangements in place to accredit transfer qualifications at programme or modular levels, which provide academic exemption from some parts of courses; and some accreditation of prior experiential learning may also be possible. There is no uniform rule about this and local enquiry will be needed to confirm what is possible. Study abroad vice versa may also be accredited to home programmes.


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3. Funding Whilst this study was not exhaustive, the type of organisations supporting exchanges will give pointers to local situations. Many opportunities are transient and it is necessary to consult the relevant websites for contemporary information. 3.1. Trans-national bodies European organisations and programmes such as Socrates Erasmus (see Useful Respondent References) have funded exchanges. Across the European Union, mobility of professions is important and encouraged. Looking at sites such as www.cordis.lu and www.europa.eu.int/ comm/education/index_en.html will identify operating programmes at any time. Exchanges are also supported as integral parts of research actions under the umbrella of funded projects through the Information Society Directorate. Heads of Agreement or Memoranda of Understanding are coming into existence to stimulate academic interchanges – as for example the previous EU:USA initiative which amongst other activities produced the book edited by Balas et al [6]. A current consortium of Australian and European Universities will jointly deliver a three year Masters degree programme with an international exchange component (see Useful Respondent References). 3.2. Competitive calls Institutions may themselves run competitive calls for student support visits to other institutions as part of or additional to the formal curriculum. For example the School of Health and Post Graduate Medicine at the University of Central Lancashire (see Useful Respondent references) selectively sends post-graduate students on its Masters programme to partner institutions in Romania and accepts reciprocal exchanges to work in the School. In addition, professional societies and academies have travel and educational bursary funds that may be applied for by staff wishing to participate in schemes abroad, sometimes to achieve the best outcomes from sabbatical periods during academic tenure. In some countries there are Scholarship Schemes, for example ‘where member governments offer scholarships and fellowships to citizens of other Commonwealth countries’ under the aegis of the Department for International Development (www.dfid.gov.uk/) and the Foreign and Commonwealth Office. There appears to be no clear pattern relating distinctly to whether visitors are on an ‘inward mission’ to your institution or ‘outward mission’ from your institution. Many potential funding sources will look at applications relating to both ways. 3.2. Funding levels In many cases the exchange funding is matched by the home institution, the individual participant or other sources. It is always necessary to declare, to each funding body, all other forms of support that contribute to any exchange. If you are planning to seek supplementary paid work to support you in addition to your studying, then you will need to check the national requirements before you make your final decision. For example, in Australia application must be made to the Department of Immigration, Multicultural and Indigenous Affairs for permission to work (www.immi.gov.au). Under a student visa you must have funds to cover your fees and living expenses, so any money raised by work must be considered incidental / additional.

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4. Duration of exchanges Exchanges can be of any length – from short lecture tours or project visits to ‘visiting staff posts’ by the semester or academic year. Some short visits are not in themselves formal exchanges but many of the issues outlined may still be faced. The ubiquity of the Internet means that the profile of internal study is changing. Many institutions now offer distance learning opportunities to both home country remote students and to foreign students. E-learning may necessitate only infrequent block attendance at residential study centres (if any) thereby reducing direct costs and impact on the individual student. This mode of learning is gaining in delivery for many reasons, including the logistic challenges covered in this chapter and the increasing need to work in parallel to personal study and development.

5. Objectives of the Exchange In some cases, the lure to a particular institution is a specific project, researcher or course leader. Additionally or alternatively, in some instances it is more basic, for example to gain proficiency in the language of the host country. Technical jargon is frequently global, but there is a considerable challenge in living and working in general in a country not of your birth. Exchanging with a country where the language of common parlance is not your own is a considerable addition to the logistic challenges a working visitor faces.

6. Logistical Issues 6.1. Main Issues Responses to the survey highlighted problems with : • • • • • •

Gaining complete funding for the exchange Identifying short term accommodation for self (and on longer missions, the family also) Coping with general day to day living where the language is not your first tongue Clearing immigration legislation and getting visas The technological infrastructure and capability to work as a virtual team Experience of being away from family

Funding for an exchange may include (notional) institutional fees and will necessarily incur personal costs too. Serious thought should be given to living expenses and possible unavoidable costs you may need to keep paying at home. Do not forget a contingency in case you need to return home in an emergency; although most institutions will be able to give advice and support in critical situations. The Bursar or Human Resources Department should be an early port of call in special circumstances. Organisationally, your University may insist on a formal agreement with the institution you wish to visit on an outward mission for study or work. The Human Resources Department will be able to advise explicitly on what arrangements with what countries and institutions are already in place and can be applied via a variation to cover your requirements. Alternatively a new arrangement will need full consideration by the Institution’s Administration and can only be developed in partnership between the specific locations. In the times we live, there is understandably increased vigilance about who is entering each country from another, and legislation regulations will require checking in both home


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and destination countries. In some cases, prior study in another country may stand you in good stead for later applications. If you are intending to make a long term base in the country you study in or go to on an academic exchange, sites like the Australian Department of Education, Science and Training’s National Office of Overseas Skills Recognition (AEINOOSR) (www.dest.gov.au/noosr/leaflets/noosr_guide_ICT.htm) or the International Education site (www.intstudy.com) will give you more information about recognition of your previous professional experience. Whilst some institutions reported that they were investing in marketing their courses to international students, some institutions, like for example the Institute for Development Policy & Management at the University of Manchester (See Useful Respondent References) have a good track record and are frequently over-subscribed on their courses by overseas students. The Internet, discussion groups and high-speed networking make it more feasible to work on the same project from different bases, thereby not necessitating long periods away from home base. As staff get more senior, their personal / family commitments may increase to the point where exchanges are no longer attractive and contribution to virtual networks remotely takes precedence.

7. Support to Exchanges 7.1. Student handbooks Guidance notes are frequently available in the host institution (for example the University of Leeds) or on its website (www.leeds.ac.uk/wlfare/stuinuk.html ); or may be nationally provided, such as in Australia at http://studyinaustralia.gov.au . In some cases, the documentation provides implicit selection criteria, for example the Galil Centre in Israel (see Useful Respondent References) presents its documentation only in Hebrew. 7.2. Guides from a personal perspective Previous year’s students or visiting staff are usually a source of real information and will probably be willing to tell you ‘off the record’ about their experiences. As part of discussions about your potential placement, ask if there are people who have been through the process before who have agreed to act as ambassadors formally or informally. It is also worthwhile to look at generic national and local sites to find out more about the area – weather, cultural customs and the like which could give you help in deciding which locations are suitable for you. 7.3. Language courses Fluency in the language of the institution you are going to may not be a total blockage to you participating academically in that country. Many universities offer language courses to facilitate you ‘brushing up’ your skills, but you must have some competence to start with. 7.4. Transit Desks and facilities for Visiting persons Many institutions which take visiting staff and students frequently allocate a space, perhaps identified as the ‘Transit Room’, with desks and facilities for networking and computer use. Persons on visiting positions will need to be given passwords and access to the systems of

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the host organisation, and will be required to sign up to the Code of Conduct of that organisation. Once a Visiting appointee goes home at the end of the exchange, their password/user code should be withdrawn and if possible arrangements made for routing email to another location or person. 7.5. Making best use of the expertise In the UK, as with some other countries, there is pressure on academic units to generate income through contract work. In that case it may not be possible to spend as much time with visiting personnel as you would wish, reducing the level of knowledge exchange. Involving visitors in the institution’s new staff Induction Programme may be worth considering.

8. Summary Recommendations This chapter reflects a very superficial picture of the situation internationally. However it does indicate that whilst there is a tremendous amount of useful and useable guidance out there, there is no real pattern to its presentation or its access. In view of the continually changing tensions throughout the world, what is recommended is that IMIA as a core professional body in our domain continue to grow a reference repository of pointers to information relating to educational exchanges rather than attempt to manage the information per se. The IMIA national representatives from member countries are an excellent gateway into informed people and organisations in each country and can be accessed through the IMIA website (www.imia.org).

References [1] [2] [3] [4] [5]

[6]

International Medical Informatics Association (IMIA) www.imia.org (accessed May 2004) UK Council for Health Informatics Professions www.ukchip.org.uk (accessed May 2004) Special Issue including A UK Operational Practitioner View - some Challenges of Health Informatics are trans-national, Roberts J, Methods of Information in Medicine (2002; 41 55-59) Are you an individual professional or a member of a profession – which is the priority for recognition Roberts, JM in Conf. Proc. HC2002, Harrogate UK (March 2002) Jaspers MWM, Gardner RM, Gatewood LC, Haux R, Leven FJ, Limburg M, Ravesloot JH, Schmidt D, Wetter T. IΦE: An International Partnership in Health Informatics Education. In: Hasman A, Blobel B, Dudeck J et al., editors. Medical Infobahn for Europe. Amsterdam: IOS Press; 2000. p. 549-53. (see also www.iPHIe.org ) Balas EA, Boren SA, Brown GD (Eds) Transferring Research to Practice for Health Care Improvement: Information Technology Strategies from the United States and the European Union. IOS Press (Health Technology and Informatics series (76) May2000).

Useful respondent references Main Theme Australian Immigration guidance re advice such as supplementary work whilst studying : example Australian International Education Network guidance : example Central Queensland University

Web address (as at 05.2004) www.immi.gov.au/study/overview/index.htm

aei.dest.gov.au/general/activities/04Activity11. htm www.international.cqu.edu.au handbook.cqu.edu.au


Main Theme Computer Science, University of Manchester

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Web address (as at 05.2004) www.cs.man.ac/uk/Research_subweb/visitors.a sp www.cs.man.ac.uk/mig/jobs/potentialstudent.pdf Council for International Education www.ukcosa.org.uk Department for International Development, www.dfid.gov.uk UK Foreign and Commonwealth Office, London, www.fco.gov.uk UK Galil Centre for Telemedicine and Medical www.techion.ac.il Informatics, Haifa, Israel Institute for Development Policy & Manage- Idpm.man.ac.uk ment at the University of Manchester) International Student Advisory Services, Uni- www.leeds.ac.uk/sas versity of Leeds : example International Student Information, University www.newcastle.edu.au/study/international/adm of Newcastle, example iss/visa.html Student Visas for the United Kingdom – ex- www.intstudy.com/visauk.htm plaining rules, visas and how to apply : example UK Home Office, Immigration & Nationality www.homeoffice.gov.uk United States of America – Student Entry in- www.usembassy.org.uk/cons_web/visa/niv/stu formation dent.htm University of British Columbia, Canada www.ubc.ca University of Ulster nikel.infj.ulst.ac.uk/personet/personet.htm University of Ulster www.ulster.ac.uk/international/handbook/eras mus.html Gateway to the European Union - Socrates– Europa.eu.int/comm/education/index_en.html Erasmus Programme (European) Community Research & develop- www.cordis.lu ment Information Service University of Central Lancashire, School of www.uclan.ac.uk Health and Post-graduate Medicine University of Victoria, BC, Canada www.uvic.ca/international/students.html hinf.uvic.ca/sinfo/Admit/Prospect.htm

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1.5. Gaining Support from Health Disciplines and Other Stakeholders Jeannette MURPHY Senior Lecturer in Health Informatics Centre for Health Informatics and Multiprofessional Education (CHIME) Royal Free & University College Medical School, University College London [email protected] Abstract. The Health industry employs health professionals from many disciplines all of whom need to have a basic understanding of helath informaytics principles and how information technologies may be used to improved health service delivery and patient/community/population health outcomes. This is not well understood by the workforce as a whole resulting in a low demand for health informatics education. Many health service managers and policy makers do not appreciate the power and potential usefulness of all health related information and the many technologies now available. This impacts on decisions regarding their acquisition, implementation and staff training/education support. This chapter includes recommended strategies on how to best overcome such knowledge deficits so that greater support for Health Informatics education is achieved.

Introduction There is consensus in the Health Informatics community that everyone who works in health care requires appropriate knowledge and competencies to enable them to make effective use of information systems. The IMIA Recommendations on Education state quite categorically that the systematic processing of health data, information and knowledge depends on: “…health care professionals who are well-trained in medical informatics or health informatics ….” [1] In the UK, after two national health information strategies, it is widely recognised that the NHS: “…needs staff who are ready, willing and able to use [IT] if the benefits are to be realised. Improving the management of information remains at least as great a challenge as delivering the necessary IT.”[2] Health professionals need more than just one-off training when a new information system is implemented. They need to be able to periodically update and extend their health informatics knowledge and skills when their roles change. Health Informatics education needs to encompass broader developments in health care provision and management. Key stakeholders must understand the distinction between IT skills and broader Health Informatics competencies. Speaking about recent developments in the United Kingdom (UK), Michael Humber [3] warns that: “The term national programme for information technology is misleading because the programme isn't just about technology. Its

J. Murphy / Gaining Support from Health Disciplines and Other Stakeholders

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successful implementation will affect the ways in which people work and services are delivered. (A good example is the electronic booking of appointments, which will require clinicians—who have traditionally been very independent—to relinquish some control over their diaries.) The national programme must spend money on facilitating these changes. Otherwise, the result could be good information and communications technology but no change in the way things are done.” (emphasis added, 2004) Tony Eardley (2004), Director of Health Informatics Services at South Staffordshire Healthcare Trust and Chairman of Assist, (a group representing National Health Service IT managers), makes a similar point about the dangers of focusing exclusively upon the acquisition of technological solutions and forgetting about people and organisational development: "The national programme is so all-consuming that people tend to think that this is an answer to all the problems …. that is not the case. Training, change management and cultural changes all have to be put in place. That message needs to get across.” [4] Although experts in the fields of Health Informatics and organisational development are convinced about the importance of investing in people, the demand for Health Informatics Education, Training and Development (ETD) has been low. For evidence relating to the UK see the RHIED study [5] and the recent report from the NHS Information Authority [6]. How can we explain this low demand for Health Informatics ETD? The thesis underpinning this chapter is that low demand stems primarily from a lack of understanding on the part of the workforce and major stakeholders on the need to invest not just in technology but in the people who will use these systems. Up until now, many stakeholders have not been convinced that return on investment in information systems is dependent on having an Education, Training and Development Strategy for Health Informatics. Furthermore, there appears to be a lack of clarity as to who is responsible for funding Health Informatics programmes. Is it employers or central government or regional bodies or individual staff themselves? This chapter will focus on ways of engaging the hearts and minds of the key stakeholders. The underlying argument is that technology does not deliver benefits unless the workforce is trained, and motivated to use information systems. The danger is that without sustained investment in education and training, the massive investments in healthcare technology that are taking place around the globe will not yield the anticipated benefits. The challenge facing Health Informatics educators is to find ways to get stakeholders on board and to ensure they recognise the importance of HI ETD.

1. Stakeholders 1.1. The Concepts of Stakeholders Stakeholders are defined as “individuals or organizations who stand to gain or loose from the success or failure of a system”. Nuseibeh & Easterbrook, 2000) (7)). In the context of this chapter, stakeholders are those who are impacted by (or have an impact on), educational programmes; their perspectives need to be taken into account in order for our programmes to be successful. Stakeholders can have positive or negative views, and often do not agree with one another, making it a challenge to reconcile their varied viewpoints. (8) Who are the key stakeholders as regards Health Informatics ETD? Although there are bound to be differences from one country to another, the key stakeholders will include many of the following groups identified in Table 1.

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Table 1. The Main Stakeholders: Health Informatics ETD.

1) Professional Bodies, Regulatory Bodies for: • Clinicians • Health Care Managers • Knowledge Managers: Library and Information Staff • Health Informatics, Nursing Informatics and Medical Informatics Professionals; Information Management and Technology Staff (IM&T) 2) Government Agencies and Departments 3) Academia / Educational Providers 4) Industry and Suppliers – providers of health information systems, medical software 5) Employers - Health care Providers 6) Funding Bodies, Commissioning Bodies (for ETD) 7) Patients and Carers 8) Standards Agencies 9) Health Science Libraries Note: The Australian Analysis of Stakeholders and Partners is quite similar but collapses these nine categories to four. [9]

1.2. The Role of Stakeholders Stakeholders are important to the community of Health Informatics educators and researchers because they: • • • • • • • •

Are involved in setting the standards for ETD (Education, Training and Development); Commission ETD; Fund ETD; Provide incentives to staff to undertake ETD; Write job descriptions; Carry out staff appraisals; Design and use health information systems; Evaluate the impact and benefit of ETD.

If we are to create a global market for Health Informatics Education (a prerequisite for a “global health informatics university”), we need stakeholders who: • • • • • •

appreciate the need to fund training; provide protected time off to enable staff to undertake training; make HI training mandatory for all healthcare professions; reward those who undertake training; create incentives and opportunities for staff; work with Health Informatics professionals to design and deliver appropriate education and training; ensure that HI is part of Life Long Learning and Continuing Professional Development

The next section of this chapter will consider how to “sell” Health Informatics education to stakeholders. This is followed by a case study of development in the UK over the past decade. Finally, the chapter concludes by outlining strategies and recommendations which will be relevant to IMIA’s elearning agenda. 2. Selling Health Informatics Education, Training and Development to Stakeholders Many stakeholders do not understand what Health Informatics involves or how it relates to the day-to-day work of professionals or to patient care. All too often they cannot distinguish between IT skills and Health Informatics. There is also a tendency to assume that health


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informatics is a rather academic discipline with little practical relevance. The challenge facing the HI community is to overturn these misconceptions and convince stakeholders that, as health providers invest in advanced information and communication systems, it is in everyone’s interest to create a workforce which has both the skills and knowledge to use technology to transform heath care. To convince stakeholders that HI ETD is important to the organisation and to the quality of patient care, it would be useful to be able to present evidence on the benefits of HI education and training. However, at present there is little evidence on either the direct or indirect benefits of HI education, training and development. Most of the literature on Health Informatics education is descriptive, focusing on a specific university and the perceptions and experiences of its students. Existing research falls into the following categories: 1) Case studies which describe the setting up of programme, its philosophy and curriculum. These are mostly descriptive with little or no outcomes reported. (See for example [10], [11], [12]) 2) Cohort studies which track students after they have graduated. Quite a number of studies have been carried out to find out what happens to HI students after they complete their programme (See for example, [13]). Such studies help us to understand how participants use their knowledge and skills after they have entered (or re-entered) the job market. However, they do not provide any evidence as to the benefits or returns on investment from the point of view of other stakeholders – viz employers. We do not know whether there are significant changes in professional practice which in turn result in better patient care, or a reduction in errors, or a saving of time. We assume that those who have had the benefit of specialist Health Informatics training are more productive than colleagues who have not received the same training but there does not appear to be any data which compares the two groups of staff. (And indeed there may be many logistical and ethical reasons why such a study would not be feasible.) Recent work undertaken by the NHS Information Authority in the UK (NHSIA, 2004) concludes there is an urgent need to generate evidence to demonstrate how ETD benefits healthcare providers and patients: “There must be clear evidence to support the fact that having health informatics standards and health informatics education improves the delivery of services and supports better patient care.” (p8) [6] Likewise, the New South Wales strategy document for IM&T ETD [14] notes that whilst there is a wealth of opinions expressed on the need for ETD and the types of curricula that are called for, evidence on the effectiveness of these programmes is lacking. In the absence of empirical evidence on the broader impact of HI ETD, there are two other possible sources of evidence which might be used to persuade stakeholders of the importance of investing in ETD. One way of trying to demonstrate the importance of education is to look at negative evidence (i.e. what happens if an organisation fails to train and educate its healthcare professionals; what are the risks of not investing). Another possibility is to focus more narrowly on IT skills training to see whether there is evidence to show skills training justifies the initial investment. 2.1. The Risks of not investing in Education and Training There is a considerable literature which explores the reasons why information systems fail, and why investment in technology does not yield returns on investment, some of which is directly related to healthcare environments. Nearly all the literature cites a lack of adequate education and training as a factor which contributes to failure. A recent report research from the Royal Academy of Engineering and the British Computer Society, The Challenges of Complex IT Projects, [15] concluded that only around 16% of IT projects can be considered truly successful, leading to billions of pounds being wasted every year on IT systems. The

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authors maintain that most system failure relates not to technology but to the people and processes. “We have”, says one of the contributors, “an educational problem, not a technological problem.” (p.34) [15] “A striking finding from the evidence gathered is that education, rather than technology holds the key to improvements in software success rates. Education is required at all levels… Improving education will not make an immediate change to practice, but is a vital part of the long-term solution to the problems.” The UK National Audit Office and Office of Government Commerce compiled a list of the eight most common causes of project failure, one of which was insufficient training. “.... it is essential to devote sufficient time and attention to user training. If this does not happen, there is a danger that the IT system, and the change it represents, will be resented and resisted, potentially endangering the success of the project.” p22 (quoted in report) [15] A number of studies in health care settings illustrate the connection between failure to provide the appropriate staff development in health informatics and system failure. Heeks, Mundy & Salazar’s 1999 paper, (16) reviewed the evidence up until the late 1990s as to why health care information systems succeed or fail, and painted a rather gloomy picture: “There is .. plenty of specific evidence that many – even most – health care information systems are failures. Anderson’s [17] work on Health Care Information Systems (HCIS) cites “studies that indicate half of all computer-based information systems fail”. Keen [18] notes that, “For every documented success, there seems to be a clutch of failures.” Likewise, Paré and Elam [19] state: “Research shows that many health care institutions have consumed huge amounts of money and frustrated countless people in wasted efforts to implement information systems”. Heeks et al developed a seven factor model for making sense of why systems succeed or fail. The authors maintain that these seven factors are necessary and sufficient to provide an understanding of the conception—reality gaps which give rise to system failures. One of their factors was `staffing and skills’ which links closely to Education, Training and Development in health informatics. The authors argue that if the assumptions made by the system developers about the knowledge, skills and attitudes of the end-users of the system do not match the actual skills of the workforce (and inadequate provision is made for supporting staff to acquire the necessary skills and knowledge), the system either will fail totally or else under-perform. A UK investigation into the failure of a nursing information system by Wilson and Howcroft at the Manchester School of Management [20] implicated a faulty strategy for staff development as one of the factors leading to the failure of the system. Although efforts were made to secure commitment to the system by participation in implementation committees, training sessions, and benefits realisation seminars, this strategy failed to secure support for the system. According to Wilson and Howcroft, this was because: “Firstly, participation was limited because of the selection process for user representation. It had been assumed that high-ranking nurses on the ward would make the most suitable candidates. But these were often older nurses, less familiar with computers, and hostile to the information system. Secondly, the training strategy was cascade training – with sisters as the ward tutor who was to initially train others. This was a problem since the sister was likely to be very busy and not familiar with computers prior to training. Thirdly, the ‘benefits realisation’ sessions were attended voluntarily


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and therefore unlikely to make any impression on those who were hostile to the whole IS project since they simply elected not to attend. This had led to the outright refusal by some to use the system. ….alternative means of persuasion such as outright coercion were evidenced, but not applied, as systematically as some supporters of the system would have liked. Resistance, through nonusage, was both possible and effective.” [20] The failure of the London Ambulance Service (LAS) in November 1992, was, like all major failures, blamed on a number of factors, one of which was inadequate training given to the operators. Claims were made in the press that up to 20-30 people might have died as a result of ambulances arriving too late on the scene. An inquiry was carried out into this disaster at the LAS and a report was released in February 1993. The main summary of the report said that staff, both within Central Ambulance Control (CAC) and ambulance crews, had no confidence in the system, were not all fully trained and there was no paper backup. “Inadequate testing of the system, along with the poor staff training was identified to be the main root of the problem. The management staff was highly criticised in the report for their part in the organisation of staff training. The ambulance crew and the central control crew staff were, among other things, trained in separate rooms, which did not lead to a proper working relationship between the pair. Here is what the report said about staff training: "Much of the training was carried out well in advance of the originally planned implementation date and hence there was a significant "skills decay" between then and when staff were eventually required to use the system. There were also doubts over the quality of training provided, whether by Systems Options or by LAS's own Work Based Trainers (WBTs). This training was not always comprehensive and was often inconsistent. The problems were exacerbated by the constant changes being made to the system." [21] Lack of staff training was implicated in a case of medical error in Australia. A pathology service was found liable in respect to an injury to a patient on the grounds that the doctor who used the system had inadequate knowledge and training, and as a result she did not realise that there was a second part of a pathology report to be printed as this function was not automatic. Part 2 of the report indicated that there was no evidence of overt malignancy while the first part suggested an adenocarcinoma. The company providing the pathology service was found to have not provided adequate support to its pathologists in the use of the computer system and was found partly responsible for damages to the plaintiff who had unnecessarily had an oesophagogastrectomy. One lesson to be drawn from this case, according to Alison Choy Flannigan, is that Healthcare providers must ensure that computer systems used by them are not defective and that they provide adequate training, ongoing assistance, supervision and support to staff and consultants regarding the use of those computer systems. [22] Looking outside the healthcare arena, the UK Passport Office IT system fiasco of 1999 provides further proof that a lack of education and training is tied in with system failure. Following the launch of the system there were huge delays in the issue of passports. Several hundred people were unable to travel and phone lines were continually congested. A report by the National Audit Office [23] identified a number of reasons why the system had failed. From the point of view of this chapter, what is noteworthy is that lack of adequate education and training were deemed to be a contributory factor. The planners underestimated the amount of time required for staff to become familiar with the new manual and computer-

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ised systems. One of the lessons for project managers was that staff must be fully trained and there must be adequate time allowed to learn new processes. “A failure to assess and test adequately the time needed by staff to learn and work the new passport processing system, which involved some changes in clerical and administrative processes as well as computerisation.” (p2) [23] 2.2. Benefits of IT Skills Training Although there is a dearth of evidence to prove that HI education and training yields benefits, there are studies which have tried to quantify the benefits of providing IT skills training. In the UK, the European Computer Driving License (ECDL) has been adopted as the referenced standard for basic IT skills in the NHS. To encourage as many staff as possible to obtain the qualification, the NHS Information Authority has arranged for learning materials to be available through an online portal. Given the criticisms made of the first ETD strategy (discussed in the next section), those who manage the ECDL project are anxious to demonstrate value for money. A pilot project at an NHS trust in Manchester, looked at staff who did the ECDL. It found the staff saved an average of 38 minutes a day because they were no longer struggling with IT. "That is 38 minutes per person per day that they are not with their PC and 38 minutes more they are spending with patients," said NHS manager Lavinia Wilkinson. More than 95% of the Manchester users who have completed the European computer driving licence said they now rarely need to call on IT support, compared to 71% who did so regularly before achieving the standard. [24] In 2003, a survey was emailed to NHS staff who had passed the ECDL to establish how well the project was working and whether they felt the qualification helped them in their work environment. The survey was sent to about 1,400 people and 515 forms were returned. The data was analysed in two ways: in terms of the job category of the respondents and in terms of the respondents’ skills before they commenced the training. Although the numbers of respondents in the sub-groups was small, and the data is based on self-report, the results suggest that the training yielded benefits to the individual, the organisation and to patients. Not surprisingly, those who had the most basic skills reported the most benefits. There were six important outcome measures reported. The findings are summarised below. [25] Outcome 1 - Effect on Need for Help • •

Before the training only 4% of Very Basic users and 24% of Basic users were able to say they ‘rarely needed to ask for help’. After the training 83% and 85% respectively rarely needed help, indicating a huge increase in confidence and capability.

Outcome 2 - Time Saved All categories reported time saved as a result of their training: • Very Basic users estimated they saved 41 minutes a day as a result of their new skills. • Basic users estimated a saving of 29 minutes a day. All categories saved more time, over a year, than they spent in their learning. However one category - ‘Nurses, Midwives & Health Visitors’ - benefited substantially more than the average as shown in Figure 1. Outcome 3 - Benefit to Patients Of those who worked with patients, two thirds of previously Very Basic users reported that their skills had brought direct benefits to patients.


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Hours Learning & Hours Saved (Per Year) 150 100 Hours Learning Hours Saved

50 Medical

Allied

Nurses

Support

Primary

Figure 1. Comparison of Hours Learning and Hours Saved by Staff Category.

Outcome 4 - Return on Investment The return on investment (including student and tutor time spent learning) ranged from 88% for Expert users to 238% for Very Basic users. Outcome 5 - Effect on Morale • •

Before their training just 29% of Very Basic users and 50% of Basic users felt positive about their jobs. After achieving their ECDL this rose to 75% and 65% respectively.

Outcome 6 - Effect on Attitude to New Systems • •

Before their training, only 10% of Very Basic users and 26% of Basic users felt positive about the new IT systems planned for the NHS. After achieving ECDL these figures rose to 86% and 71% respectively.

3. Case Study of Health Informatics Education and Training in the United Kingdom (1992-2004) This section will describe how the evolution of the national health information strategy in the UK and the efforts that have been made to persuade stakeholders of the need to invest in education, training and professional development to build expertise in Health Informatics. The review begins with the 1992 Information Management and Technology (IM&T) Strategy and then moves on to 1998 Information Strategy and the current National Programme for Information Technology (NPfIT). Both information strategies had an accompanying educational strategy and, as we shall see, there has been a concerted effort to identify the key stakeholders and to engage them in the process of defining educational needs and developing education and training opportunities. As well as describing what has been done to inform and engage the stakeholders, an assessment on the success of these activities will be provided and some lessons will be drawn. 3.1. The First Information Management &Technology (IM&T) Strategy (1992-1998) The first national information strategy was launched in 1992, and focused primarily on the information requirements of managers. According to a National Audit Office Report, the

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NHS Executive spent some £152 million on developing and implementing the Strategy between 1992 and 1998. (This excluding expenditure in the wider NHS.) [26], [27] The remit of the education/training strand of the strategy, the Enabling People Programme, was to help NHS staff to manage information better through the use of information technology, mainly through education and training. The education and training strategy aimed to stimulate, guide, and support training at the local level. Three Programme Boards were established, one for clinicians, one for managers and one for IM&T specialists. Each board produced guidance on training and training materials to support local training. In addition, a Training and Development Adviser was funded in each NHS Region to provide a link between local training work at trusts and health authorities and the NHS’s Executive Team. The total cost of the Enabling People Programme up to 31st March 1998 was £18.5 million, which equated to about 12% of total budget for the NHS Information Executive. Although the Enabling People Programme was centrally funded, the delivery of training remained a local responsibility 3.2. The Drivers behind the 1992 Strategy The early 1990s were a time of major changes in the National Health Service (NHS). An internal market was created whereby purchasers (local health authorities and General Practitioners) were given budgets to buy health care from providers (including acute hospitals, community hospitals and ambulance services). The hospitals became independent trusts, with their own management and financial control, competing with each other for contracts from purchasers. Fifty seven hospitals became trusts in 1991. By 1995, all health care was provided by NHS trusts. For the first time hospital trusts had responsibility for implementing their own information systems and running their own IT departments. “This had to be done on a short time scale and from a very primitive starting point. IT in hospitals was archaic. IT skills levels were low. Many hospitals had little experience of developing IT strategies and implementing IT. ” (Hackney & McBride) (28) In view of these developments in the NHS, one might have expected that stakeholders would have been readily persuaded to invest in Health Informatics education. The reality was quite different; it proved very difficult to achieve local buy-in to the national goals. At the close of the education and training programmes in 1998, demand for health informatics education remained disappointingly low. Nicholson and Peel’s comments encapsulate the views of many observers: “The history of training and education for health information and technology has been one of recurrent difficulties and missed opportunities. There has been confusion between technology related training and information related training.” [29] Why did it prove so hard to promote health informatics education and training? From the start of the 1992 education and training programme it was evident that very few stakeholders had any concept of what health informatics meant. (Indeed, it was decided to steer clear of this phrase; most of the documents referred to IM&T.) The programme boards struggled to define which elements of health informatics needed to be incorporated into the curriculum of clinicians, managers and IM&T specialists. There was on-going debate about the relationship between IT skills training, computer-based learning and health informatics. Emphasis was placed on building consensus and trying to communicate an understanding of why health informatics needed to be embedded into clinical programmes. Funding went into sponsoring regional and national meetings and developing learning resources. A variety of tools and frameworks (most notably, Learning to Manage Health Information) ([30] were developed to assist curriculum development groups.


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3.3. Verdict of the National Audit Office (NAO) on the 1992 IM&T Strategy In 1999 the National Audit Office, the body which scrutinises public spending on behalf of Parliament, interviewed twenty health authorities and trusts about the strategy, including the Training Programme. [27] Respondents agreed that a training strategy was necessary but the majority of those consulted were not satisfied with the training developed. It was not seen as irrelevant to the 1992 Strategy and it was felt the training strategy did not provide benefits. Those questioned thought there was too much material and that it was poorly indexed and hard to search. Even at the close of the 1990s, most NHS staff did not have easy access to the web which made it difficult to disseminate training materials. (p64) Materials were often distributed via IM&T departments and did not reach managerial or clinical staff. Quite often, the information management and technology departments were regarded as providers of computer facilities rather than authorities on training needs. Consequently, they were not well placed to influence information management and technology training in their wider organisations. (p40) What this suggests is that in the climate of the late 1990s, IM&T departments were the wrong group to sponsor health informatics training for clinicians and service managers. The NAO review [23] observed that a fundamental problem with the strategy as a whole was that there was a lack of measurable outcomes. In relation to IT skills and health informatics competencies, there was a lack of data regarding skill levels in the NHS when the programme started in 1992, and no data was collected at the close of the programme. In the absence of any before-after measures, there was no way of knowing whether there had been any return on investment. 3.4. Legacy of the Enabling People Programme (Education & Training in IM&T) Despite these problems, there were some positive outcomes from the first strategy from the perspective of health informatics education. The Education Strategy achieved the following outcomes: • • • • • •

Identified the important stakeholders and encouraged networking within and between groups (via conferences and other events) Raised awareness of the importance of IM&T education and training for the workforce (through conferences, meetings, working groups, publications) Initiated a debate on the difference between IT skills training and Health Informatics education Identified some of the obvious `champions’ within the clinical professions Developed a variety of reference standards, the most important of which was Learning to Manage Health Information Set the agenda for the next education and training strategy

3.4. 1998 Strategy – Information for Health Following the election of a Labour government in 1997, a new health information strategy, Information for Health, was announced in 1998. [31] This was preceded by a White Paper, The New NHS: Modern; Dependable, (32) which sought to reverse some of the reforms of the previous Conservative government, most notably the internal market. Information and IT were seen as central to the so-called `modernisation agenda’. As with the previous information strategy, there was an accompanying education strategy which sought to ensure greater integration between learning programmes and organisational changes. When the NHS Information Authority (NHSIA) launched the second national EDT strategy for

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Health Informatics, they were in a position to reflect on what had been learned during the life of the first strategy. In particular, there were the criticisms made in the NAO report. The aim was to look beyond short-term training needs, to the longer-term goal of changing the culture of the NHS: “Whilst there are some short-term, system-specific needs to be met, the intention was to complete this with education and training aimed at the long-term goal of developing an information culture in the NHS.” [23] To nurture stakeholder relations, a specific directorate was set up within the NHS Information Authority to manage and co-ordinate stakeholder relations and communications. It is too early to provide an assessment of what has been achieved since the publication of the 1999 ETD Strategy (Ways of Working with Information), but we can give an overview of where we are in 2004. 3.5. Taking Stock - Where we are now in the UK in 2004 1) We have a national information strategy, Information for Health, which has been followed by a number of further policy documents spelling out what needs to be done to harness information technology for patient care. (see Delivering 21st Century IT Support for the NHS, and the Wanless Report) [33], [34] 2) Major investment is taking place in IT systems and infrastructure (the National Programme for IT, NPfIT). Four key deliverables have been agreed: • Appointment booking • An integrated care records service (CRS) • E-prescribing • IT infrastructure to support national applications and local systems 3) On the ETD front, there has been some success in relation to IT skills development with the general acceptance of the European Computer Driving License as the NHS standard for computer literacy. However, progress in getting the ECDL into pre-registration, undergraduate training has been slower, mainly because of the costs. 4) There is now a commitment to collecting data on the Health Informatics skills and competencies of NHS staff. An assessment tool (the Competency Profiles) has been developed which specifies what IT skills and Health informatics knowledge is required by ten different categories of NHS staff. [35] 5) Health Informatics is making strides in gaining acceptance as a profession. A national human resources strategy has been adopted for Health Informatics Professionals, Making Information Count. (36) In addition, a new umbrella group, UKCHIP (UK Council for Health Informatics Professionals) has been established to promote professionalism in Health Informatics (HI). It operates a voluntary register of HI professionals who agree to work to clearly defined standards. 6) There has been a notable expansion in the number of specialist HI programmes, mainly at graduate level, designed for those already working in the NHS. From the expressions of interest we receive from potential students, there is a market for such programmes. Despite these successes, it would be misleading to suggest that in the UK we have succeeded in achieving major `buy-in’ from the stakeholders. Many are still unaware of the standards the NHS has endorsed or else they choose to ignore them. Research into the attitudes and ETD practices of three UK trusts, found that human resource departments tended to adopt a `wait and see’ approach. Managers said they would wait until new systems were implemented and then worry about training. [37] When Dennis Protti [38] assessed the readiness of the NHS to implement the national information strategy, Information for Health, he found that in 45% of the local health communities he reviewed, their score in


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relation to `Human Resources Infrastructure’ were so low as to signal impending risks. What was equally worrying was that there was little indication as to how these deficiencies would be addressed. The most recent piece of work investigating the uptake of proposed educational standards (summarized below), demonstrates yet again that much effort is still required to sell health informatics to stakeholders. 3.5. Implementation of Educational Standards: What’s been achieved? One of the enduring legacies of the first information strategy was a consensus document called Learning to Manage Health Information (LtMHI). [30] This document was compiled in 1999 and sets out standards for professionals, expressed as expectations for learning about health informatics themes at different career stages. The document was the outcome of an extensive consultation process and was endorsed by twenty-eight professional, regulatory or accrediting bodies for health professionals in the UK. It is instructive to follow the fate of this document because there are some important lessons on how to ensure buy-in from stakeholders. Although there appeared to be commitment to the `expectations for learning’ outlined in the document, there was no specific national plan for implementation, the assumption being that that the professional, regulatory or accrediting bodies would put in place systems to ensure that the standards were embedded into learning programmes. This reliance on voluntary compliance turned out to be somewhat misguided. The RHIED investigation demonstrated that few educational providers were incorporating the standards into their curricula. This study, funded by the Department of Health, was a national survey which covered both medical, nursing and management programmes. [5] These findings were confirmed by a more recent report published in March 2004 by the NHS Information Authority which concluded that implementation of the standards by Allied Health Professionals and nursing programmes had been patchy and inconsistent. “Worse still there appeared to be little or no awareness of the standards by education commissioning organisations” (p12) [6] The authors of the report noted that those who commission education were often unaware of the standards or else the whole area of health information education was very low on their agenda. These findings led the Information Authority to sound this warning: “Unless more is done quickly to extend the education of clinical staff there is a real danger that the major IT investment may not be as effective as planned and the benefits may be reduced.” p13 3.6. What are the Lessons to be drawn from the UK experience? Clearly, there are some approaches that have been shown not to work: •

Just publishing standards does not bring about change. For example the ECDL is a Department of Health endorsed standard for IT skills, but it still is not a development priority for many qualified staff. Learning to Manage Health Information has not been universally embedded into clinical curricula. • Producing learning resources does not guarantee they will be used by trainers or educators. • Funding pilot projects does not necessarily lead to national roll out.

Given that a range of national initiatives have not led to a massive change of culture and take-up of education and training, what do we do next? If we contrast the first and second information strategies in the UK, the most striking difference is that under the current National Programme for IT, the government has abandoned its previous laissez-faire approach.

48


Instead of `let a thousand flowers bloom’, it has adopted a philosophy of ruthless standardization in relation to standards and suppliers. This has not yet happened in the arena of HI ETD but there are indications that the training division of the NHSIA is moving from voluntarism to compulsion. There are some signs that the next step may be to make some elements of Health Informatics statutory or mandatory for all who work in health care. This change of approach is signaled in a recent NHSIA report: “The national role has been one of encouragement, review and exploration … p14 “However the time for a laissez-faire approach may now be over as the need for health informatics knowledge and skills become more urgent. The information technology is almost there and we still cannot with any confidence state that health professionals working in the service are ready to receive it.” p14 [6] 3.7. Lack of Investment: Major Threat to ETD in Health Information Another point worth stressing is that so far in the UK no clear funding channels for healthcare-informatics education and training have been established. There is widespread belief amongst HI educators that a lack of ring-fenced monies for education and training is suppressing demand. According to ETD Project Manager Stephanie Wilson [39], the historical levels of funding from IM&T departments will not be adequate for the development of healthcare-informatics professionals. What we are seeing is a growing disparity between investment in IT infrastructure and investment in informatics education, training and development. “As access to electronic records increases, and more clinical staff within healthcare communities are given PCs, the need for training increases substantially. Staff need to acquire knowledge and skills in areas such as information governance, email and Internet policy, computing, clinical terms for NSF disease registers and GP clinical systems, to name but a few. This in turn presents a range of funding needs for training, including trainers, training suites, equipment, materials, course development and training subcontractors.” (p 14 ) [39] An unpublished survey (40) which asked twenty-five would-be health informatics students to identify factors which might prevent them from enrolling on a HI programme, found that the two main deterrents were `financial costs’ (64%) `lack of support from their employer’ (48%). 5. What should we expect of stakeholders? Those wanting to promote Health Informatics (both as a discipline and a programme of study relevant to all healthcare professionals), need to be clear as to what is being asked of the various stakeholders. What do stakeholders need to understand? How do we convince them of the relevance of HI? And what are the possible barriers or resistances we might expect to encounter in our dialogues? Based on the research and development in the UK environment over the past fifteen years, I propose the following ways in which stakeholders might promote health informatics competencies: 1) Provide funding. Monies for HI ETD need to be ring fenced at local, regional and national level. It is no longer sufficient to create a special training budget every decade


2)

3)

4)

5)

6)

7)

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or so to support the implementation of a new system. Opportunities for HI education and training need to be available throughout an individual’s career. Human Resources departments, training departments, boards of directors of trusts all need to appreciate that technology will not deliver benefits unless staff are trained and supported. Create incentives for professionals to engage in HI ETD. As new regulations for maintaining professional accreditation and registration develop, it is essential that Health Informatics competencies are built into these schemes. Where appropriate, HI should be designated as mandatory. Literature relating to Life Long Learning (LLL) and continuing CPD should mention the need to develop HI competencies. Another way of providing encouragement and support is by linking HI education to career advancement or pay increments. There need to be ways for clinicians to have dual roles, as clinicians and as clinical informaticians. As appraisal schemes and personal development plans (PDPs) are introduced, human resources departments need to be briefed on how to incorporate HI into both appraisals and PDPs. (For an example, see A Practical Approach to IM&T Training and Development for Primary Care Staff, NHS Scotland) [41] Provide mentoring and careers advice (for all professionals and for those who may want to specialise in HI). Stakeholders must provide clear guidance on the evolving requirements for CPD and LLL in relation to HI and how these can be satisfied. Stakeholders need guidance, and information to enable them to direct professionals to the most appropriate HI training to meets the needs of the employing agency, the requirements of the profession, and the aspirations of the individual. Provide protected time off from work. Once staff have signed up to attend a course, line managers need to work with the person to ensure that work commitments do not encroach on study time. With all courses (including on-line, distance learning courses), students need time to read, reflect, prepare assignments and engage in on-line or faceto-face chat. Ensure adequate library and computer support in the workplace. Irrespective of whether or not the student is engaged in distance learning or e-learning, all students need access to networked computers and electronic resources. Create local learning networks, learning sets, learning communities. To support learners and to increase the chances that what they learn will be incorporated into practice, there needs to be some mechanism for networking individuals who are developing their health informatics competencies. Stakeholders need to find ways to overcome the loneliness and isolation often experienced by adult learners. Keep abreast of local, national and international trends in relation to health informatics.

To discharge their responsibilities, stakeholders need information and evidence about: • Drivers (statutory requirements, regulations, requirements imposed by government, by professional bodies) • Benefits, payoffs of HI education • Supply – what courses available; for whom appropriate; cost; content; demands on student; length of time involved • Costs – full-time and part-time and distance learning modes • Funding mechanisms

6. Actions IMIA could take to gain stakeholder support for ETD There are two outcomes we are hoping to achieve with this book. The first is to make a convincing case for a Global University for Health/Medical Informatics. Secondly, the

50


book seeks to identify and to find ways of addressing factors which may stand in the way of achieving this objective. This chapter has addressed one such obstacle: the fact that many of the key stakeholders are not aware of the benefits of Health Informatics education. Consequently, they may be reluctant to provide funding to those who are keen to sign up for online learning. This chapter has identified the key stakeholders and tried to understand why, even after several decades of efforts by the health informatics community, they are still not wholly persuaded of the need to create and sponsor learning opportunities, not just for specialist staff, but for the rank and file of health care professionals. There are two actions which the IMIA working group on education might consider. 1 Compile and disseminate evidence to demonstrate that education and training is not a luxury, but an essential part of the whole process of using technology to improve patient care. IMIA might also indicate what type of new research is needed to stimulate demand for HI education and training. For all of us engaged in dialogues with stakeholders, it would be helpful to have this evidence to show that HI Education delivers benefits. 2 Collect evidence to show how HI education and training is currently funded in different countries – i.e. a map of the various funding mechanisms and some data as to how common each one is. (This could consist of a series of case studies.) For instance, how common is it for employers to fully or partially fund specialist, graduate-level training? What level of funding is provided by regional or strategic health authorities? Are there instances of IT suppliers funding scholarships or bursaries? Do universities allow HI students to apply for generic bursaries? Do generic funding bodies (such as the UK Medical Research Council or the Economic and Social Research Council) allow would-be health informatics students to apply? What are the funding mechanisms for short courses and Continuing Professional Development as compared to graduate programmes which lead to a university award? Do other countries have an equivalent funding body to the National Library of Medicine in the USA?

References [1] [2]

[3] [4] [5]

[6]

[7] [8]

Recommendations of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics, page 3, pdf file, http://www.imia.org/wg1/rec.pdf (accessed 11/06/04) Pattison J, Drury P, Developments in direction and delivery of IM&T for the National Health Service in England. In K Dean editor. Thought Leaders: Essays from health innovators. p.87 Cisco Systems. Connected Health; 2004. London: Premium Publishing Humber M (2004) National programme for information technology, BMJ 2004;328:1145-1146. Eardley T (2004) as quoted by Lindsay Clark, Tuesday 4 May 2004, National programme for IT will push NHS IT spending growth up by 61% in 2004, Computer Weekly.com. http://www.computerweekly.com/ (accessed 11/06/04) Murphy J, Stramer K, Clamp S, Grubb P, Gosland G, Davis S. Health Informatics Education for Clinicians and Managers – What’s holding up progress? International Journal of Medical Informatics. Volume 73, Issue 2, 18 March 2004, Pages 205-213. (Special Issue: IMIA Working Group on Education) NHS Information Authority. Health Informatics Education and Development for Clinical Professions: Making progress? Research reports sponsored by the NHS Information Authority into the implementation of Learning to Manage Health Information: a theme for clinical education, carried out between April 2001 and March 2004 in four parts. 16 March 2004. http://www.nhsia.nhs.uk/informatics/pages/resource_informatics/ltmPart1.PDF (accessed 11/06/04) Nuseibeh B, Easterbrook S, Requirements Engineering: A Roadmap , Proceedings of International Conference on Software Engineering (ICSE-2000), 4-11 June 2000, Limerick, Ireland, ACM Press. Boutelle J (2004) Understanding Organizational Stakeholders for Design Success. May 6, 2004. http://www.boxesandarrows.com/archives/understanding_organizational_stakeholders_for_design_succ ess.php (accessed 11/06/04)


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[9] Hovenga E. National Capacity Building in Health Informatics. 2003. Unpublished working paper. [10] Jaspers MW, Fockens P, Ravesloot JH, Limburg M, Abu-Hanna A. Fifteen years medical information sciences: the Amsterdam curriculum. International Journal of Medical Informatics 2004;73(6):465-77. [11] Patton GA, Gardner RM. Medical Informatics Education: The University of Utah Experience. Journal of the American Medical Informatics Association 1999;6:457-65. [12] Hersh W. Medical informatics education: an alternative pathway for training informationists. J Med Libr Assoc 2002; 90(1):76-79. [13] Knaup P, Frey W, Haux R, Leven FJ. Medical informatics specialists: what are their job profiles? Results of a study on the first 1024 medical informatics graduates of the Universities of Heidelberg and Heilbronn. Methods Inf Med 2003;42(5):578-87. [14] NSW Health Department. Information Management and Technology Education, Training and Development Strategy: A Strategy for NSW Healthcare Workers. June 2002. NSW Government Action Plan, Sydney. http://www.health.nsw.gov.au/policy/gap/strategies/im&t_strategy.pdf (accessed 5/31/04) [15] Royal Academy of Engineering and the British Computer Society. Hatton, The Challenges of Complex IT Projects (2004 p.34) The Royal Academy of Engineering, London. http://www.bcs.org/NR/rdonlyres/3B36137E-C5FE-487B-A18B-4D7281D88EF7/0/complexity.pdf (accessed 11/06/04) [16] Heeks R, Mundy D, Salazar A. Why Health Care Information Systems Succeed or Fail. (1999) Institute for Development Policy and Management, iGovernment Working Paper No. 9, University of Manchester, Institute for Development Policy and Management. http://idpm.man.ac.uk/publications/wp/igov/igov_wp09.shtml (accessed 6/1/04) [17] Anderson JG. Clearing the way for physicians’ use of clinical information systems. Communications of the ACM 1997;40(8):83-90. [18] Keen J. editor. Information Management in Health Services, Buckingham, UK: Open University Press; 1994. [19] Paré G, Elam JJ. Introducing information technology in the clinical setting. International Journal of Technology Assessment in Health Care 1998;14(2):331-343. [20] Wilson M, Howcroft D. Gender and User Resistance in Nursing Information Systems Failure, Manchester School of Management, Working Paper Series 2000. (2000) http://www.sm.umist.ac.uk/wp/Papers/wp2013.htm (accessed 03/06/0404) [21] Brief summary report of the Inquiry into the London Ambulance Service, February 1993. http://www.scit.wlv.ac.uk (accessed 6/11/04). Full report available at http://www.cs.ucl.ac.uk/staff/A.Finkelstein/las/lascase0.9.pdf [22] Flannigan AC. New Health Information Technology Case. Health Law Update, p6, June 2001. http://www.bdw.com.au/frameit.asp?page=/scripts/publications-index.asp (accessed 5/31/04) [23] National Audit Office. The passport delays of Summer 1999. HC 812 Session 1998-99. 27 October 1999. http://www.nao.org.uk/publications/nao_reports/9899812.pdf (accessed 11/06/04) [24] Kavanagh J. NHS saves staff time by pushing European computer driving licence qualification. Computer-Weekly.com. Wednesday 23 April 2003. http://www.computerweekly (accessed 11/06/04) [25] NHS Information Authority. Evaluating the Impact of ECDL in the NHS: Research Results http://www.ecdl.nhs.uk/pages/evaluating_the_impact_of_ECDL_in_the_NHS_version_1.pdf, May 2004 (accessed 11/06/04) [26] National Audit Office, Report by the Comptroller and Auditor General, The 1992 and 1998 Information Management & Technology Strategies of the NHS Executive, April 1999. HC 371 1998/99. [27] House of Commons (2000) Select Committee on Public Accounts Thirteenth Report - The 1992 and 1998 Information Management and Technology Strategies of the NHS Executive. available on line as pdf file http://www.parliament.the-stationeryoffice.co.uk/pa/cm199900/cmselect/cmpubacc/406/40603.htm (accessed 11/06/04) [28] Hackney, R and McBride, N (2002). Non-Implementation of an IS Strategy within a UK Hospital: Observations from a Longitudinal Case Study. Communications of the Association for Information Systems 8, 8. (Volume 8 Article 8 February, 2002 p.143) http://cais.isworld.org/contents.asp?show=8 (accessed 6/11/04) [29] Nicholson L, Peel V. Manpower Development for NHS Information Systems. In R Sheaff, V Peel editors. Managing Health Service Information System: an introduction. Buckingham: Open University Press; 1995. p145-157. [30] M. Severs, C. Pearson, Learning to Manage Health Information: A Theme for Clinical Education. Enabling People Programme. 1999. Revised October 2002. Available at: http://www.nhsia.nhs.uk/informatics/pages/resource_informatics/Learning_to_Manage02.pdf (accessed 6/11/04) [31] NHS Executive. Information for Health. 1998. http://www.dh.gov.uk/ (accessed 11/06/04) [32] Department of Health. The New NHS: modern, dependable. December 1997. http://www.archive.official-documents.co.uk/document/doh/newnhs/forward.htm (accessed 11/06/04)

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[33] The Department of Health. Delivering 21st Century IT Support for the NHS: national strategic programme. 2002. http://www.dh.gov.uk/assetRoot/04/06/71/12/04067112.pdf (accessed 11/06/04) [34] HM Treasury. Securing Our Future Health: Taking A Long-Term View - The Wanless Review. 2002. http://www.hm-treasury.gov.uk/consultations_and_legislation/wanless/consult_wanless_final.cfm (accessed 6/11/04) [35] NHS Information Authority. National Health Informatics Competency – Profiles (2001) http://www.nhsia.nhs.uk/informatics/pages/resource_informatics/hi_competencyprofiles.pdf (accessed 11/06/04) [36] The Department of Health. Making information count : a human resources strategy for health professionals. 2002. http://www.dh.gov.uk/assetRoot/04/07/30/84/04073084.pdf (accessed 6/11/04) [37] Murphy J, Stramer K, Clamp S, Grubb P, Gosland G, Davis S. Health Informatics Education for Healthcare professionals (the RHIED report). Final report to Department of Health (ICT Research Initiative, ref ICT/136). 2001. Project proformas and results available on project website: http://www.rhied.org.uk Executive Summary available on website of the Information Authority, http://www.nhsia.nhs.uk/nhid/pages/resource_informatics/RHIED_report.pdf [38] Protti D. An Assessment of the State of Readiness and a Suggested Approach to Evalutiang Information for Health: An Information Strategy for the Modern NHS (1998-2005). Report to the NHS Information Policy Unit. 24th October 1999. [39] Wilson S. Delivering 21st century IT: how will healthcare informatics education and training be provided? The British Journal of Healthcare Computing & Information Management, June 2003, vol 20, No 5, 14-15. [40] CHIME unpublished survey (conducted by Murphy J). Attitudes and aspirations of 25 people who expressed an interest in studying for a HI graduate qualification. (Attendees at an Open Evening, May 2004). [41] Information Systems Support Group, Scottish Executive Health Department. NHS Scotland. A Practical Approach to IM&T Training and Development for Primary Care. Staff, document not dated. http://www.circlesquare.biz/dev/imandt/index.html (accessed 11/06/04)

Section 2 Curricula and Degree Structures (Outcomes and Recognition)



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2.1. A Health Informatics Educational Framework Evelyn J.S. HOVENGA Faculty of Informatics and Communication, Central Queensland University, Rockhampton MC4702 Australia Abstract. There is a need to be able to define a Health Informatician by their graduate attributes. Futhermore global health informatics education that facilitates student mobility requires a common understanding of educational outcomes. An internationally agreed health informatics education framework will facilitate us to meet these needs. This chapter provides an overview of a considerable amount of work undertaken in a number of countries and by IMIA’s health and medical informatics education working group. We need to make good use of these foundations as they clarify the various health informatics roles and functions together with their associated health informatics competency requirements. We are now in a good position to progress this work by developing a health informatics qualifications and educational framework. This is expected to assist educational providers with curriculum development.

1. Introduction Educational frameworks are very useful tools to provide clarity about the relative position of different qualifications. This then supports decision making regarding the progression between various educational sectors, including countries and providers. Such frameworks assist with program accreditation, positioning the results of any recognition of prior learning exercise, and the administration of credit transfers. As a consequence such frameworks provide a desirable infrastructure supporting student mobility, trans-national and borderless education. It is highly desirable to establish such a framework for Health Informatics education as this would assist with the identified need to be able to define a Health Informatician by their graduate attributes. An internationally accepted framework needs to describe learning opportunities and clarify relationships between qualifications. It needs to clarify entry and exit points and routes for progression within the entire health informatics education providers’ sector and increase opportunities for credit transfer. It needs to facilitate a sound understanding of previous learning and credits accumulated and how this can be used to progress HI learning as a component of a chosen career path.

2. Existing Foundations IMIA has endorsed a set of recommendations on education [1] in 1999 and a scientific map was developed in 2002. These provide a very sound foundation for a more comprehensive health informatics education framework needed to enable a virtual HI university to function

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E.J.S. Hovenga / A Health Informatics Educational Framework

Table 1. Learning Outcomes for IT Users and H & MI specialists. Learning outcomes for all healthcare professionals in their role as IT users Enabling healthcare professionals to efficiently and responsibly use information processing methodology and information and communication technology. These learning outcomes need to be included in all undergraduate curricula, leading to a health care professional qualification.

Learning outcomes for health and medical informatics specialists Preparing graduates for careers in health and medical informatics in academic, healthcare (e.g. hospital) or industrial settings. These learning outcomes need to be included in all curricula, leading to a qualification as specialist in health and medical informatics.

optimally. In depth analysis of the many emerging roles and functions of health informaticians around the world is expected to inform this process. The IMIA recommendations have been divided into three knowledge/skill domain groups: 1. methodology and technology for the processing of data, information and knowledge in medicine and healthcare 2. medicine, health and biosciences, health system organisation 3. informatics/computer science, mathematics, biometry Two major learning outcomes were identified and are described in the table 1. The recommendations include topic areas to be covered within each of the three knowledge/skill domains and indicate the level of knowledge required in terms of introductory, intermediate or advanced. Some of these are applicable only to certain specialty areas which are also indicated. The recommendations have recognised that students undertaking health informatics education are either undertaking an undergraduate degree in one of the health professions or in informatics (i.e. computer science, ICT, IM/IS, bioinformatics) or they have previously graduated with a degree in a wide variety of knowledge domains. This diversity makes it difficult to model a health informatics education framework that clearly indicates the many different pathways one can follow towards a professional health informatics qualification. In addition a lot of work has been undertaken by others to date to analyse the various roles and functions of Health Informaticians and to develop associated competencies [2, 3, 4, 5]. Collectively this provides a very good foundation from which to develop a health informatics educational framework. Both the Canadian and UK work have used a ‘roles based’ approach to develop their frameworks. Competencies were identified for each role. The NHS multidisciplinary framework is based on the most widely recognised national standards of competency in Information Management as outlined in the Management Charter Initiative (MCI) Management Standards and applies to all staff working at strategic and operational levels of management [6]. This competency framework consists of core competencies for information management within the context of information management and technology, information planning and NHS systems with a number of supporting and emerging competencies. It includes five cumulative skill levels. The framework is used as a template for training consortia and NHS organisations to specify the IM&T requirements for various job roles. Health Informatics (HI) careers are described in six main HI specialist groups as detailed in table 2 [7]. The Canadians [5] identified three macro roles for which competencies were identified, 1) applied HI, 2) Research and Development HI and 3)Clinician HI. These roles are described as follows in table 3. In the process of identifying our target educational market, an Australian HL7 educational advisory committee identified three broad areas of content as well as three levels of decision making [8]. This description and classification of the HL7 education target market is considered to also apply to the health and medical informatics education target market as


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Table 2. NHS Health Informatics: Careers in IM & T. Specialist HI Group in NHS Information & Communication Technology (ICT) staff

Health records staff

Knowledge management staff

Information management staff

Clinical informatics staff Health informatics senior managers and directors of services.

Role description Run the internal and external electronic communications systems. Staff roles include network management, technology and help desk support, application and systems development, project management and implementation, system security and staff training. Collate, store and retrieve the patient records used in diagnosis and treatment. Staff roles include health records staff, assistant manager of a medical records department and clinical coders. Support health professionals and management staff in their education, training, development and professional practice. Assist NHS employees to access information. Staff roles include administrative assistant, knowledge managers, information specialists and librarians. Use statistics and other information in order to plan, monitor and develop the health service. Staff roles include research, clinical audit, data protection and confidentiality, planning and performance management. Qualified health professionals who have moved into a part-time or full-time role in health informatics. Run health informatics services and plan for the future. Can come from any of the specialist HI areas.

Table 3. Canadian Macro Health Informatician Roles [5]. Applied Health Informatician (AHI) Professionals that deploy information technologies in support of health system processes. They require both a well developed knowledge base that encompasses the health system, computer science, and health information systems related topics, as well as a set of intellectual and procedural skills and preparatory experiences (section A p.4).

Research and Development Health Informatics (RDHI) Professionals able to effectively use information for a) governance and policy formulation, b) administration, and c) health care and clinical decisions. This curriculum also addresses supportive matters such as the structuring, collection, and use of information from care for performance indicators, and the use of information for quality improvement, and issues around clinical decision support tools and methodologies (section B p.5).

Clinician Health Informatics (CHI) Clinicians capture, process and store information about particular patients, and search for information to facilitate care. Clinical research is an effort to link healthcare activities with the results they produce. Practicing clinicians need to be familiar and proficient with existing information tools so they can be used to develop individual patient records, search for answers to patient problems, and collect information that could be used to further our knowledge of how healthcare works. Clinicians are concerned with how care activities influence the comfort, function and life expectancy of individuals and groups of patients. They need to be able to communicate their needs to AHIs and RDHIs, this requires them to have a basic understanding of the nature, capabilities and uses of existing health informatics tools and the potential for health information technology to influence care.

a whole. There are essentially three streams, business operations, healthcare delivery systems that include many clinical specialties, and information technology including systems. For each of these individuals occupy specific organisational roles and functions from the high level strategic, policy or executive decision makers, through the middle managers to the doers or practitioners in each stream. The educational content offered by any Health Informatics program or course needs to vary in depth and breadth based on these variations in the target market characteristics.

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Table 4. NSW Health Educational Target Groups. Target Group Operational information users – largest group

Role and functions Data input staff, local managers, clinicians, ancillary and administrative staff who document, process, analyse, review, evaluate and communicate a plethora of information and data from a variety of sources to support patient care at the point of service.

Business users – managers and analysts

Staff who retrieve and review the outputs and outcomes of the data and information taken from the operational level. These include unit and departmental managers, accounts department and decision-support staff.

Business users – operational planners

These staff take the aggregated data and information from the previous users and identify service management and planning. These business users include hospital and clinical managers who use this information for management, planning and performance monitoring.

Strategic users

Specialists in the development and interpretation of the data produced by the various systems and who develop policies and guidelines for the ethical use of information. This group includes epidemiologists, information specialists, quality improvement staff, workforce planners etc.

Application specialists and training support

These staff design the training courses, user documentation and course evaluation methodologies and provide hands on training to teach staff how to use the information system. They also provide retraining when new modules or system upgrades require staff to learn additional functions. Application specialists prepare super-users to provide on-going training support to staff in their business units when and where it is required,

Informatics professionals

Work with vendors and information technology staff to develop, design, implement, test and maintain the information systems. This includes defining the data within the tables and specifying the rules, prompts and links that drive the system. Informatics specialists have the expertise in the core business functions so that they can advise the vendor what is required.

The New South Wales Government Health department’s Information Management and Technology Education, Training and Development working group noted that the clinical information environment is more complex than for other healthcare workers [9]. Clinicians were identified as having the following educational needs: learn how to use information to challenge and change clinical practice be aware of medico-legal and ethical issues in using information know when and how to use clinical guidelines to inform clinical decisions understand the use of rules, alerts and prompts to inform decisions understand the benefits that can be derived from using information systems Four target groups were identified (p.13), informatics professionals, super users, end users and application specialists, these are listed in terms of their organisational level with role descriptions in table 4. They also developed an educational model requiring a collaborative management arrangement between key stakeholders, trainers and support providers, operational, strategic, and business users. It identifies the most important aspects towards achieving a successful implementation of an information system. Another group who undertook competency development were a US based public health informatics competency working group [10]. This initiative was undertaken during 2001 and 2002 within the larger context of a global and national implementation plan for public health workforce development. The resulting informatics competencies complement the consensus set of core competencies for public health professionals. They identified the public health workforce as consisting of four segments or educational target groups. These are described in table 5. The competencies were identified in terms of three levels of expertise, basic, moderate and advanced and the need to achieve individual or public health enterprise


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Table 5. Public Health Workforce Segments [10] (p.9-10). Workforce segment Front line staff

Functional descriptions Individuals who carry out the bulk of day to day tasks (e.g. sanitarians, counsellors, nurses and other clinicians, investigators, lab technicians, health educators). Responsibilities may include basic data collection and analysis, fieldwork, program planning, outreach activities, programmatic support, and other organisational tasks.

Senior Level (Technical) Staff

Individuals with a specialised staff function but not serving as managers (e.g. epidemiologists, attorneys, biostatisticians, health planners, health policy analysts). They have increased technical knowledge of principles in areas such as epidemiology, program planning and evaluation, data collection, budget development, grant writing, and so on, and may be responsible for coordination and oversight of pieces of projects or programs.

Supervisory and Management Staff

Individuals responsible for major programs or functions of an organisation, with staff who report to them. Increased skills can be expected in program development, program implementation, program evaluation, community relations, writing, public speaking, managing timelines and work plans, presenting arguments and recommendations on policy issues.

Chief Information Officer

This special class of public health professionals work as policy advisors and leaders at the highest level of a public health agency, bringing special expertise in the areas of information architecture, information resource management planning, enterprise level information systems development and integration and organisational change management.

Table 6. Informatics Classes and Associated Domains Used for Competency Development. Effective use of information

Effective use of IT

Analytic assessment skills Policy Development/Program Planning Communication skills Community dimensions of practice Basic public health sciences

Digital literacy Electronic communications

Financial planning and management Leadership and systems thinking

Selections and use of IT tools On-line information utilisation Data and system protection Distance learning Strategic use of IT to promote health information and knowledge development

Effective Management of IT Projects System development Cross disciplinary communication Databases Standards Confidentiality and security of systems Project management Human resources management Procurement, Accountability and Research

effectiveness but exclude clinical informatics competencies as this was seen as being outside the scope of this project. The competencies were separated into three classes: 1. use of information 2. use of information technology (IT) 3. effective management of IT projects: development, deployment and maintenance of information systems (IS) (incl. requirement specifications, contracting, purchasing) Specific domains were identified for each of these and competencies were listed for each domain. The three classes and associated domains are detailed in table 6 [10] (p.16-18) In summary there is agreement that all educational offerings need to meet the needs of many health informatics professionals. This includes meeting the information management needs of all health professionals responsible for many different clinical and management

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Table 7. Australian Department of Health and Ageing Workforce Capacity Building Priorities and Objectives. Priority

Objectives

Leadership

Give direction to the health informatics capacity building policy agenda nationally Foster a positive policy environment for the consideration of e-health workforce issues. Establish a body of reliable and relevant data which will provide a foundation for workforce capacity planning and building, to inform investment and to support evidence based policy. Promote the conduct of research relevant to the use of IM&T in the health sector Encourage research that is aligned with national priorities for health. Develop and promote a national curriculum and agreed core competencies to inform education and professional development in health informatics. Improve access by current and future health workers to health informatics education and ongoing professional development

Business Case and Planning Support for Research Education Development and retention of staff

functions in all areas of the health industry. These functional information needs represent various combinations of content. In addition, information management needs vary according to professional levels or positional/organisational levels of decision making.

3. A Global Health Informatics Qualifications Framework During 2003 the Australian government recognised the need to build the country’s health information workforce capacity as the use of information and information systems is expanding within the health sector. It was noted that these systems are becoming more sophisticated in terms of their ability to aid clinical practice and decision making. A ‘think tank’ was held where invited representatives from the health and health information technology sectors, academia and government investigated the issues, to identify areas of need, and to propose strategies to promote the effective development and use of information and information technology in the health sector. Priorities for action and suggested strategies were translated into a national action plan which was endorsed by the Australian Health Information Council late 2003 and is now in the process of being implemented [11, 12]. These priorities are detailed in table 7. A global HI qualifications framework needs to address issues associated with both formal and lifelong learning which may also be referred to as continuing professional development. The framework needs to facilitate educational access to all wishing to fulfil their personal, professional, social and economic potential thus building the desired HI expert workforce capacity. Such a framework should clearly identify where prior learning fits and how a student should structure an educational plan to achieve a predetermined and desired outcome in terms of a recognised qualification that has provided the necessary preparation to fit within a health informatics career structure. The Scottish Credit and Qualifications Framework [13] notes that this requires a consensus about levels of outcomes of learning and the volume of these outcomes described in terms of agreed definitions of credit points. It is proposed that Health informatics education exists of five levels, 1) pre-degree (diploma or certificate for some front line staff), 2) bachelors degree (all health professionals), 3) honours degree, 4) Masters degree and 5) doctorates. Each level is increasingly demanding in terms of complexity, depth of knowledge and degree of autonomy exercised by the learner [13]. SCQF have adopted five headings for each level to assist with describing each level in terms of broad, general but meaningful indicators of the characteristics of learning at each level. These are:


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1. knowledge and understanding – mainly subject based 2. practice: applied knowledge and understanding 3. generic cognitive skills, eg evaluation, critical analysis 4. communication, numeracy and IT skills 5. autonomy, accountability and working with others. This provide guidance to the identification and description of competencies relevant to specific work roles and functions and is one way of clearly differentiating between the qualifications levels and educational outcomes. If we are to establish a global HI virtual university it becomes necessary to reach a consensus regarding these issues so that student mobility and educational standards are not compromised. The IMIA recommendations have identified educational areas relevant to all. We need to reach agreement on their associated HI competencies. Given the work already undertaken in this area this should not be such an onerous task in the first instance. Ideally these competencies are integrated within all undergraduate health professional programs to adequately prepare new health professional graduates. Courses specifically providing this basic HI education need to be made available via distance learning adopting the lifelong learning and flexible delivery principles for the existing workforce and for new graduates where these competencies were not included in their professional degree program. The IMIA health and medical informatics education working group has agreed to adopt the European Credit Transfer System (ECTS) globally to facilitate credit transfers. We therefore urge all IMIA academic institutional members to adopt these when describing the program(s) offered by them. The ECTS is a student-centred system based on the student workload required to achieve the objectives of a programme, preferably specified in terms of learning outcomes and competencies to acquired [14].

4. Conclusion A considerable amount of work has been undertaken towards describing the roles and functions of health informaticians. These in turn were used as the basis to identify required HI competencies. In addition it has been recognised that not only do we need specialist health informaticians but we also need to ensure that all health professionals acquire a set of yet to be internationally agreed informatics competencies. The IMIA HI education recommendations are providing a very solid foundation for the development of an agreed international HI educational framework to match an increasingly clearer HI qualifications framework. The chapters that follow provide further details regarding educational outcomes and professional recognition.

References [1]

[2] [3]

[4]

[5]

Haux R, Grant A, Hasman A, Hovenga E and Knaup P. Recommendations of the International Medical Informatics Association (IMIA) on education in health and medical informatics. Methods Inf Med 2000; 39: 267-77. See also www. IMIA.org. Saba V, Skiba D.J, Bickford C 2004 Competencies and Credentialing: Nursing Informatics in: Global Health Informatics Education, Hovenga E, and Mantas J (Eds), IOS Press, Amsterdam NHS Information Authority 2002 Health Informatics Skills and Competencies: A framework to support NSF implementation, NHSnet: http://www.nhsia.nhs.uk/informatics/pages/resource_informatics/Informatics.pdf accessed 25 June 2004 Canadian Nursing Informatics Association, 2003 Educating Tomorrow’s Nurses: Where’s Nursing Informatics? OHIH Research Project: 2002-2003 Final Report, http://www.cnia.ca/OHIHfinaltoc.htm accessed 25 June 2004 Covvey H.D, Zitner D, Bernstein R.M (Eds) 2001 Pointing the Way: Competencies and Curricula in Health Informatics, http://www.informatics-review.com/thoughts/pointing.html accessed 25 June 2004

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[6]

[7] [8] [9] [10]

[11] [12] [13] [14]


Institute of Health and Care Development (IHCD), 1998 IM&T Competency Framework for NHS Managers, http://www.nhsia.nhs.uk/nhid/pages/resource_informatics/compete.pdf accessed 25 June 2004 NHS Careers, Health informatics: Careers in Information Management & Technology, http://www.nhscareers.nhs.uk/careers/healthinformatics/careers.html accessed 25 June 2004. Hovenga E.J.S 2004 Globalisation of Health and Medical Informatics Education – what are the issues? International Journal of Medical Informatics Vol.73 No.2 pp.101-110 NSW Health 2002 Report of the Information Management and Technology Education, Training and Development Working Group. http://www.health.nsw.gov.au accessed 24 June 2004 O’Carroll P.W and the Public Health Informatics Competency Working Group 2002, Informatics Competencies for Public Health Professionals. Seattle WA: Northwest Center for Public Health Practice http://www.nwcphp/phi/comps/ accessed 25 June 2004 Australian Department of Health and Ageing, 2003 Report on the Health Information Workforce Capacity Think Tank, http://www.health.gov.au/healthonline/docs/july03think.pdf accessed 25 June 2004 Australian Department of Health and Ageing, 2003, Health Information Workforce Capacity Building Action Plan, http://www.health.gov.au/healthonline/docs/wcbnap03-04.pdf accessed 25 June 2004 SCQF 2003 2nd An Introduction to the Scottish Credit and Qualifications Framework, http://www.scqf.org.uk/upload/downloads/IntrotoSCQF2ndEdition.pdf accessed 12 May 2004 ECTS – European Credit Transfer System http://europa.eu.int/comm/education/programmes/socrates/ ects_en.html accessed 7 May 2004


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2.2. Curricula in Medical Informatics Arie HASMAN Department of Medical Informatics, University Maastricht, The Netherlands Reinhold HAUX Inst. for Health Information Systems, University for Health Sciences, Medical Informatics and Technology (UMIT), Innsbruck, Austria Abstract. Education in medical informatics is needed not only for those who want to become specialist in this area but also for health professionals. Since students, depending on the program they are enlisted in, require different types of knowledge and skills in medical informatics, curricula should be adapted to those needs. The curriculum structure also depends on the expert level the students want to attain. This contribution presents the knowledge and skills levels for different groups of students and presents two examples of curricula.

Introduction Medical informatics is a very broad field: it is the discipline concerned with the systematic processing of data, information and knowledge in medicine and healthcare [1]. The broadness of the field is also apparent from the many subjects that are presented in the IMIA (International Medical Informatics Association) scientific map (www.imia.org/scientific_map. html). The subjects cover among others applied technology (bioinformatics, pattern recognition, algorithms, human interfaces, etc.), applications and products (quality management, knowledge-based systems, EPR, operations/resource management, etc.) and humanorganizational factors (managing change, legal issues, needs assessment, etc.). No wonder that medical informaticians usually are expert in only a part of the field. In this contribution we use the term medical informatics to name the discipline. IMIA also uses the term medical informatics in its name but others use the term health informatics or clinical informatics. Furthermore nursing informatics and dental informatics are used to indicate subspecialties. Medical informatics has evolved to become a separate discipline with its own specific methods and tools for handling problems in medicine and healthcare. Education and training are necessary to become a medical informatics specialist. In addition, since information systems are increasingly used in healthcare, also healthcare professionals have to know the advantages and limitations of the use of information systems for their work. This knowledge again has to be acquired via education. Because medical informatics is such a broad field, education in medical informatics needs to emphasize different aspects for different groups of students. The goal of this chapter is to present guidelines for setting up curricula for these different groups (e.g. IT users and specialists). For the Working Group Health and Medical Informatics Education (in this chapter abbreviated as WG 1) of IMIA the subject of curriculum development and curricula in medical informatics has been an issue for a long time. WG 1 organized 7 conferences on educa-

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A. Hasman and R. Haux / Curricula in Medical Informatics

tion and published their results. The conferences took place in Lyon, France (1970, [2]), Chamonix, France (1983, [3]), Victoria, Canada (1989, [4]), Prague, Czech Republic (1990, [5]), Heidelberg/Heilbronn, Germany (1992, [6]), Newcastle, Australia (1997, [7]), and Portland, USA (2003, [8]). In addition WG 1 also published the Recommendations on education in health and medical informatics [9]. These are discussed later in this chapter. In this chapter we will first explain why education in medical informatics is necessary. Then we discuss the Recommendations that contain three factors used to determine what students in medical informatics have to know and which skills they need to learn: 1) the type of program the student is enlisted in, 2) the stage of career progression and 3) the type of specialization in medical informatics the student is pursuing. The scientific map of IMIA and the Recommendations show us the many subjects that are covered by the medical informatics discipline. This does not mean that for each of these subjects sufficient courseware is available. Therefore IMIA encourages the development and sharing of courseware of high quality. Sharing of courseware is not only important for education; the courseware also provides insight in what knowledge and skills in the eyes of the developers were needed to fulfil the learning goals of the Recommendations. To give an idea of how curricula can be developed we present one example that explains how to determine learning goals for EPR (electronic patient record) related education to be included in programs in medicine, nursing, pharmacology, etc. We also present an example of the curriculum of an existing dedicated medical informatics program.

1. The need for education in medical informatics Information systems are increasingly used in healthcare. They not only support administrative and financial but also clinical and logistic processes. Healthcare workers have to use information systems and therefore should know the possibilities but also the limitations of using information systems. In addition they should have the skills to work with information systems. Information systems relevant for healthcare professionals include hospital information systems, departmental systems, electronic patient record systems, order entry and result reporting systems, etc. But healthcare workers should also be proficient in the use of productivity tools like word processing systems, etc. Although healthcare professionals still predominantly use paper records for entering patient data, patient management increasingly has become the combined task of a group of healthcare workers. Therefore the memory-aid role of the patient record more and more changes into a communication role. Paper records have several limitations in this respect. Also, since the appearance of the report “To err is human” of the IOM it is apparent that due to communication errors (among which are problems with reading handwritings, incomplete information, etc.) medical errors are made that may even lead to the death of patients. Electronic patient records and order entry systems can reduce the number of errors by being more readable but also, when standardized terminology is used, by providing decision support. This decision support can be passive in the sense that the healthcare professional takes the initiative to search for information, e.g. via PubMed or the Cochrane Library, or active when the EPR is directly coupled to decision support systems that either pro-actively suggest the next step in the diagnostic or treatment process or reactively remind the healthcare professional that a (preventive) procedure was not considered or a step in the protocol was not carried out. Health and medical knowledge increases at such a rate that professionals cannot stay up-to-date without the help of information systems. Logistics is becoming more important these days. Hospitals have to work not only effectively but also more efficiently, thereby taking the preferences of patients into account. Planning systems can reduce the time that ambulatory patients have to spend in the hospital


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for undergoing tests and also the length of stay of hospitalised patients can be reduced by planning both the patients and the needed capacity. It is important for healthcare workers to know which support information systems can provide and to know which conditions have to be satisfied in order that information systems can really be of help. Optimal use of information systems therefore does not only depend on acquired skills but also on the insight in and knowledge of the principles, concepts and methods behind information systems. This is true for all types of healthcare professionals. When hospitals or physicians consider the purchase of information systems they must be able to specify their requirements so that at the end they will not be confronted with systems that do not perform as expected. It is clear that healthcare professionals need to have medical informatics knowledge in order to optimally use information systems. We also need experts that develop health information systems or are able to support healthcare workers in designing terminology servers, coding systems, etc. These experts need to have medical informatics knowledge, know how the healthcare system is organized and how healthcare professionals are working in order to develop systems that are appreciated by healthcare professionals. Graduates with an informatics or computer science background are therefore not directly suitable for such jobs. Medical informatics cannot be equated with the application of informatics methods and tools to medicine. There need to be opportunities for students with a background in informatics/ computer science to specialize in medical informatics. Graduates from healthcare related studies can also play an important role when information representation, capture, storage and delivery are concerned. They have the required basic knowledge but also need to increase their medical informatics knowledge. Apparently there are various groups of students with quite different backgrounds who want to become informed IT users or experts in the field of medical informatics. Each of these groups will have to learn different subjects depending on previous education and the type of specialization they want to achieve.

2. The IMIA WG 1 international recommendations Although there are opportunities worldwide for obtaining education in medical informatics, there are still many countries where such opportunities are not sufficiently present. To deal with this situation, IMIA felt the need to develop international recommendations for medical informatics education. These recommendations are also necessary for enabling an international exchange of students and teachers and for establishing international programs. (A program is defined as an organised, structured set of course offerings aimed at preparing participants for specific career paths and culminating in a degree, diploma or certificate). As was explained above every professional in healthcare needs some core medical informatics knowledge. This knowledge can be obtained during the undergraduate stage of the study, during specialisation (in medicine) or via continuing medical education (CME) after graduation or specialization (medicine). The IMIA recommendations focus on underand post-graduate education. What knowledge and skills have to be learnt depends on the career progression (bachelor, master, doctor, etc.). Medical informatics instruction should be integrated within the educational programs (medicine, nursing, physics, informatics or computer science) for the students who are not enlisted in a dedicated medical informatics program. The educational components will vary in depth and breadth to suit the needs of specific student groups. The IMIA recommendations describe the educational needs as a function of three axes (fig. 1): (a) professions in healthcare, (b) extent of specialization in medical informatics and

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knowledge and skills needed in health and medical informatics

learning outcomes

... by students in ... medicine nursing health care management dentistry pharmacy public health ... to reach career progression ← ... health record administration doctor informatics/ master computer science health/medical bachelor informatics ← others IT user ... HMI specialist ... to get a specialisation in HMI as ...

... in programs of ...

... lead to ...

- medicine - nursing - health care management - dentistry - pharmacy - public health - health record administration - informatics/computer science - others (courses/course tracks in HMI as part of educational programs) and in - dedicated HMI programs (dedicated educational programs in HMI) ... and have to be transformed into educational components with appropriate depth and breadth

Figure 1. Structural outline of the IMIA recommendations on education in health and medical informatics (HMI): knowledge and skills needed in HMI by students in health care, to get a specialisation in HMI and to reach a career progression lead to learning outcomes in programs, and have to be transformed into educational components with appropriate depth and breadth.

(c) stage of career progression. The first axis denotes the various programs (nursing, medicine, pharmacy, dentistry, public health, health record administration, informatics, computer science, medical informatics, etc.) that include medical informatics education and training. The second axis indicates the extent of specialisation (ranging from IT user to medical informatics expert). The third axis indicates the stage in the program the student currently is in (bachelor, master, PhD). The recommendations specify learning outcomes for IT users and HMI (health and medical informatics) specialists. Learning outcomes are specified and for each learning outcome an indication is given of the level of knowledge and skills required for IT users and HMI specialists. Three levels are distinguished: introductory, intermediate and advanced, leaving the definition of these levels to the teachers. Learning outcomes are either recommended for all types of professionals or for certain professions (e.g. health record administrators or bachelors in medical informatics). Three domain areas of knowledge and skills are defined: Methodology and technology for the processing of data, information and knowledge in medicine and healthcare; Medicine, health and biosciences, health system organisation; Informatics/computer science, mathematics and biometry. The learning outcomes have to be transformed into educational components with appropriate depth and breadth. When new curricula have to be developed this can still provide problems. Medical informatics textbooks do not yet cover the whole domain and are not always of the right level so that they can be used both for IT users and for medical informatics specialists. The recommendations distinguish between a more informatics-based and a more healthcare based approach to medical informatics education. The objective of an informaticsbased approach to medical informatics is to focus on the processing of data, information

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Table 1. Recommended student workload in ECTS credits for the three knowledge and skills areas of health/medical informatics course tracks inside programs of medicine and other health sciences.

Knowledge/Skill Area

(1) methodology and technology for the processing of data, information and knowledge in medicine and health care (2) medicine, health and biosciences, health system organisation (3) informatics/computer science, mathematics, biometry Σ

Program Medicine, Nursing, Health Care Management, Dentistry, Pharmacy, Public Health, Allied Health 40 5 15 60

Table 2. Recommended student workload in ECTS credits for the three knowledge and skills areas of a health/medical informatics course track inside informatics/computer science programs.

Knowledge/Skill Area (1) (2) (3) Σ

methodology and technology for the processing of data, information and knowledge in medicine and health care medicine, health and biosciences, health system organisation informatics/computer science, mathematics, biometry

Program Informatics/ Computer Science 40 15 5 60

and knowledge in healthcare and medicine with a strong emphasis on the need for advanced knowledge and skills in medical informatics, mathematics as well as of theoretical, practical and technical informatics/computer science. Healthcare problems can be treated cooperatively with physicians and other healthcare professionals. In such an approach to medical informatics education, knowledge and skills of informatics/computer science dominate. The healthcare-based approach to medical informatics focuses on the processing of data, information and knowledge in healthcare and medicine requiring, apart from knowledge in medical informatics, also knowledge of medicine or of other health sciences to an extent that can only be obtained within the scope of a medical or health science education. In such an approach to medical informatics education knowledge and skills of medicine and of other health sciences dominate. Recommendations are presented for both approaches. The levels of knowledge and skills in medical informatics are also expressed in terms of the total student workload for educational components. The total workload for IT users should be in the order of 40 hours devoted to lectures, exercises and practical training. For students in a medical or other healthcare program who want to become medical informatics specialists it is suggested that 60 ECTS (European Credit Transfer System) credits have to be obtained next to the core knowledge of the program (medicine, nursing, etc) itself. This workload is similar to dedicated master programs in medical informatics. Table 1 shows how the workload is divided over the three knowledge and skills areas. A workload of 60 ECTS to become a specialist in medical informatics (informatics based) is also suggested for students from an informatics/computer science faculty. In Table 2 it is indicated how the workload should be divided over the three knowledge and skills areas. There also exist dedicated programs in medical informatics. They comprise bachelor and master studies. A bachelor study in medical informatics emphasizes a practice-related

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Table 3. Recommended student workload in ECTS credits for the three knowledge and skill areas of a health/medical informatics bachelor program.



Program Health/Medical Informatics/ (bachelor) 50 20 110 180

Table 4. Recommended student workload in ECTS credits for the three knowledge and skill areas of a health/medical informatics master program.



Program Health/Medical Informatics/ (master) 40 10 10 60

education so that students are able to translate the acquired expertise into practical activity. Bachelor studies may have a focus ranging from a very strong emphasis on technical IT skills to a stronger emphasis on health applications with less IT skills. The master study has as objective to provide an education with a scientific character including theory, specialized knowledge and practical skills. Graduates should be able to independently participate in research and in the methodological advancement of the field of medical informatics. Apart from recommending learning goals it is also indicated how the workload should be divided over the three knowledge and skills areas for both bachelor (Table 3) and master studies (Table 4). For programs leading to a doctoral degree, in addition to the requirements previously mentioned, the student should independently carry out comprehensive research. Knowledge and skills should also have additional depth or breadth. Although the recommendations indicate the levels of knowledge and skills the various student groups should acquire, no further information is provided about how these levels are defined. Since the field of medical informatics is in constant evolution this information is difficult to formulate. Therefore the implementation of the recommendations heavily depends on the insight and views of the educators. IMIA offers help by providing expert advice to persons and institutions in this field. This kind of help is especially of interest when commencing with educational activities and when national institutions are not yet established. The quality of a program can be made visible through IMIA certificates. Medical informatics education can be given in various modes. Since a number of years problem based learning (PBL) approaches are popular. Instead of the discipline based approach that is lecture and discipline oriented, the PBL approach aims at the simultaneous realization of three objectives: learning to learn, learning to analyse and solving problems. The approach is characterized by self-directed study. We have shown that for medical informatics education at the IT users level PBL is a good mode. We are confident that a PBL


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approach is also an alternative for dedicated programs in medical informatics because such education requires integration of information and a cross-disciplinary understanding [10]. Medical informatics education can be delivered via distance education possibly complemented with visits to the university. This type of open learning is well suited for students who already have a job and for CME purposes.

3. Defining learning goals for EPR related education in the Netherlands In the Netherlands the government stimulates the introduction of EPR systems in daily practice. Three medical informatics departments (from the universities of Maastricht, Nijmegen and Rotterdam) were asked to investigate what knowledge and skills, related to the use of EPR systems, students in medicine, nursing, pharmacology, etc. need to have that are not yet included in the respective curricula. In order to be able to identify grey or white areas in the curriculum first a list of relevant knowledge and skills subjects was needed. We therefore studied a number of national and international recommendations (e.g. the proposed guidelines for European curricula [11], the IMIA recommendations, the end terms for medical students in the Netherlands, etc.). We also studied the subjects mentioned in the NHS report: ‘Learning to manage health information. A theme for clinical education. Moving ahead’. On the basis of this information we selected possibly relevant subjects and for each subject we formulated a number of learning goals. We then developed a questionnaire containing the selected subjects and learning goals. The questionnaire consisted of two parts. The first part concerned educational components that students must have followed before they can start with EPD related subjects. These pre-requisites concern general background knowledge (general skills, general knowledge, knowledge about the scientific basis of medical practice). A number of learning goals were formulated for each subject. The second part concerned the EPR related education proper. This part contained the relevant subjects obtained from the literature (patient records in general, problems with patient records, electronic patient records, decision support, coding, communication, secondary use of data, legal aspects of EPRs). Again per subject a number of learning goals were specified. For each learning goal we wanted to know whether the learning goal was considered relevant for EPR related education. For all relevant learning goals we also wanted to know if they were already included in the curriculum and to what level. In order to obtain these answers we asked the respondents whether the education related to each learning goal was included in the curriculum and to what level and what level they considered necessary for the future (where the answer also could be that the learning goal was not relevant). The relevant faculties (medicine, dentistry, pharmacy, nursing), various scientific boards of health professional societies and institutions for vocational education were approached with the question to provide us with the names of persons who were familiar with the contents of their curriculum. To these persons we then sent the questionnaire. In total 53 questionnaires were sent of which 30 were returned (response rate 57%). Of the 30 returned questionnaires 7 were not filled in. Questionnaires filled in by respondents belonging to the same discipline (medicine, nursing, etc.) were analysed together. For each discipline the median value of the indicated levels of expertise per learning goal were determined for both the current curriculum and the future curriculum. For those learning goals that had a higher median value for the future than for the current curriculum it was inferred that more education was needed. The reason for the relatively low response (the response, after correction for the blank questionnaires, was only 44%) might have been that the questionnaire was rather long. We

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concluded from the analysis that our respondents did not always have a good insight in whether EPR related education was actually included in the current curriculum. This is probably due to the fact that EPR related education usually is not an end in itself and therefore is scattered over a number of courses. The respondents had more specific opinions with regard to which learning goals should be pursued in future curricula, however. From the analysis we deduced nine learning goals that we considered relevant and that needed more attention in the curriculum. Because of the low response and the occasional lack of knowledge about the current curriculum we were not certain that educators would agree with these choices. We therefore decided to send a shorter questionnaire with the list of learning goals that needed more attention to a large number of educators (57) from the various faculties and the scientific boards (150 questionnaires for 21 specialisms). In the questionnaire the nine learning goals were translated into theses of the form: At the end of the study the physician possesses insufficient knowledge of the scientific base of medical practice (such as evidence-based medicine and the role of guidelines). The educators were asked whether they agreed, disagreed or had no opinion about the theses. A tenth thesis was added to investigate whether the respondent had the opinion that the EPR related education should be given primarily at the undergraduate level, at the postgraduate level (during the specialization, for medicine) or via continued medical education after graduation or specialization (for medicine). In the analysis of medical education we distinguished three groups: educators of the undergraduate level, educators responsible for medical specialist training (except those responsible for the training of GPs) and educators responsible for the GP training. The response to the short questionnaire was very high (about 75%). For the undergraduate medical education more than 70% of the respondents stated that the topics: shortcomings of paper patient records; possibilities and limitations of EPRs; decision support in EPRs and legal aspects of EPRs should get more attention. Educators responsible for medical specialist training indicated shortcomings in the following topics: possibilities and limitations of EPRs; decision support in EPRs and legal aspects of EPRs. Educators of GPs identified the following grey areas: decision support in EPRs; possibilities and limitations of electronic data exchange and secondary use of EPR data. Restricting ourselves to medical education, the answer to the question whether EPR related education had to be given at all was almost unanimously answered positively. Only 3% of the respondents indicated that EPR related education was not necessary. The answer to the question whether this type of education should be part of under- or postgraduate training depended on the group the respondent was a member of. About 8% of the respondents indicated that the education should be given via CME after specialization. The majority indicated that the education should be given either at the under- or postgraduate level. About 33% indicated that the education should be given in both phases. Specialist trainers were of the opinion that EPR related education should be given in the under-graduate phase, whereas educators in the undergraduate phase recommended the post-graduate phase for EPR related education. Trainers of GPs were of the opinion that EPR related education should be given during the specialization phase. So no consensus was obtained regarding the place of this type of education in the curriculum. The differences in opinion between educators of the undergraduate phase and educators of specialists except GPs on the one side and educators of GPs on the other concerning what subjects should be taught may be due to the fact that GPs are much more experienced in the use of EPRs than the other groups and therefore are more interested in the secondary use of EPRs and in electronic data interchange. We can conclude from this example that although recommendations for curriculum content are available and useful for determining what subjects are relevant for certain goals


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Figure 2. Medical informatics programs at UMIT. Texts in italics show the entrance levels for the respective educational programs (from [12]).

(like EPR related education) there are still questions about where in the career track medical informatics education for IT users has to be given. These questions have to be settled with the educators in the various programs.

4. Experiences with dedicated programs Dedicated programs in health informatics / medical informatics today often comprise three levels of education. These are the undergraduate studies (approximately 3 years), leading to a bachelor degree, the postgraduate studies (approximately 2 years), leading to a master degree, and the PhD studies, which are mostly research oriented and last approximately 4 years. This structure can e.g. be seen in figure 2, describing these levels for the medical informatics programs of UMIT at Innsbruck, Austria ([12]). The medical informatics program of the University of Heidelberg and the University of Applied Sciences Heilbronn was founded in 1972 as the first dedicated program in this field in Germany. Because of the accumulated experience over more than thirty years this program is a good example to present here [13,14]. The first section of the curriculum (2 years) covers fundamentals especially of informatics and medical informatics as well as fundamentals of mathematics, medical physics, electrical measurement techniques, medicine and health economics. The second section (2 years) comprises mandatory lectures in medical informatics, in informatics and in medical biometry, epidemiology and stochastics and six major subjects in medical informatics (health care information systems, health care management, medical biometry, signal and image processing in diagnosis and therapy, knowledge based systems in medicine and distributed systems in medicine). The students have to choose ‘core‘ lectures from one of these major subjects plus a practical course. In addition they have to choose additional elective courses in accordance with the selected major subject course. The study finishes with a master thesis. The number of students is limited to 70 per year. The program can be completed within 4 years for lectures and practical training and half a year for preparing a master thesis. The

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program provides a comprehensive education of basic methods and dedicated methods in medical informatics, both on a formal basis. The program can be characterized as an informatics-based approach to medical informatics. This means that graduates should be able to compete with informatics graduates for informatics positions outside of medicine and healthcare. In addition graduates of the program should have better professional chances in medical informatics than informatics graduates. The Heidelberg/Heilbronn medical informatics program is, due to historical reasons, an integrated bachelor and master program. In order to also provide physicians and other health care professionals with possibilities to study medical informatics on the postgraduate level, an additional Master of Science program a health information management has been added recently [15]. Recently the job situation of the Heidelberg/Heilbronn medical informatics graduates was assessed [16]. The respondents were also asked to evaluate the curriculum. The investigation was performed via a structured questionnaire. The response rate was 46 percent. About one third of the graduates are working in software/hardware companies, about half of them outside medical informatics. In total 43 percent of the graduates work in medical informatics. Of the responding graduates 15 percent received a doctor’s degree. Of the subjects taught, the respondents valued software engineering and database and information systems highest for their work. The low number of unemployed graduates and the high level of satisfaction with the education and job situation confirm, according to the authors, the quality of the program. The curriculum is already in its 5th revision. Triggers for the last curriculum revision were: known weak points in the organization of the 4th version, feedback from the graduates, the growing competition in the field of medical informatics curricula, new laws on healthcare structures in Germany, and the requirement for a shorter length of studies. Furthermore the evolution of the discipline of medical informatics, besides the need to cover many new application fields of medical informatics, was a very important trigger. This indicates that curriculum structure also depends on national characteristics.

5. Discussion and Conclusions Curriculum structures are dependent upon or influenced by the educational system of a country, university conventions, the availability of expertise and other resources. The traditional educational system is discipline oriented whereas the problem based approach requires the educational program to be divided into educational units covering a particular theme. Aspects of different disciplines with respect to the theme are integrated, stimulating the students to study the contributing basic disciplines as well as the integrated use of this knowledge. In PBL students set their own specific learning goals within the broader limits set by the faculty. The curriculum structure of schools with the traditional approach therefore can be quite different from the structure used by schools with the PBL approach. The structure also depends on the fact whether we deal with programs (in the sense defined above, e.g. a program in medical informatics) or with course tracks, that is: set of courses, dedicated to a certain field as part of an educational program, e.g. nursing informatics (as a set of courses in this field) in a nursing program. In the latter case integration of nursing informatics subjects with subjects of the nursing program is essential, so that the students can appreciate the value of nursing informatics for their career. In the former case it is important to demonstrate the value of knowing the application domain: a pure informatics education will not result in students with a feeling for working in a healthcare environment. As was stated in the beginning medical informatics is very broad and most medical informatics professionals are experts in only a part of the domain. This breadth will also be


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reflected in the curricula, where one curriculum may emphasise technical and imaging related aspects, whereas another curriculum will focus more on information delivery. A philosophy is driving curriculum development. The curriculum philosophy of the Heidelberg/Heilbronn medical informatics program for example is based on the concept that medical informatics is a separate scientific medical discipline and that the program does not teach just medicine and informatics. The consequence of this philosophy is that the program covers the total spectrum of medical informatics, ranging from information systems in healthcare, biosignal and medical image processing, medical documentation, to information and knowledge processing in medicine. The need for education in medical informatics for healthcare professionals (IT users) is now being accepted by the majority of those working in the field. As was discussed for the Dutch situation educators are not unanimous about when this education should be given. A problem in a number of countries is the level of interest of students in a medical informatics study. Interest may be low due to the fact that there are no recognized positions as specialists in medical informatics. In the Netherlands the job title of clinical physicist is recognized. Clinical physicists can only start working in hospitals when they have the required qualifications. Such a situation does not yet exist for medical informaticians. Medical informatics societies and leaders of medical informatics programs should take the initiative to start discussions with the healthcare institutions to obtain recognition for the graduates of their programs so that the job of medical informatics specialists will only be offered to these graduates.

References [1] [2] [3] [4] [5] [6] [7]

[8] [9]

[10] [11] [12] [13] [14]

Hasman A, Haux R and Albert A. A systematic view on medical informatics. Comp Meth Prog Biomed 1996; 51: 131-9. Anderson J, Grémy F, Pagès JC, editors. Education in Informatics of Health Personnel. Amsterdam: North Holland Publ Comp; 1974. Pagès JC, Levy A H, Grémy F, Anderson J, editors. Meeting the Challenge: Informatics and Medical Education. Amsterdam: North Holland Publ Comp; 1983. Salamon R, Moehr JR, Protti DJ, editors. Medical Informatics & Education. Victoria: University of Victoria Press; 1989. Van Bemmel JH, Zvarova J, editors. Knowledge, Information and Medical Education. Amsterdam: North Holland Publ Comp; 1991. Haux R, Leven FJ, Moehr JR, Protti DJ, editors. Health and Medical Informatics Education. Methods Inf Med 1994; 33: 246-331. Haux R, Swinkels W, Ball MJ, Knaup P, Lun KC, editors. Health and Medical Informatics Education: Transformation of Healthcare through innovative use of Information Technology. Int J Med Inf 1998; 50: 1-300. Hersh W, Gorman P, editors. IMIA Working Group on Education. Int J Med Inf 2004; 73: 95-213. Haux R, Grant A, Hasman A, Hovenga E and Knaup P. Recommendations of the International Medical Informatics Association (IMIA) on education in health and medical informatics. Methods Inf Med 2000; 39: 267-77. See also www. IMIA.org. Hasman A and Boshuizen HPA. Medical informatics and problem based learning. Methods Inf Med, 2001; 40: 78-82. Hasman A, Albert A, Wainwright P and Klar R. Education and training in health informatics: guidelines for European curricula. Amsterdam: IOS Press; 1995. Haux R. Biomedical and health informatics education at UMIT - approaches and strategies at a newly founded university. Int J Med Inf 2004; 73: 127-38. Leven FJ, Haux R. Twenty five years of medical informatics education at Heidelberg / Heilbronn: discussion of a specialized curriculum for medical informatics. Int J Med Inf 1998; 50: 31-42. Leven FJ, Knaup P, Schmidt D, Wetter T. Medical informatics at Heidelberg/Heilbronn: status - evaluation - new challenges in a specialised curriculum for medical informatics after thirty years of evolution. Int J Med Inf 2004; 73: 117-25.

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[15] Haux R, Schmidt D. Master of Science Program in Health Information Management at Heidelberg / Heilbronn: a Health Care Oriented Approach to Medical Informatics. Int J Med Inf 2002; 65: 31-9. [16] Knaup P, Frey W, Haux R and Leven FJ. Medical informatics specialists: what are their job profiles? Methods Inf Med, 2003; 42: 578-87.


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2.3. Competencies and Credentialing: Nursing Informatics Virginia K. SABA, EdD, RN, FAAN, FACMI Distinguished Scholar, Sdjunct School of Nursing & Health Studies Georgetown University Washingt5on, DC, USA Diane J, SKIBA, PhD, FAAN, FACMI Professor, School of Nursing University of Colorado Health Sciences Center Denver, CO, USA Carol BICKFORD, PHD, RN, BC Senior Policy Fellow Department of Nursing Practice and Policy American Nurses Association Washington, DC, USA Abstract. This paper provides an overview and description of the processes that address the competencies and credentialing of nurses in the field of nursing informatics (NI). It provides the highlights of the informatics competencies that were proposed as the NI field advanced. It also provides an overview of the ANCC nursing informatics credentialing process. It will also present the credentialing process of the HIMSS organization which offers several different certifications. And finally it will address the new process for the international certification entitled Nursing Informatics Competency Recognition Certificate. The Nursing Informatics Special Interest Group of the International Medical Informatics Association (IMIA/NI-SIG) approved this certificate at the general assembly meeting during NI’2003 in Rio de Janeiro, Brazil. The certification is based on a professional portfolio that demonstrates expertise in this field for nurses outside the USA and Canada.

Introduction As the computer industry grew, the uses of computers in health care similarly expanded. During the 1960s and 1970s computers introduced into health care industry were initially used for business and financial applications. During the early days of this new industry, a few nursing professionals began to use computers to advance nursing practice. As computers, computer systems, and the nursing profession advanced from 1980 to the present, computer competencies were also being addressed. The early competencies were derived primarily from those skills that were developed from experiences with the new technologies as they emerged in the health care settings. [1] Computer competencies became necessary for nurses involved in computer applications, and in turn became requisite for Nursing Informatics – the new title for this specialty.

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V.K. Saba et al. / Competencies and Credentialing: Nursing Informatics

As the specialty expanded and became recognized by the nursing profession, nursing informatics competencies generally focused on the knowledge of computers or computer literacy, knowledge of the data and information being processed by the computer, and how each applied to nursing practice. [1]

Background of Nursing Informatics The term “Informatics” emerged from a French term “Informatique” or the study of information; whereas “Medical Informatics” came from the Special Interest Group known as the International Medical Informatics Association (IMIA) of the International Federation for Information Processing (IFIP). Barry Barber and Maureen Schools are credited with coining the term “Nursing Informatics” as the platform for a new nursing specialty. [2] The term emerged in Harrogate England in 1982 during a workshop entitled “The Impact of Computers on Nursing” sponsored by IFIP-IMIA. Nursing informatics subsequently became the preferred name in the USA as computers were introduced into nursing and as nursing information systems (NIS) were developed to process nursing data into information and knowledge. [3] Numerous experts and organizations provided definitions to distinguish Nursing Informatics and Nursing Information Systems. In 1986, Saba and McCormick. [3] defined a Nursing Information System: as NIS is a computer system that collects, stores, processes, retrieves, displays, and communicates timely information needed to do the following: Administer the nursing services and resources in a health care facility; Manage standardized patient care information for the delivery of nursing care; and Link the research resources and the educational applications to nursing practice[3] (p.120). In 1989, Graves and Corcoran [4] developed a model entitled “Conceptual Framework for the Study of Nursing Knowledge” in which they outlined the relationship between concepts of management processing by computers of nursing data, information, and knowledge. Their work served as the foundation for the first definition of nursing informatics from the American Nurses Association (ANA) [5] published in 1994 in the Scope of Practice for Nursing Informatics. Evolving informatics practice mandated establishment of a workgroup to review and revise the definition, scope of practice statement, and standards of practice. This work culminated in the publication in 2001 of the Scope and Standards of Nursing Informatics Practice [6] and a new definition. Nursing informatics is a specialty that integrates nursing science, computer science, and information science to manage and communicate data, information, and knowledge in nursing practice. Nursing informatics facilitates the integration of data, information, and knowledge to support patients, nurses, and other providers in their decision-making in all roles and settings. This support is accomplished through the use of information structures, information processes, and information technology [6] (pp.vii, 17).

Background of Informatics Competencies In the late 1970s and early 1980's, the nursing informatics movement emerged as computer applications began to be developed for the health care industry. Nurses became interested in this new field and as a result continuing education programs, workshops, and conferences began to be conducted to provide nurses with an understanding and capabilities of this new technology and its impact on nursing.[1]


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Early Workshops and Conferences: At these initial workshops or conferences, many of the early pioneers gave presentations on educational applications in nursing. They addressed not only computer fundamentals, but also described educational capabilities. For example, they identified the available educational software, tools, and other materials, such as computer-assisted instruction, that could have an impact on nursing education. These topics were informative but not necessarily deemed required competencies. In 1981 at the first National Conference on Computer Technology and Nursing conducted by the National Institutes of Health (NIH), Department of Health and Human Services, one panelist predicted that a computer course would be required in nursing education. [7] Also in 1981 at the Fifth Annual Symposium at Computer Applications in Medical Care (SCAMC) when the first nursing papers were presented, several speakers addressed educational issues that focused on specific computer content for computer courses. Educational content was also presented during the second NIH Conference [8] where it was recommended that the content should focus on: (a) fundamentals of data processing, (b) how the computer functions, e.g. hardware and software, (c) requirements for a computer facility, laboratory, and/or resources, and (d) retrieving nursing literature using bibliographic retrieval systems. During this period, newsletters, journals, and books on computers in nursing began to be published that supported the need for nursing education that included informatics content Early Books: In the 1980's several books or book chapters were published that focused on computer applications in nursing education and provided valuable content for computer education. The first book, Computers in Nursing, edited by Zielstorff [9] in 1980, included several chapters that addressed the educational aspects of computer technology in nursing education, including computer-assisted learning. In 1984 another book, written by Grobe [10] entitled A Computer Primer and Resource Guide for Nurses, provided a separate chapter on Nursing Education Applications that focused on “Teaching About Computers”, “Teaching by Computer”, and “Using Computers for Instructional Tasks”. Later in 1986 Saba and McCormick’s Essentials of Computers for Nurses [3] provided an in depth chapter on Educational Applications focusing primarily on Computer-Assisted Instructional Materials. Then in 1987, two booklets were published; one by the American Nurses Association (ANA) that addressed Computers in Nursing Education [11], and the other by the National League for Nursing (NLN) entitled A Guidelines for Basic Computer Education in Nursing. [12] Early Competency Framework: In 1987, Ronald & Skiba [12] moved beyond a general discussion to present for the first time, a framework for computer education in nursing. Their model was the first attempt to describe computer competencies of nurses. The model consisted of “a continuum of learning experiences with both cognitive and interactive components” (p.3). Cognitive components referred to the specific content related to basic computer concepts and applications, whereas the interactive components referred to the specific skills needed to operate computer systems for three types of users – the informed user, proficient user, and developer.

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Initial International Competency Effort: In 1988, the Swedish Federation of Salaried Employees in the Health Services convened a special meeting of the IMIA Working Group Eight Task Force on Education to define broad competency statements for nursing informatics for the different types and levels (user, developer, and expert) of nurses in this field. According to Grobe, the competencies were to be “useful for guiding these nurses’ preparation for using informatics competencies in performing their nursing roles. [13]. The Working Group Eight Task Force consisted of 11 international nursing informatics experts and educators who presented articles on his/her recommendations, and also participated in working groups to recommend specific educational content for four nursing roles (practicing nurse, administrative nurse, educator and researcher) focusing on the three levels (user, modifier and innovator) of informatics competencies. Task Force members analyzed the tasks associated with each role and recommended that the competencies for the practicing nurse focus on four major functions: (a) documenting nursing practice, (b) accessing nursing information, (c) using nursing data and information, and finally (d) coordinating the flow of the nursing information. The administrative nurse requires information primarily for decision making and planning which involves: (a) directing the collection and organization of the information, (b) accessing the collected information, (c) using the data and information for their activities, (d) communicating the information inside and outside the organization, and (e) assuring that ethical standards and data protection measures are in place. The educator role requires that the educator be sufficiently prepared with the informatics knowledge and skills to prepare the different levels of students. Four competencies were identified that focused on nursing informatics: (a) teaching computer-based applications, (b) teaching computer-based instructional materials, (c) selecting computer-based materials for the organization and (d) assessing student performance. Finally, the researcher informatics role requires that the information processing technology support research methodologies, specifically (a) bibliographic retrieval systems, (b) electronic communication, (c) data management and processing, and (d) text processing and graphic applications. The resultant monograph was published and endorsed by the National League for Nursing and formed the basis for Nursing Informatics education for several years. Early Competency Model: Since then, other competencies were proposed by many experts and presented in the numerous books and papers that have emerged since the Informatics Movement began. Riley and Saba [14] proposed The Nursing Informatics Education Model (NIEM). The authors focused on three dimensions -- nursing science, information science, and computer science – and proposed five steps for developing competencies for nursing informatics. They include: “Basic concepts and applications; Access information systems; Utilize data and information systems; Coordinate and evaluate data & information systems; Integrate Nursing Informatics”(p.558). They further outlined four steps for integrating informatics into the undergraduate curriculum; namely: (1) overview of computer science -- computer hardware and software, (2) overview of information science -- data, information, and knowledge (3) nursing applications such as care planning, (4) evaluate care applications such as quality improvement.


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Initial ANA Competencies: The early nursing pioneers who focused on computer applications in nursing, became recognized as a special interest group and solicited the ANA to become involved and provide professional guidance for this new nursing specialty. As a result, in 1986 the ANA approved the creation of a new council called the Council on Computer Applications in Nursing (CCAN) with a mission to promote and support the introduction of computers in nursing practice. The first CCAN included five members and was chaired by Dr. Harriet Werley. The Council initiated several activities that demonstrated that this specialty was in fact unique from the existing councils in the ANA. The CCAN subsequently was able to have Computer Technology in Nursing renamed Nursing Informatics and become recognized as a new nursing specialty by the ANA Congress of Nursing Practice in January 1992. [15]. Once the CCAN obtained specialty status for the new Nursing Informatics group, a Task Force on the Scope of Practice was formed to develop an initial scope of practice statement, which was finalized and published as The Scope of Practice for Nursing Informatics. [5]. This monograph outlined the initial ANA recommended competencies for basic nursing informatics practice for an informatics nurse with a bachelor’s degree in nursing (See Table A). The Task Force also proposed competencies for an informatics nurse specialist with a master’s degree preparation (See Table B).

Current Competencies The Scope and Standards of Nursing Informatics Practice [6] replaced the original basic and advanced nursing informatics competencies with a new framework that resulted from research completed by Staggers, Gassert, and Curran. [16]. Staggers, Gassert, and Curran [17] had identified computer skills, informatics knowledge, and informatics skills comprised the informatics competencies necessary for beginning nurses, experienced nurses, informatics specialists, and informatics innovators. Level One: Beginning Nurse: The beginning nurse prepared for entry level nursing practice is expected to have basic computer literacy, information literacy, and basic patient care management skills. The computer literacy skills are those basic computer technology skills using generic software applications such as word processing, spreadsheets, databases, and/or graphical presentations using the desktop or laptop personal computer. They should also be able to use the computer applications to document patient care or communicate e-mail via the Internet. Information literacy requires the beginning nurse to have the capability to know when information is required and then know how to find, evaluate, and use the data correctly [Association of Colleges and Research Libraries (ACRL). [18] Thus, this skill is based on information access and evaluation such as bibliographic searching and retrieval from library retrieval systems as well as information resources from the Internet. In other words, these skills represent basic library science skills. The basic patient care management skills refer to computer applications relevant to the nursing care of patients such as developing plans of care following the nursing process. It also refers to implementing the policies and procedures of the facilities where the nurse functions.

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Table A. Preparation for Practice in Nursing Informatics Competencies (Recommended Bachelor’s Degree).

Requisite competencies for nursing informatics practice include:

• • • • • • •

•

• • • •

Systems analysis Systems design Development of structures for organizing data and databases Testing and evaluating applications for nursing Consultation on the configuration of hardware and software to meet nursing’s needs. Knowledge about the workings of computers and how computer information resources need to function to support nursing practice The technologies, methodologies, and processes involved in the interface between nurses and information technologies used to support nursing practice. Bi-cultural and bilingual skills sufficient to serve as a translator between nurses and the engineers, analysts, and system designers who develop and implement information systems designed to support nursing practice. Use of applications software Networks and distributed information resources. Employment of computer programming tools and utilities in the accomplishment of nursing informatics work. Employment of principles from supporting disciplines as needed.

Additional Skills valuable in the practice of nursing informatics are:

• • • • • •

Competence in the development of hardware and software necessary for the practice of nursing informatics. Functional skill in hardware (e.g. installation, setup, and maintenance of computer hardware components). Software installation and maintenance (original installation, debugging, and updating). Writing software in one or more computer languages – e.g. C, Cobol, Fortran, or Basic. Skills in integrating two or more computer systems. Ability to coordinate projects of various sizes involving diverse team members and constituencies.

Adapted from American Nurses Association. The Scope of Practice for Nursing Informatics. Washington, DC, American Nurses Publishing , pp 13-14, 1994. Level Two: Experienced Nurse: The experienced nurse should not only be proficient in the competencies of the beginning nurse but also have additional advanced skills. The experienced nurse is highly skilled in information technology management as well as communication skills using the Internet. The experienced nurse uses current informatics solutions, including collaboration with the


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Table B. Specialist Practice in Nursing Informatics. (Recommended Master’s Degree).

Specialists in nursing informatics must be competent in the following areas:

• • •

• •

•

•

The design and/or implementation of applications of nursing informatics science to practice problems. Analysis and evaluation of information requirements for nursing practice. Appraisal of computer and information technologies for their applicability of nursing practice problems. That includes: a. appraisal of the effectiveness of the technology to the nursing situation, b. appraisal of the effectiveness of the proposed technology to the specific problem, c. appraisal of the impact of the proposed technology on nursing efficiency and productivity, and d. Analysis of any ethical issues pertaining to proposed application of information technology to nursing practice – especially those concerned with patient safety and privacy. Developing and teaching theory and practice of nursing informatics. Consultation practice in the field of nursing informatics. Consultation clients may include (but not limited to ) administrators, nurse practitioners, nurse educators, nurse researchers, vendors of information technology with health care applications, and other consulting firms. Collaboration with other health informatics specialists and other specialists from supporting disciplines in the creation or application of informatics theory and practice for nurses and/or nursing. Development of strategies, policies, and procedures for introducing, evaluating. and modifying information technology applied to nursing practice.

Adapted from American Nurses Association. The Scope of Practice for Nursing Informatics. Washington, DC: American Nurses Publishing, pp 14-15, 1994. informatics nurse and other health care provider specialists. Specifically, they can use computer applications to manage the data, information, and knowledge for their specific specialty areas, participate as a content expert, promote safety issues, support the development or implementation of a standardized language, and act as an advocate for adding new informatics applications and concepts in their area of specialty. Level Three: Informatics Nurse Specialist: The informatics nurse specialist will have the competencies outlined for the basic and experienced nurse for computer literacy, information literacy, and patient care management skills. Additionally, the informatics nurse demonstrates these standards of practice and professional performance identified in the American Nurses Association Scope and Standards of Nursing Informatics Practice. [6] The Standards of Practice are organized according to a general problem solving framework and closely bear a resemblance to the nursing process as exemplified in Table C. In

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Table C. Standards of Practice.

I.

Identify the Issue or Problem-The informatics nurse specialist synthesizes data, information, and knowledge to clarify informatics issues or problems.

II.

Identify Alternatives-The informatics nurse specialist analyzes multiple approaches/solutions to the informatics issue or problem.

III. Choose and Develop a Solution-The informatics nurse specialist develops an informatics solution for a specific issue or problem. IV. Implement the Solution-The informatics nurse specialist manages the process for implementing the solution to the informatics issue or problem. V.

Evaluate and Adjust Solutions-The informatics nurse specialist evaluates all processes and solutions used to address the informatics problem.

Adapted from American Nurses Association. Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing, pp 33-39, 2001. addition, a set of Professional Performance Standards was defined and is listed in Table D. For each performance standard, there are several measurement criteria that accompany each standard.

Credentialing The credentialing for Nursing Informatics was deemed necessary to reinforce the acknowledgment of the professional specialty of nursing informatics. After approval and publication of the Scope of Practice for Nursing Informatics [5] and Standards of Practice for Nursing Informatics [19], the American Nurses Credentialing Center (ANCC) used these documents as the foundation for development of the generalist nursing informatics certification examination for registered nurses. Textbooks and other published resources supplement the current version of the nursing informatics scope and standards as references for the certification examination. American Nurses Association Credentialing Center The ANA Certification Program was established in 1973 to provide recognition for professional achievement in a defined functional or clinical area of nursing. Certification validates that a nurse meets nationally recognized standards in a given specialty. In 1991 the American Nurses Credentialing Center (ANCC) became a separate corporation to develop and operate its own credentialing programs based on recognized specialty scope and standards of practice. The ANCC certification examination questions are submitted by Board-certified health care professionals, reviewed by subject experts, and critiqued for


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Table D. Standards of Professional Performance.

I Quality of Nursing Informatics Practice-The informatics nurse specialist evaluates the quality and effectiveness of nursing informatics practice. II. Performance Appraisal-The informatics nurse specialist evaluates one’s own nursing informatics practice in relation to professional practice standards and relevant statutes and regulations. III. Education-The informatics nurse specialist maintains knowledge and competency that reflects current nursing informatics (NI) practice. IV. Collegiality-The informatics nurse specialist contributes to the professional development of peers, informatics colleagues, and others V. Ethics-The informatics nurse specialist bases decisions and actions on ethical principles. VI Collaboration-The informatics nurse specialist collaborates with others in the conduct of nursing informatics (NI) practice. VII. Research-The informatics nurse specialist contributes to the body of informatics knowledge. VIII. Resource Utilization-The informatics nurse specialist considers factors related to safety, effectiveness, cost, and impact in conducting informatics practice. IX. Communication-The informatics nurse specialist employs effective ommunications. Adapted from American Nurses Association (2001). Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing, pp 40-45, 2001. accuracy and relevance. ANCC staff members provide the psychometrics and prepare the final examination for computer-based testing. Informatics Nurse Certification The ANCC initiated in 1995 the computer-based certification examination. The first usage of this computer-based technology was for the Informatics Nurse Certification. Each applicant must hold at least a bachelor’s degree, hold a current active RN license, and meet all the application criteria and requirements to sit for the examination. They include specified time in the field of informatics nursing practice as well as continuing education and/or academic credits in informatics. Also, specific requirements, payment options, application forms, and other details about this computer-based certification examination are available at the ANCC website: http://www.nursingworld.org/ancc/certification/cert/ certsteps.html Informatics Nurse A credentialed Informatics Nurse according to the ANCC is recognized as being an expert in this new nursing specialty. “The Informatics Nurse is involved in activities that focus on the methods and technologies of information handling in nursing. Informatics nursing practice includes the development, support, and evaluation of applications, tools, processes, and structures that help nurses to manage data in direct care of patients/clients. The work of an informatics nurse can involve any and all

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aspects of information systems including theory formulation, design, development, marketing selection, testing, implementation, training, maintenance, evaluation, and enhancement. Informatics nurses are engared in clinical practice, education, consultation, research, administration, and pure information” HIMSS - Certification Program: In 2002, the Healthcare Information and Management Systems Society (HIMSS) initiated a multi-faceted professional certification program for healthcare information and management professionals with its first offering, Certified Professional in Healthcare Information and Management Systems (CPHIMS). Collaboration with the American Health Information Management Association (AHIMA) has expanded the offerings to three more certifications that may be of interest to informatics nurses: Certified in Healthcare Security (CHS): A specialty credential denoting advanced competency in designing, implementing, and administering comprehensive security protection programs in all types of healthcare organizations. American Nurses Credentialing Center (CHP): A specialty credential denoting advanced competency in designing, implementing, and administering comprehensive privacy protection programs in all types of healthcare organizations. Certified in Healthcare Privacy and Security (CHPS): A credential denoting advanced competency in designing, implementing, and administering comprehensive privacy and security protection programs in all types of healthcare organizations. For more information about these certifications, access the HIMSS web site at: http://www.himss.org/asp/certification_cphims.asp

UK Council for Health Informatics Professions In 2002, the UK Council for Health Informatics Profession (UKCHIP) was established to promote Health Informatics (HI). UKCHIP is an organization which operates a voluntary register of HI professionals who agree to adopt a Code of Conduct. This Code represents clearly defined standards that Informatics Experts adopt depicting competencies required of the professionals. For more information about the UKCHIP Code of Conduct access its web site at: http://www.ukchip.org

Nursing Informatics Competency Recognition Certificate Many European countries and the United Kingdom have tackled the issue of credentialing informatics nurses. One such effort is the National Health Service’s initiative to require nurses to have their European Computer Driver’s License (ECDL) (http://www. ecdl.nhs.uk/). A recent research report 20 stated that more than 60,000 nurses within the National Health Service had registered on the online portal to study for the ECDL. The study examined the initial impact of this initiative impact and concluded that many nurses reported an improvement in their computer skills and their confidence in using information systems. This also had a concomitant effect of improving staff morale and that nurses felt their skills brought direct benefits to their patients (http://www.ecdl.nhs.uk/pages/ researchresults.asp)


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IMIA/NI-SIG Education Working Group Initiative: In 2001, the International Medical Informatics Association Nursing Informatics-Special Interest Group (IMIA NI-SIG) Education Working Group conducted a survey of country representatives to determine the need for a credentialing process for nursing informatics specialists. The positive response, especially from countries that did not have an existing credentialing system, was a catalyst for the IMIA NI-SIG Education Work Group to examine this need. To this end, a small subcommittee investigated the potential and presented a proposal to the IMIA NI-SIG at the 2002 General Assembly meeting in Budapest, Hungary. An initial proposal was critiqued and feedback provided to the Education Working Group. The titling of this credential and some of the mechanisms to evaluate the portfolio were areas of concerns expressed by the several members of the IMIA NI-SIG. The subcommittee proceeded to further refine the process. As a first step, subcommittee members polled international representatives who attended the 2002 American Medical Informatics Association meeting in Washington, DC. Two primary questions were the focus of the poll. First, was there a need for this credentialing process and second, what was an appropriate title for this credential that could be recognized across countries. Six participants from different countries reiterated the importance of this credentialing process and they offered several different titles. The titles suggested were: Designate, Diplomat, Diploma and Competency recognition. In addition, the subcommittee refined the purpose, process and evaluation criteria. The revised proposal, presented at the IMIA NI-SIG General Assembly meeting in Rio de Janeiro, Brazil, was unanimously approved. The approved purpose is as follow: The International Medical Informatics Association Nursing Informatics-Special Interest Group (IMIA NI-SIG) Education Working Group administers a Nursing Informatics Competency Recognition Certificate program to recognize nurses who can demonstrate knowledge and skills in specified areas of nursing informatics. A portfolio serves as a basis for assessment of the informatics competencies. Professional Portfolios: A professional portfolio is simply defined [21] as a collection of visible documentation of credentials and contributions to the practice of nursing. In this case, the practice of nursing is in the area of informatics. The use of portfolios as a means of assessing one’s performance is used by many disciplines, including nursing. A recent review [22] indicated that portfolios are used for the assessment of competencies of both students and practicing nurses. This comprehensive review identified that three different approaches were used with an appropriate assessment. The first approach, behavioral or performance approach [22], defines competence as a description of an action, behavior or outcome that is capable of being observed or measured. The second approach, generic [22], competence is indicative of a degree of capability sufficient in a particular activity. The last approach, holistic [22], competence is defined in terms of knowledge, skills, attitudes, performances and level of sufficiency. All three approaches have strengths and weaknesses. A final approach incorporates a self-reflection component that is deemed most appropriate for the assessment of competence in nursing students. Another finding was that although there was no consensus on a definition of a portfolio, theories of adult learning were used as the theoretical basis for professional portfolios.

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Many countries, such as the United Kingdom, Australia, Canada, New Zealand and the United States, use Professional Portfolios as a mechanism to assess continued professional development. This is particularly true for many different specialties within nursing. For example, Driscoll and The [24] described Professional Portfolios in the area of orthopedic nursing practice in the United Kingdom. In New Zealand, the Nursing Act of 1997 requires that nurses demonstrate competence in practice through the development and maintenance of a Professional Portfolio. [25]. In the USA, to apply for credentialing as an Advanced Practice Nurse in Genetics requires the submission of a Professional Portfolio. [26] For the teaching profession, there is a multitude of examples of Professional Portfolios as a means to document professional development and in some instances to provide support for tenure review. [27] The education literature also examined the use of electronic portfolios with both students and professionals. [28] Informatics Competency Recognition Certificate: The Education Working Group subcommittee generated a list of competency areas relevant to informatics. It was agreed upon by the subcommittee that a person seeking the Nursing Informatics Competency Recognition Certificate must demonstrate competency in four areas. The person must choose at least three competency areas from an extensive list developed by the subcommittee. The fourth competency can be selected from the list or can be a new competency area such as bio-informatics. A sample of three competencies is provided below. Competency Areas: Health Information Systems Life Cycle • • • • • •

Major applications Long range and operational planning System analysis System design Implementation strategies Evaluation of information systems

Telecommunications / Telehealth • • • • • •

Consumer informatics Distance education including web-based education Telemedicine Internet and web site development E-Health Web-based or mobile health care systems

•

Security, confidentiality and privacy

Documentation and structuring of practice data • Technical and professional standards • •

Standard languages and vocabularies Nursing minimum data sets


• • •

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Reference terminologies National and International Standards Security, confidentiality and privacy

The development of a Professional Portfolio requires several steps. First, the definitions of a Professional Portfolio and their purposes are explained. Second, general guidelines for the organization of a portfolio are detailed. Perhaps the most important area is the selection of evidence you will provide to support expertise in the four selected areas of competence. Panel participants will review present sample portfolios providing examples of documentation. Portfolio Example: For example in the area of informatics, the following sources can be used in the documentation of competency areas. Objective evidence may include such items as continuing education certificates from workshops, modules, performance assessments from your informatics employment, and your resume or curriculum vitae. Other evidence to support your portfolio may include such items as: Χ Χ Χ Χ Χ

Work samples that may include: samples of modules or units you have taught; committee reports, system implementation plans, system analyses, project proposals and reports Publications including unpublished research studies, papers, published articles in journals, monographs, proceedings of conferences; chapters in books, books, monographs, edited volumes Presentations given at local, national and international conferences. Evaluations of your presentations, samples of PowerPoint slides, or handouts. Products you have developed including software, system design, CD-ROMs, multimedia Consultations, reports, policies & procedures, grant reviews and job descriptions.

In order for the assessment of Professional Portfolios to be successful, evaluation criteria must be established and a method to insure inter-rater reliability is necessary. This is particularly true for the Nursing Informatics Competency Recognition Certificate that will be assessed at the individual country level and granted by the IMIA SIG Education Working Group. Next Steps: As next steps, each country representative was charged to determine the process they will use in their respective countries to implement this program. A second action is for each country representative to develop his or her professional portfolio to serve as an example. All country representatives can work with members of the IMIA NI-SIG Education Working Group to develop their own portfolios. The development by these country representatives constitutes a pilot to assess any logistical details that need attention. The IMIA NI-SIG Education Working Group was charged with the task of developing sample portfolio, preparing a web site and developing training materials for the creation of portfolios. In addition, the Working group must determine guidelines to train assessors and establish methods to insure inter-rater reliability.

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Conclusion This chapter has provided the background on the development of competencies and credentialing for nurses who are specialists in nursing informatics. The different competencies and methods of credentialing are described. The credentialing of the nursing informatics experts continues to evolve and advance nationally and internationally.

References [1] [2[ [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25]

Saba, VK, & McCormick, KA. Essentials of Computers for Nurses: Informatics for the New Millennium 3rd Ed.. New York City, NY:McGraw-Hill, 2001. Scholes, M., Bryant, Y., & Barber, B. The Impact of Computers on Nursing: An International Review. Amsterdam, The Netherlands: Elsevier Science Publishing, 1983. Saba, VK, & McCormick, KA. Essentials of Computers for Nurses. Philadelphia, PA:: J.B. Lippincott Co, 1986. Graves, JR, & Corcoran, S. The study of nursing informatics .Image.Journal of Nursing Scholarship, 1989: 21(4), 227-231. American Nurses Association. Scope of Practice for Nursing Informatics. . Washington, DC: American Nurses Publishing, 1994. American Nurses Association. Scope and Standards of Nursing Informatics Practice. Washington, DC: American Nurses Publishing, 2001. Clinical Center, NIH. 1st National Conference: Computer Technology and Nursing. Bethesda, MD: CC, NIH (83-2142), DHHS, 1983. Clinical Center, NIH (1984). 2ndst National Conference: Computer Technology and Nursing. Bethesda, MD: CC, NIH (84-2623), DHHS, 1984. Zielstorff RD (Ed). Computers in Nursing. Wakefield, MA: Nursing Resources, 1980. Grobe, SJ Computer Primer & Resource Guide for Nurses. Philadelphia, PA: J.B. Lippincott, 1984. American Nurses Association Task Force on Computer Applications in Nursing Education. Computers in Nursing Education. Kansas City, MO: Council on Computer Applications in Nursing, ANA, 1987. Ronald, JS, & Skiba, DJ, Guidelines for Basic Computer Education in Nursing New York City, NY: National League for Nursing, 1987. Petersen, HE, & Gerdin-Jelger, U. Preparing Nurses for Using Information Systems: Recommended Informatics Competencies. New York City, NY: National League for Nursing, 1988. Riley, JB. Educational applications (pp. 527-573). In VK. Saba, & KA. McCormick. Essentials of Computers for Nurses 2nd Edition. New York City, NY: J.B. Lippincott Company, 1996. ANA Council on Computer Applications for Nursing. Report on the Designation of Nursing Informatics as a Nursing Specialty. Washington, DC: CCAN, Congress of Nursing Practice, ANA. 1992. Staggers, N., Gassert, CA., & Curran, C. Informatics competencies for nurses at four levels of practice. J of Nursing Ed, 2001: 40(7), 303-316. Staggers, N., Gassert, CA., & Curran, C. A delphi study to determine informatics competencies for nurses at four levels of practice. Nursing Res, 2002:51(6), 383-390. Association of Colleges and Research Libraries (ACRL). Information Literacy Competency Standards for Higher Education. San Antonio, TX: American Library Association, 2000. American Nurses Association. Standards of Practice for Nursing Informatics. Washington, DC: American Nurses Publishing, 1995. National Health Services: Information Authority. Evaluating the impact of ECDL in the NHS. May 2004 . Retrieved from http://www.ecdl.nhs.uk/pages/researchresults.asp. Koch, RW & Koch MW. Your professional portfolio: Don’t leave home without it. Retrieved on September 6, 2003 at: http://allnurses.com/Nurse-zine/Articles/professional-portfolio.shtml McMukkan M, Endascott R, Gray MA, Jasper M, Miller CML, Scholes J and Webb, C. Portfolios and assessment of competence: A review of the literature. J Adv Nsg, 2003: 41(3) 283-294. Ball E, Daly WM & Carnwell R. The use of portfolios in the assessment of learning and competence. Nsg Stand, 2000: 14(43), 35-37. Driscoll J & The B. The contribution of portfolios and profiles to continuing professional development. J Orthoped Nsg, 2001:10, 151-156. Nursing Council of New Zealand. Guidelines for competence-based practicing certificates for registered nurses. Wellington: Author, 2000.


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[26] Applying for credentialing as an Advanced Practice Nurse in Genetics APNG. Retrieved on September 6, 2003 at http://www.geneticnurse.org/APNGnf.htm. [27] A guide to the Development of Professional Portfolios in the Faculty of Education. Retrieved on September 6, 2003 at: http://www.edu.uleth.ca/fe/ppd/contents.html [28] Cambridge BL, Kahn S, Tompkins DP, & Yancey KB (Eds). Electronic portfolios: Emerging practices in student, faculty and institutional learning. Washington, DC: American Association for Higher Education, 2001.

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2.4. Health Informatics Needs Regulation and Registration to Add Value Recognition Jean ROBERTS and Glyn HAYES UK Council for Health Informatics Professions British Computer Society HQ, 1 Sanford Street, Swindon, Wiltshire, SN1 1HJ, UK

Abstract. Education is only one step towards being recognised as ‘fit’ to carry out an operational role in informatics to support health at any level. For many years there has been little real ‘brand image’. Although significant bodies like IMIA and the BCS welcome a wide range of professionals, there is still confusion over what the discipline really means and does. In order to become a mature profession in the health domain, particularly in the UK, it is necessary to operate a registration process that recognises both qualification and competency, and the responsibility to keep skills and knowledge contemporary. This paper describes the steps taken to establish a registration and regulatory body to maintain high quality professionalism in operational care delivery, academic and commercial organisations in the health domain. The concepts described have resonance internationally.

Introduction Since early 2000, there has been an expressed wish to increase the recognition of health informatics (HI) because of the increasing numbers of people working in that area[1,2]. They had a need for an improvement in their stature as expectations, contemporary appointment gradings, pay rates, entry requirements and qualifications were very confused and inconsistent. Exploratory discussions were held within the community involving clinicians, computer scientists, technologists, librarians and managers – in care delivery, academic research and teaching, commercial and policy-making units. The UK Council for Health Informatics Professions (UKCHIP) [3] was formed in September 2002. Preparation of standards, codes, guidance and registration processes then commenced. Over 50 of the leading HI professionals from around the UK accepted personal invitations to become shadow Council members. A Constitution was agreed and the Council set up as a company limited by guarantee. Since the formal launch, as at June 2004, over 1100 are registered or in the process of having their applications peer reviewed. The main objectives of UKCHIP are: • • •

To promote, advance and encourage the study and practice of the application of Informatics in the promotion of health, well being and dying with dignity To establish, uphold and improve the standards of qualification, training, competence and conduct of Health Informaticians in the United Kingdom To establish mechanisms for the benefit and protection of the public

J. Roberts and G. Hayes / Health Informatics Needs Regulation and Registration

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1. Process UKCHIP has been founded to be the regulatory body for all branches of health informatics (HI) in the UK. It is thus a professional registration and regulatory body with similar functions to the General Medical Council or the Nursing and Midwifery Council; notably to set appropriate standards of qualification, experience and behaviour for such professionals; validate that a Registrant meets expressed standards before being registered. Thereafter checks are made annually to determine Registrants carry out appropriate continuing professional/personal development to maintain or enhance their registered status. If they fail to continue to meet such standards UKCHIP has in place the process to de register them if their standards lapse, in order to protect patients. More information is available on the UKCHIP website. The Registration and Regulatory body was established by a group of people concerned about improving the professional status of health informaticians and ensuring that the areas where informatics had an impact on patient safety were risk-reduced. UKCHIP has been supported since its launch by the Departments of Health in all the UK home countries, the NHS Information Authority, the learned society (British Computer Society through its Health Informatics groups), the in-house association of ICT professionals (ASSIST), a preexisting virtual network of those involved in HI in the UK (UKIHI) and the Institute of Health Management (IHM). At present UKCHIP stands alone as a charitable company limited by guarantee. It has the aim to position itself to function under the Health Professions Council (HPC), which is moving towards statutory regulation for all health professions. The process of gaining entry to the HPC requires the entrant body to demonstrate a need for its functions, a demand amongst the professional population to participate in it and rigorous processes for entry and withdrawal of registration and continuing refreshment of skills and knowledge.

2. Demand for Professional recognition As Benson stated in 1992, a professional body should meet various criteria, covering : • • • • • • • •

Being controlled by a governing body which directs behaviour Setting entry standards and professional competence Setting ethical rules and professional standards That is a body is designed for benefit of public & not members Whose work often reserved by statute That ensures fair and open competition Has members who must be independent in thought and outlook The Body giving leadership in a field of learning

UKCHIP aspires to address the above points. It encompasses both full time informatics professionals and the “hybrid” informatics professionals who have a dual role, often as informaticians and as clinicians. It is not targeted to the needs of end users who do not have an involvement in HI other than to use it to do their main job. The scope of Health Informatics is defined as “The knowledge, skills and tools which enable information to be collected, managed, used and shared to support the delivery of healthcare and promote health” (NHSIA 1999). It thus includes staff involved in medical records, coding, audit, libraries and knowledge management, information systems development, Information and Communications Technology (ICT) staff, Help desk and Call centre personnel, data analysts and clinical / medical and general health informaticians. In ad-

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dition, those who research these areas, teach the next generation of practitioners and are involved commercially in deploying HI solutions are also encouraged to register to show their commitment to and competence in the domain. Ultimately it is hoped that the UKCHIP practice and kudos will encourage the specialist fields on the periphery (such as those in genomics, ethnographic and epidemiological informatics too) to join. There are estimated to be about 29,000 working in health informatics in the UK currently. The number is growing with the increase in demands for professional resources by significant national ICT programmes.

3. Professional status There are two key reasons for seeking to establish a collective professionalism. The main one is to protect patients. We have many examples of where bad informatics has damaged or even killed patients. The best known examples, from those happening in the UK, include a faulty ambulance management system failure, inappropriate abnormal cervical smear analysis and information-driven recall systems, incorrect radiotherapy dosages and inaccurate Downs Syndrome risk reporting. These types of incidents have both tragic individual and corporate implications. As the NHS, and any other care delivery system, embraces more and more information systems, there is an increasing impact of informatics on direct patient care. Clinicians are becoming increasingly reliant on the patient information they are provided with electronically. They also value very highly complex decision support processes provided. For example, it is now the norm for all prescribing in primary care (by far the largest part of NHS prescribing) to be done via the computer. (90% of all family physician (GP) prescriptions are computerised). It could thus be regarded as negligent for a GP not to prescribe by computer. We have to ensure that those who develop, implement and manage such systems are competent to take on such responsibilities. Informatics is an undervalued profession with an annual turnover of nearly half of the overall staff in the NHS. HI staff are often subsumed in finance departments and have little identity or status. Even in distinguishable HI departments their role and function is frequently not understood by senior management. Remuneration packages across the NHS are typically relatively poor. In informatics, the discrepancy between NHS remuneration and that which can be obtained by working in the private or commercial sector is immense. In addition to date there has been no clear career progression for HI staff, many of whose careers have developed eclectically. Personal development is often constrained by managers not allowing time off for study, not understanding the speed of growth in the domain or the complexities with which innovative technologies may potentially be utilised. Those who are in ICT are very marketable in the wider IT world and vote with their feet, hence the low retention rate for HI professionals. Many of those in the HI field have made a conscious sea-change part way through their career to move into informatics within health. In the UK, there are typically many less graduate health informaticians than in any other developed world nation. Many of those who have shown an interest in informatics solutions whilst still in their clinical professions have developed skills and expertise in informatics over many years, then currently return to their clinical professions if they want adequate career development. Any health organisation that, like the NHS in England, is in the process of massive investment into its informatics, requires HI staff who are appropriately rewarded, working in reasonable environments and who have good career prospects. A registration and regulatory body can help to achieve those goals.


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UKCHIP provides : •

Defined qualification and experience standards for HI professionals; which are mapped onto other industry standards to recognise professional mobility Defined behaviour for HI professionals – a code of conduct Recognised CPD schemes (an ongoing process) that maintain or facilitate promotion through the levels of membership Registration to provide recognition for HI professionals De-registration to protect patients

• • • •

All this takes time to develop into a stable professional body that gives status to those who meet its criteria.

4. Educational contribution to Registration It was agreed from the early development of UKCHIP that ‘fitness to practice’ was not indicated by academic qualification alone, but needed to include : • • •

Job role in terms of responsibilities, autonomy and influence Time spent in both the health domain and the area of informatics; these could be sequential or in parallel Academic qualifications

A scheme referred to initially as ‘grandparenting’ has been put in place to cope with verification of the status of those already operating in the domain. This scheme takes account of proven definitional structures that are recognised industry-wide (the British Computer Society Industry Structure Model [4], which maps into the Skills For the Information Age framework [5] applicable internationally. In addition academic qualifications are scored for the relevance to HI in addition to their level. By the four-component formula (academic level, job role, years in health, years in informatics), pre-registrants apply for one of three registration levels. After a critical mass of registrants is achieved, it is intended to reverse analyse the profiles of those who are registered and issue more detailed guidance to potential registrants from then on. The themes described for entrance onto the register are echoed in the main themes for continuing professional development (CPD) to prove continuing competence. CPD in the case for registration can include the writing and presenting of scientific and academic papers, gaining further academic qualifications but also recognises the value of internal activities such as training colleagues, writing for in-house newsletters and developing briefings for organisations on HI topics.

5. Summary For all of us, as patients, the regulation and registration activities of UKCHIP are to be applauded for the contribution of these initiatives to the improvement of the care we receive. UKCHIP is seen to be on track for this, as witnessed by its launch by the Chairman of the National Patient Safety Agency, Lord Hunt. The principles and processes undertaken to establish UKCHIP in the UK can be readily adopted and adapted for any other community of health informaticians internationally, and recognise both academic educational and vocational values.

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References [1] [2] [3] [4] [5]

Are you an individual professional or a member of a profession – which is the priority for recognition Roberts, JM in Conference Proceedings of HC2002 CD-ROM A UK Operational Practitioner View - some Challenges of Health Informatics are trans-national, Methods of Information in Medicine (2002; 41 55-59) UK Council for Health Informatics Professions www.ukchip.org (accessed May 2004) British Computer Society www.bcs.org.uk (accessed May 2004) Skills For the Information Age www.sfia.org.uk (accessed May 2005)


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2.5. Educational Standards – Terminologies Used Rolf ENGELBRECHT, Josef INGENERF*, Jörg REINER GSF National Research Center for Environment and Health, Institute for Medical Informatics, Munich-Neuherberg, Germany, *) Medical University Lübeck, Institute for Medical Informatics, Lübeck, Germany Abstract. Efficient and effective delivery of health care requires accurate and relevant knowledge, patient-centred clinical data and medical information which is available to different actors and institutions in health care. Sharing data and knowledge means understanding the underlying concepts, terms, etc. Therefore a basic requirement in medical education is terminology, coding and classification. Vocabularies, data sets, schemes are to be used for medical documentation, medical statistics, analysis and system operation. Communication between heterogeneous environments will be possible when common terminologies etc. are available and used during system development. The following chapters give an overview on this important field of health telematics.

The new information and communication technologies have started off an 'informational revolution' comparable to the industrial revolution. The information society has a big impact on life and is changing our way of living. Everyone will have access to a global communication network. This will change the communication habits, the access to knowledge und its processing, the division of labour and the way enterprises are operated. The health care sector, its industry and its services will be part of this global change and not remain isolated. Communication of data and knowledge will be a main issue during the next decade. Interoperability on different levels will be a key issue for communication. Efficient and effective delivery of health care requires accurate and relevant knowledge, patient-centred clinical data and medical information. Integrating electronic patient records, decision support and information retrieval systems is the key to providing that information at the point of care. Four key problems inhibit the development of integrated systems: •

access to actual and relevant patient data and clinical knowledge (evidence, guidelines, reference data and cases,. . ) • user-friendly data entry and retrieval systems for clinicians and other health professionals which improve efficiency, reduce risks and return investments • safe and secure communication -internally between subsystems- and -externally between different institutions and persons• terminology and data items which are unique to each system and cannot be shared Decisions on managing the patient and also on managing the institution (hospital, ward, GP office, . .) are based on information. Major tasks are, besides making all the information stored in electronic health records (EHR) and knowledge available, aggregating, sharing and communicating EHRs. Active areas of research dealing with this, for example, HARP

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R. Engelbrecht et al. / Educational Standards – Terminologies Used

and openEHR and results of recent EU projects such as TrustHealth, are being utilised to ensure that standards, European Directives and national data protection legislation is reflected within most systems. Beyond the specific needs of the differing country-specific healthcare systems there seems to be a consensus on the priority for integrated, cross-sector and patient-oriented healthcare activities. This integration best fulfils the requirements of the health needs taking into account quality of care and economic feasibility. The necessary information, communication and security infrastructure play a key role in meeting these needs. 1.1. Standardisation and Structure The standardisation of medical terminology has been shown as a very important but also very difficult task of medical informatics. Problem solutions in daily practice or in theory are focussed on their use. The difficulty is the object and the terms used for its description in the different areas of business and life, e.g. health care professionals of different specialties, para medicals and consumers. In this situation a classification of terminology is helpful and mostly done by putting short descriptions in a hierarchical order. For medical documentation and communication in practice controlled vocabularies are used incorporating terms, descriptors or preferred terms. These entities often are linked to codes which leads to a wide range of coding systems used in medicine such as ICD, SNOMED, LOINC. They are result oriented, e.g. for audit, and not centered on the users’ needs. Therefore a different way using natural language(NL) is more promising. Natural language input and its processing (NLP) is a highly relevant research and development area. [20], Building structured tables by the extraction from EHR is a promising way to use NLP and will support also statistical and knowledge bases applications. For this purpose multi lingual lexicons have to be established with an underlying semantical network. Research and industries have started (GALEN, ID Berlin) in this field which is also a very European one serving different countries and languages. An intended outcome is the multilingual access to data, knowledge and its translation for a multilingual and mobile society. This approach opens contents from from classifications, nomenclatures, reimbursement systems, books, guidelines as well as clinical pathways.[21]. These tools can also serve as a semantic interface between different applications. 1.2. Interoperability The target for interoperability is to offer an exchange of clinical data between computer based applications, e.g. for multi-country communication a chip card can be considered as a transparent device for all healthcare users regardless of card technology or contents. The information necessary to treat the patient as well as security functions will have to be available in the preferred language of the health professional. Under strict security conditions, authorised healthcare personnel will be able to read and write information locally or remote. The interoperability of health information systems therefore defines as follows: "Interoperability of computer based health Information systems is the ability to access, use and update computer readable data issued by any health information system, healthcare organisation, any healthcare facilities to the extent that accessing, managing and processing these data is possible for those healthcare facilities and healthcare professionals that are legally authorised " . Interoperability has to be seen on four levels: • Data, a common definition of the content • Technical, enabling the use of different environments


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• Data presentation, in order to integrate the different applications • Security, to ensure a trustful environment

2. Terminology Terminology is defined as a collection of terms used in specific (scientific) fields. Collecting a terminology together with terms’ definition is the starting point for any classification and nomenclature of objects, a s the intermediate step to coding. [23]. A clinical terminology has following main benefits: • • • •

Data can be used for clinical decision support Basis for medical research and audit Easy exchange of data on a language basis Compressing clinical data

Classification is the ordering of objects (terms, procedures, etc.) into classes or groups on the basis of their relationships. 2.1. Existing classifications and nomenclatures The terminology service is a basic feature of future infrastructures. One of the major drawbacks in communications between different medical systems in the past at the information exchange level was the use of different terminologies. Descriptive definitions and terminology vary between the countries and even between physicians at the same country. To achieve data integration on a semantic level TOSCA has done some work on a standardised terminology. There exist numerous coding systems (e.g. SNOMED nomenclature, MeSH thesaurus, ICD-10 and ICPM classification) that are a possible basis for standardisation. However these key systems are stand-alone vocabularies and are inadequately maintained as far as software engineering is concerned. With the aim ‘ophthalmology platform’ in health service, a suitable architecture of terminological services with a clearly defined server was established. This server communicates with the information broker and the subsystems as well. All TOSCA applications rely on a telemedical infrastructure for communication, based on established and new technical standards, like XML for the data transfer via network, DICOM for the image transfer and HTTPS for the interaction of different application systems within the telemedical communications infrastructure. The sensitive patient related data are transferred by European safety standards. The communication platform includes brokering services, telescreening, image processing, a reference image database and the monitoring system. To enable the integration of different systems and services, developed within the TOSCA project and with patient data management systems, a standardised ophthalmological terminology for Glaucoma and Diabetic Retinopathy were developed. Partly, medical terms were adopted from previous and current European projects (e.g. OPHTEL, MUSTANG) and adjusted for the TOSCA project. New terms relevant for TOSCA were added to the terminological component. The terminological component is the basis for structured documentation and reports. Descriptive definitions, hierarchical relations among concepts, and language specific terms of a common terminology for Diabetic Retinopathy and Glaucoma are provided. The terms and definitions for the medical concepts are in accordance with international standards (e.g. ICD, SNOMED, MeSH etc.). The terminology also provides the functionality necessary for maintaining the consistency of medical contents and other components.

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Figure 1. Block diagram.

Figure 2. Hierarchical layers.

A central data dictionary is a prerequisite for the integration of systems and subsystems. It defines the syntax and semantics of data. The data dictionary contains definitions of parameters, including data types, value sets, units etc., that are used for the documentation of data. The basic resources of an evaluated TOSCA terminology are various coding systems and vocabularies that are relevant for the project. These are described in detail in the following sections 3.1.1 – 3.1.6. This extensive resources has to be managed for usability by a special information system. In TOSCA two of them are used in dependence of the task. The MUSTANG Terminology Server and the KAMATO terminology management module. 2.1.1. Unified Medical Language System (UMLS) The Unified Medical Language System (UMLS) is a product of the U.S. National Library of Medicine and published since 1986. The UMLS is meant to be consulted and used by


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Figure 3. UMLS—metathesaurus integrating most relevant medical vocabularies, taken from [IR].

applications programs to interpret and refine user queries, to map the user's terms to appropriate controlled vocabularies and classification schemes, and to assist in structured data creation. UMLS shows the source vocabularies with the properties of structure and contents transparent on the level of concepts. This view brings the vocabulary-inherent relationships and relations together on the level of the concepts. Therefore UMLS is a complex and quantitative comprehensive collection of concepts, terms, strings and relations between them, originating from the included standard vocabularies [1]. UMLS consists of four main components: Metathesaurus, Semantic Network, Information Source-Map and the Specialist Lexicon. The Metathesaurus is the central vocabulary component of the UMLS, based on hierarchies and associations, which are inherited form the source vocabularies and attached to the unique UMLS concept. The purpose is to link alternative names and views of the same concept together and to identify useful relationships between different concepts. Each concept or meaning in the Metathesaurus has a unique concept identifier (CUI) . The metathesaurus is built from most of the relevant medical vocabularies like e.g. ICD-9, ICD10, SNOMED, MeSH, Read Code and COSTAR. The 2001 edition of the Metathesaurus includes about 800,000 concepts and 1.9 million concept names in different source vocabularies. New in the 2001 Metathesaurus are: DDB00, Malcolm Duncan's Diseases Database 2000; ICD10AM, the Australian Modification of ICD10; ICPC2E, International Classification of Primary Care 2nd Edition Electronic version; ICPC2P, International Classification of Primary Care, Version 2-Plus, Australian Modification and MTHICD9, NLM-generated entry terms for ICD-9-CM. The Semantic Network is a network of the general categories or semantic types to which all concepts in the Metathesaurus have been assigned. By the Semantic Network the concepts are associated with the generic types (disease or syndrome) or relations (is_a, associated_with..) [2]. The Information Source map contains meta-information concerning medical onlineresources. The Specialist Lexicon contains linguistic information (e.g. Diabetes) about medical terms. Syntactic, morphologic and orthographic information, necessary for natural language processing, is included [3], [4].

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2.1.2. Medical Subject Headings MeSH The Medical Subject Headings, published by the National Library of Medicine consists of a controlled vocabulary used for indexing articles, for cataloguing books and other holdings, and for searching MeSH-indexed databases, including MEDLINE. The MeSH vocabulary is continually updated by subject specialists in various areas. There are more than 19,000 main headings in MeSH. In addition to these headings, there are 103,500 headings called Supplementary Concept Records (formerly Supplementary Chemical Records) within a separate chemical thesaurus. There are also thousands of cross-references that assist in finding the most appropriate MeSH Heading, for example, Vitamin C see Ascorbic Acid.. MeSH consists of a set of terms or subject headings that are arranged in both an alphabetic and a hierarchical structure. MeSH is a principal component vocabulary of the Unified Medical Language System (UMLS®) [5]. Medical Subjects Heading is divided into two sections: Alphabetic List and Tree Structures. The Alphabetic List section contain the subject headings arranged in alphabetic order with cross-reverences. The tree structure is a list in which the subject headings are divided into categories. Most categories are further divided into subcategories, identified by an alphanumeric designation. The Terms in each subcategory are arranged hierarchically, in up to seven levels, from the most general to the most specific. MeSH Categories: Analytical, Diagnostic and Therapeutic Techniques and Equipment Category E Anatomy Category A Anthropology, Education, Sociology and Social Phenomena Category I Biological Sciences Category G Chemicals and Drugs Category D Diseases Category C Geographical Locations Category Z Health Care Category N Humanities Category K Information Science Category L Organisms Category B Persons Category M Physical Sciences Category H Psychiatry and Psychology Category F Technology and Food and Beverages Category J [6]. 2.1.3. SNOMED Systematized Nomenclature of Human and Veterinary Medicine SNOMED Systematized Nomenclature of Human and Veterinary Medicine is a broadbased, comprehensive clinical terminology and knowledge base, developed and maintained by SNOMED International, a not-for-profit division of the College of American Pathologists. SNOMED is a structured nomenclature and classification created for the indexing of the entire medical record, including signs and symptoms, diagnoses, and procedures. The terms are placed into natural hierarchies each represented by a six-digit alphanumeric termcode. SNOMED international is updated annually, Version 3.5, released in 1998, contains more than 150,000 terms. Additionally the ICD-9 terms and codes are incorporated, mostly found in the Disease/Diagnosis axis. SNOMED international contains 11 axes: • Topography (anatomy): A functional anatomy for human and veterinary medicine. (13,165 records)


• • • • • • • • • •

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Morphology: Terms used to name and describe structural changes in disease and abnormal development. (5,898 records) Function: Terms used to describe the physiology and patho-physiology of disease processes. (19,355 records) Disease/diagnosis: A classification of the recognized clinical conditions encountered in human and veterinary medicine. (41,494 records) Procedures: A classification of health care procedures (30,796 records) Occupations: Developed by, and used with permission from, the International Labour Office in Geneva, Switzerland. (1,949 records) Living organisms: Living organisms of etiological significance in human and animal disease. (24,821 records) Chemicals, Drugs, and Biological Products: Including pharmaceutical manufacturers. (14,859 records) Physical agents, forces, and activities: - A compilation of physical activities, physical hazards, and the forces of nature. (1,601 records) Social context: Social conditions and relationships of importance to medicine. (1070 records) General linkage modifiers Linkages, descriptors, and qualifiers to link or modify terms from each module (1,594 records)

Characteristic is the systematized, multiaxial, and controlled vocabulary. Terms in SNOMED are all arranged in a hierarchy, represented by an alphanumeric term code where each digit represents a specific location in the hierarchy. For example, T20000 represents the respiratory system; T-28000 the lungs; and T-28010 the alveoli. Multiaxial refers to the ability of the nomenclature to express the meaning of a concept across several axes. For example Tuberculosis (D-0188) affects the lung (T-28000), is caused by M.tuberculosis (E-2001), appears as Granuloma (M-44060), and causes Fever (F-03003). A controlled vocabulary allows the user to record data in the patient's record using any one of a variety of synonyms, but references it back to a single primary concept. For example the preferred term Atopic dermatitis, NOS (D0-10130) has the synonymes Allergic eczema, Besnier's prurigo, Atopic neurodermatitis, Allergic dermatitis, Prurigo of Besnier, and disseminated neurodermatitis [7]. SNOMED International is rapidly being accepted world-wide. The American Veterinary Medical Association and the American Dental Association have adopted/endorsed SNOMED for their use. The American College of Radiology/National Equipment Manufacturers Association will be using a subset of SNOMED in their Digital Imaging communication Standard (DICOM). SNOMED Clinical Terms will be a medical terminology resource that combines the content of SNOMED RT with the United Kingdom's Clinical Terms Version 3 (formerly known as the Read Codes V3) [8]. 2.1.4. The International Statistical Classification of Diseases and Related Problems, 10th revision - ICD10 The ICD is a classification system developed collaboratively between the World Health Organisation (WHO) and ten international centers. The Tenth Revision of the International Statistical Classification of Diseases and Related Health Problems is the latest in a series that was formalised in 1893 as the Bertillon Classification or International List of Causes of Death. While the title has been amended to make clearer the content and purpose and to reflect the progressive extension of the scope of the classification beyond diseases and injuries, the familiar abbreviation "ICD" has been

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retained. The ICD-10 was approved by the World Health Organization in 1990 and has been available for implementation since 1993. ICD-10 classifies diseases, injuries and causes of death, as well as external causes of injury and poisoning. The classification has 21 chapters with alpha-numeric categories and subcategories. ICD10 contains about 8.000 categories that are valid for cause of death. The ICD-10 uses 4-digit alphanumeric codes compared with 4-digit numeric codes in ICD-9. ICD-10 has an Alpha-numeric format with a code size ranging from 3 to 5 characters. Valid ICD-10 disease codes include three, four and five character codes e.g. R11 Nausea and vomiting, J20.6 Acute bronchitis due to rhinovirus, M08.00 Juvenile Rheumatoid Arthritis. The range of ICD-10 codes is A00.00 to Z99.99. The Morphology code range is M0000/0 to M9999/9 [9], [10]. ICD-10 is published in three volumes. Volume 1 - Tabular List: The first volume, which runs well over 1,000 pages, contains the classification at the threeand four-character levels, the classification of the morphology of neoplasms, special tabulation lists for mortality and morbidity, definitions, and the nomenclature regulations. Volume 2 - Instruction Manual: The second volume consolidates notes on certification and classification formerly included in Volume 1, supplemented by a great deal of new background information, instructions, and guidelines for users of the tabular list. Volume 3 - Alphabetical Index: The final volume presents the detailed alphabetical index [11]. Overview of ICD-10 Chapters and Code Ranges: I II III IV V VI VII VIII IX X XI XII XIII XIV XV XVI XVII XVIII XIX XX XXI

Certain infectious and parasitic diseases (A00-B99) Neoplasm (C00-D49) Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D99) Endocrine, nutritional and metabolic disease (E00-E99) Mental and behavioural disorders (F00-F99) Diseases of the nervous system (G00-G99) Diseases if the eye and adnexa (H00-H49) Diseases of the ear and mastoid process (H50-H99) Diseases of the circulary system (I00-I99) Diseases of the respiratory system (J00-J99) Diseases of the digestive system (K00-K99) Diseases of the skin and subcutaneous tissue (L00-L99) Diseases of the musculoskeletal system and connective tissue (M00-M99) Diseases of the genital urinary system (Noo-N99) Pregnancy, childbirth and the puerperium (C00-C99) Certain conditions originating in the perinatal period (P00-P99) Congenital malformations, deformations, and chromosomal abnormalities (Q00-Q99) Symptoms, signs and abnormal clinical and laboratory findings not elsewhere classified (R00-R99) Injury, poisoning and certain other consequences of external causes (S00-T99) Eternal causes of morbidity and mortality (V00-Y99) Factors influencing health status and contact with health services (Z00-Z99) [12].


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2.1.5. The Read Codes The Read Codes are a comprehensive, hierarchically arranged, thesaurus of terms used in health care in the last decade. At this moment it is only of interest for educational purposes. The NHS Centre for Coding and Classification (NHS CCC) was established in 1990 in Loughborough, Leicestershire with Dr James Read, the originator of the Read Codes, as its first Director. The NHS CCC is a branch of the Information Management Group of the NHS Management Executive and its main role is to maintain and further develop the Read Codes as the standard coded thesaurus of clinical terms for the NHS. The thesaurus was developed in full consultation with the various clinical professions, their Royal Colleges and Associations. Version 3 of the Read Codes thesaurus incorporates the results of the Clinical Terms Project. Version 3 was released in July 1994. The Read Codes are compiled and updated quarterly for the full release and monthly for drugs. The UK Department of Health distributes and licenses the Read Codes. The Read Codes were freely available for assessment of content, academic evaluation and pilot use [13]. The Read Codes provide the basis for a common language for health, enabling the communication of information to and from all sectors of health care. The cross-references to all major classifications enables data to be fully comparable. The Read Codes are being extended to provide fully detailed terms for all specialities and also for nursing and the allied professions. They have received the endorsement and full support of the UK medical professions and the National Health Service Management Executive and are the standard for General Practice, a nationally recognised source of primary coding in the hospital and community sectors for all national minimum data sets and national statistics in England and Wales, and the official vehicle for clinical coding throughout the NHS in Scotland. The Read Code is incorporated into the Unified Medical Language System (UMLS) of the National Library of Medicine, USA [14]. The Read Codes cover all aspects of health care. • • • • • • • • • • • •

The main chapters of the Read Codes cover: Occupations: list of job titles. History and observations: terms obtained from a clinical history, examination, assessment, special investigations or tests. Disorders: terms that are descriptions of disease processes, abnormal function or form. Investigations: laboratory tests and special clinical investigations. Operations and procedures: physical procedures that are performed on the patient. Regimes and therapies: clinically useful terms for a range of non surgical treatments and regimes. Prevention: terms to do with Contraception, Obstetric care, Control of infectious diseases and Childhood examinations. Causes of injury and poisoning: This chapter mirrors the External causes of morbidity and mortality chapter in ICD-10 and is provided to allow the recording of the situation in which an injury occurs. Tumor morphology: This chapter contains terms for the morphology of tumours and is fully compatible with ICD-O, ICD-9, ICD-10, SNOMED II and SNOMED International. Staging and scales: contains a list of tumour staging systems, which when used as qualifiers of tumours will allow detailed recording of staging. Administration: terms that are mainly related to General Practice administration.

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• • • • • •


Drug: This chapter covers the full range of drugs that can be prescribed under the NHS within Primary Care. In addition, other groups including special foods, dialysis fluids, radio-pharmaceuticals and camouflage cosmetics are also covered. Appliances and equipment: contains all prescribable products in the Drug Tariff for England and Wales Unit: includes SI and other units used in the clinical record. Organisms: includes lists of plants, animals, insects and all microorganisms that are considered to be of significance to humans. Anatomical sites: contains a comprehensive, set of anatomical terms, sufficient to add detail to the core terms. Additional values: contains structured lists of the remaining values [15].

The Read Code thesaurus consists of a central list of the preferred terms for each concept identified - the nomenclature - and the synonyms, eponyms and abbreviations linked to these preferred terms. Each preferred term in the Read Codes has an five character alphanumeric code that act simply as a label for each concept. Clinical concepts and their terms are arranged in a hierarchy. There are currently issued approximately 914,000,000 codes. In previous Read Code versions (Version 2) the five character alphanumeric Read Code determined both its unique attachment to a term and the position of this term within the hierarchy. Version 3 uses the actual Read Code simply as label for the term. The hierarchy position is determined by simple electronic relational tables [1]. The Read Codes are at least as detailed as, mapped to, and compatible with most widely used standard statistical national and international classifications such as • • • • • • •

International Classification of Diseases ICD-9, International Classification of Diseases – Clinical Modification ICD-9-CM diagnoses and procedures, Classification of Surgical Operations and Procedures OPCS-4, Classification and Analysis of General Practice Data RCGP 1986, International Classification of Primary Care ICPC, British National Formulary BNF and the Anatomical Therapeutical Chemical ATC drug classification.

New Terms from the ICD-10 are incorporated in the Read Code and a full mapping from the Read Codes to ICD-10 is provided [14]. 2.1.6. ICPM International Classification of Procedures in Medicine The German ICPM (International classification of procedures in medicine) is a classification of clinical procedures, describing diagnostic, surgical or other conservative procedures. The ICPM serves scientific statements, quality assurances and the representation of insurance claims and is an obliging basis of procedure documentation. The ICPM is the German translation, adaption and extension of the ICPM-DE (International Classification of Procedures in Medicine, Dutch extension), based on the ICPMWHO. The Friedrich-Wingert-Foundation is responsible for the maintenance, development and extension of the ICPM. Since 1994 Version 1.0 is used by hospitals for routine applications of classifications. In further developments of the ICPM the SNOMED nomenclature will be incorporated. The main chapters of the ICPM cover: • Diagnostic procedures • Prophylactic procedures


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• Surgical procedures • Other therapeutic procedures • Additional procedures Drugs, laboratory and radiologic procedures are not included in the German Version . The concepts are arranged in a hierarchy. Each concept has a 6 characters alphanumeric code. The nomenclature is organised into six levels of hierarchy. Example of the six levels: • Chapter: e.g. 5 - Surgical procedures • Group: e.g. 5-010 to 5-049 - Surgical procedures on the nervous system • Category: e.g. 5-01 Incision and excision on the skull, brain and meninges • Subcategory: e.g. 5-010 – Cranial puncture • 5 character or 6 character extension: e.g. 5-010.0 – Cisternal puncture The groups are ordered by the type of procedure. An exception is made in the chapter “surgical procedures”. Here a topographic-anatomical order by organs and body systems is used. The German Version of the ICPM is available as book or in three different CD-ROM Versions [16]. The ICPM Version 1.1 (Operationenschlüssel nach Paragraph 301 Sozialgesetzbuch V (OPS-301)) provided by DIMDI - the German Institute for Medical Documentation and Information - is available online [19]. 2.1.7. HL7 and RIM HL7 is a communication standard based on the needs described in the level 7 of the ISOreference model. But the new version 3 [ HL7 ] “ represents a significant departure from "business as usual" for HL7. Offering lots of optionality and thus flexibility, the V2.x series of messages were widely implemented and very successful. These messages evolved over several years using a "bottom-up" approach that has addressed individual needs through an evolving ad-hoc methodology.” HL7 version 3 addresses several issues by using a well-defined methodology based on a reference information (i.e., data) model (RIM). It will be the most definitive standard to date and is a basis for several developments already now. The German health telematics architecture will use it for all levels of care. Version 3 create messages using RIM in an object-oriented development methodology. The RIM provides an explicit representation of the semantic and lexical connections that exist between the data carried in the fields of HL7 messages and is only one model of healthcare information needs. It is using XML encoding. The RIM consists of 6 classes modelled in UML: Act represents the actions that are executed and must be documented as health care is managed and provided. Subclasses are “observation” including examination, “procedure” describing treatments, but also administrative ones as “FinancialTransaction”. ActRelationship describes the relationship of “acts” e.g. between order entry and its results / reports. Entity represents all beings (humans, animals) and things in the health care system. A subclass is LivingSubject which contains again the subclass “person”.

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Participation describes the context in which an “act” is performed: who performed it, where was it done, etc. Role describes the role entities are doing when participating in “acts”. Important subclasses are “patient” and “employee” RoleLink describes relationships between the different roles. The classes are linked either by a set of association relationships, identified by unique role names, or by generalization relationships. Each of these elements includes a textual definition. The appearance of attributes and associations is controlled by cardinality and related constraints applied to the attributes and to the roles that link the associations to the classes. The HL7 Vocabulary Domain Values table is organized alphabetically by domain table name or domain name and includes a mnemonic code, concept identifier, print name, and definition/description for each coded value. (Abstract domains are not assigned a code). The External Domains table is organized alphabetically by domain table name and includes the domain name, concept identifier, the source code system, a defining expression for extracting the domain from the source system, and a description The HL7 Domain Tables and Coded Attributes Cross-reference Table is organized alphabetically by domain table name in column one, and lists the coded RIM attribute(s) and/or the data type components that are supported by that vocabulary domain. For RIM attributes, the data types and assigned coding strength are also shown. Both the RIM attributes and the data type components are hyper-linked to the definition in their respective documents. 2.2. MUSTANG (Medical UMLS based Terminology Server for Authoring, Navigating and Guiding the Retrieval to heterogeneous Knowledge Sources) Both, for indexing and for the data-recall facilities, the terminology server MUSTANG (Medical UMLS based Terminology Server for Authoring, Navigating and Guiding the Retrieval to heterogeneous Knowledge Sources) is developed. MUSTANG a CORBAmed based central multilingual terminology server provides the semantic foundation for a repository of XML-document forms. MUSTANG delivers terminological services to applications by standardized interfaces and provides access to terminology resource related to the Unified Medical Language System (UMLS). In addition MUSTANG provides functions to retrieve medical information from Internet-located knowledge sources (e.g. PubMed) via MeSH-based queries. MUSTANG is implemented on a Windows platform using the ORACLE database management and development software [2], [17], [18]. The terminology together with the forms and IP-protocols represent the pivot elements for communication of patient related data between sites and services. 2.3. Results 2.3.1. Terminology module A terminology system was developed within the TOSCA project to establish a common terminology. As an example in the next paragraph a solution for glaucoma is described. The


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terminology system enables the integration of different systems and services with patient data management systems and provides a basis for structured documentation and reports. The terminology module provides terms and definitions for medical concepts that are in accordance with international standards (e.g. ICD, SNOMED, MeSH etc.). It also provides the functionality necessary for maintaining the consistency of medical contents and other components. 2.3.1.1. Terms for Glaucoma: Terms concerning Glaucoma relevant for the TOSCA project were collected according to the structure used for Diabetic Retinopathy. As there were no experiences and sources from the OPHTEL project the terms for glaucoma were collected from following sources: • • • • • • •

The ‚American Academy of Ophthalmology, Preferred Practice Pattern: Primary open-angle glaucoma suspect, 1995 The ‚American Academy of Ophthalmology, Preferred Practice Pattern: Primary open-angle glaucoma, 1996 The ‚American Academy of Ophthalmology, Preferred Practice Pattern: Primary angle-closure glaucoma, 1996 Duane´s Ophthalmology on CD-ROM, Lippincott-Raven Publishers European Glaucoma Society: Terminology and guidelines for glaucoma, 1998 Shields, M.B., Krieglstein, G.K.: Glaukom, Springer Verlag, 1993 Hoskins D., Kass M.: Diagnosis and Therapy of the Glaucomas, The C.V.Mosby Company, 1989

The terminology version for Glaucoma contains ca. 470 terms dedicated to following groups: patient data, anamnesis, finding, examination, laboratory finding, diagnosis, differential diagnosis, disease, treatment, medical treatment, organ part, organ function, risk factor, hormone, health care activity, therapeutic or preventive procedure, substance. Each term is described with following identifiers: • TOSCA Concept Identifier (TCP) • Semantic type: e.g. Findings, Diagnosis • Preferred Term: Preferred term of the UMLS Metathesaurus. In case the medical concept could not be referenced by one of the vocabularies of the UMLS the preferred term corresponded with the term used in the medical source. • Synonyms: Synonyms and abbreviations • German translation of the concept • Parent concepts: The terms are ordered in a hierarchical structure. Each medical concept belongs to a parent concept. • Description: If available a short definition out of the medical source was included to specify the concept. • Description of the UMLS: If available additional the semantic type and the definition from the UMLS Metathesaurus was added. • CUI: Unique identifier for the Metathesaurus concept from the UMLS to which a term and string is linked. The following coding systems were used as resources to identify the project relevant concepts, terms and codes: • ICD_10 Code: International Statistical Classification of Diseases and Related Health Problems (ICD-10). 10th revision. Geneva: World Health Organization. 1998.

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• SNMI98: Code of the Systematised Nomenclature of Human and Veterinary Medicine: SNOMED, International. Version 3.5. Northfield: College of American Pathologists; Schaumburg: American Veterinary Association, 1998. • RCD99: Clinical Terms Version 3 (Read Codes). England: National Health Service Centre for Coding and Classification, March, 1999. • MSH2001: Medical Subject Headings (MeSH). Bethesda (MD): National Library of Medicine, 2001. • ICPM code: Codes of the International Classification of Procedures in Medicine, Version 1.1. • ICPM-International Classification of Precodures in Medicine, Version 1.1 from 29.09.1995, published by DIMDI (German Institute of Medical Documentation and Information) • ICPM, International Classification of Procedures in Medicine, Friedrich-WingertStiftung, Version 1.0., Blackwell, 1994 For identification following systems were used: • MUSTANG-Terminology Server, MEDWIS-Arbeitskreis “Terminologie”, Clint Tool: UMLS-Accessability Tool of MUSTANG (ORACLE-DBSystem mit UMLSDaten; Web-Server zur Visualisierung), http://mustang.gsf.de/”. MUSTANG provides the access of various UMLS based coding systems especially to the mainly used vocabularies in this project (ICD, SNOMED, Read Code, MeSH, ICPM) • UMLS Knowledge Source Server, Metathesaurus „https://umlsks.nlm.nih.gov/“. 2.3.2. Data Dictionary for Glaucoma A central data dictionary is a prerequisite for the integration of systems and subsystems. It defines the syntax and semantics of data. The data dictionary contains definitions of parameters, including data types, value sets, units etc., that are used for the documentation of data. The Data Dictionary for Glaucoma is based on the TOSCA Glaucoma screening data model. About 40 datasets are described as follows: • • • • • • • • •

Preferred term: The preferred term from the terminology system, TCP: TOSCA Concept Identifier from the terminology system Name of parameter: Name used in the screening data model Unit: e.g. year, mmHg Datatype: Enumeration single (from a list only one value can be selected), Enumeration multiple (the selecting of more than one value is possible), Date, Boolean (yes or no), Integer (value with comma), Real (value without comma), String (text) Value set: Concept identifiers were also assigned to each value set Title/Tooltip: Name for the user interace Description for the documentation Comments

2.3.3. TOSCA terminology in KAMATO® The terminological concepts for Diabetic retinopathy and Glaucoma are also stored in the terminology module of KAMATO® (Knowledge Acquisition and Management Tool) developed by AdaKoS GmbH. The Terminology Component of KAMATO® ensures the terminological control of knowledge bases and enables also the access to Internet-located knowledge sources (e.g. PubMed) via MeSH based queries.


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Figure 4. Terminology module of KAMATO.

Figure 5. Terminology module of KAMATO: Hierarchical order of the concept ‘Eye disease’.

With a special search function terminological concepts, available in the Metathesaurus of UMLS, are automatically imported into KAMATO from the MUSTANG server. Preferred term, synonyms, source codes, and if available semantic types and descriptions are added. KAMATO® supports following coding systems: UMLS-CUI, ICD 9, ICD 10, MeSH, Read Code, SNOMED 2, SNOMED Int 3.5, HL7 Terminology, WHOART, ICPM, ULMER, BLS. Further coding systems can be added by request.

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Figure 6. Patient-centred knowledge-based Information System for Glaucoma: preferred term and code set for ‘Visual field defect’.

The concepts are arranged in hierarchical order in parent and child concepts. Figure presents the parent concepts of the TOSCA terminology project. Figure 5 shows the hierarchical order of the concept ‘Eye disease’. With the terminology module of KAMATO the ophthalmological concepts for Diabetic retinopathy and Glaucoma can be presented in structured hierarchical order. Via the terminology server MUSTANG, new concepts, based on UMLS, can be imported automatically. The structured order and the clear users interface allows an easy and fast maintenance of the terminological concepts and a multilingual usage.. For the TOSCA project the terminological concepts in KAMATO are used for the ‘Patient-centred Knowledge-based Information System for Glaucoma’. The concepts provide the basic for indexing documents and contents of the knowledge base. Indexing enables the terminological control of the knowledge base and the accurate retrieval of documents and knowledge contents (Figure 6). The terminology module of KAMATO enables also the access to Internet-located knowledge sources (e.g. PubMed) via MeSH based queries (Figure 7). 2.4. Data sets Terminologies and data sets are closely related. Within the GALEN project the DIABCARD data set was used as a basis for a terminology server which was used for the development of a medical information system. It showed that work has to be done on the harmonisation of data sets and terminology with the goal of implementing interoperable EHRs.


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Figure 7. Access to PubMed via KAMATO: Publications of the selected term ‚Glaucoma, open-angle’ are listed.

“The content of the Electronic Health Record: Clinical Datasets for continuity of care and pathology networks” was the title of the EFMI - Special Topic Conference 2003 in Rome. Its working hypothesis was: Clinical Dataset describes the set of predefined data Entries stored, shared or presented as a unit within clinical applications, messages and EHR systems. A Clinical Dataset is able to describe a particular aspect of the patient's status, of a procedure, of a clinical document in relation to a given health issue or task, across heterogeneous contexts. A set of recommendations was developed on the basis of the actual situation in telematics in health care: • • • •

Standardization efforts on the EHR Need for sharing and aggregating clinical information Need for Clinical Datasets to improve the coherence on the content of the HER The gradual process of convergence for Clinical Datasets

The experts participating agreed on 20 recommendations.which were grouped under the following headers: 1. Create a network of organizations interested in Clinical Datasets, within the context of the ongoing actions on EHR

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2. Stimulate the production and the systematization of Clinical Entries (a kind of Archetypes) and Clinical Datasets (a kind of Templates) 3. Define the role of the Responsible Organizations and produce the guidelines for accurate documentation on Packages of Clinical Datasets 4. Set up a Repository of Templates, based on a standard processable formalism 5. Set up a gradual process of convergence, assisted by the Repository of Templates Especially group 4 is of interest in the context of terminology. •

• •

Production, retrieval, distribution, implementation, comparison and systematization of Clinical Datasets should be facilitated by setting up a suitable Repository of Templates – with an appropriate version control – and by stimulating the production of authoring tools. The upload and the download of the descriptions of Clinical Datasets to and from the Repository of Templates, as well their usage should be free of charge. Several organizations already developed their own Clinical Datasets, according to a specific local formalism. It is expected that suitable software tools will be able to assist in the semiautomatic translation and refinement of the existing Clinical Datasets into a unique standard formalism, possibly passing through a set of intermediate formalisms convenient for developers and users of each particular type of Clinical Datasets.

The collection of data sets has just started. First results will be discussed at a continuation workshop in October 2004 and will be available from the EFMI web pages (www.EFMI.org) 2.5. Conclusion Terminology was used all the time in the medical field for communication between the professionals. In former time it was Greek and Latin language based and not to be understood by others, especially the patient. Coding was used for the analysis and description of diseases and the health care system. Structured documentation for better communication and easy data entry was a step to exchange clinical data between professionals and based on classifications. The Internet is changing the habits. More than 60 % percent of adults in some countries are online and 75% of them use the Internet to look for health care information. [XC] This is influencing the decisions of the patients regarding treatment etc. Terminology has to be adapted to the consumers clinical and mental model of diseases and their treatment. This will be the challenge of the next future and has to take into account that also the health professional has to be knowledgeable about health consumers and their communication profile. Health telematics has the chance to be the health information professional for all participants in the health care setting. It has to organise the communication, storage and retrieval of data and knowledge and the organisation of information in a global health care system.

References [1] [2]

[3]

National Library of Medicine; UMLS Knowledge Sources, 14th Edition, November 2003 Ingenerf, J., Reiner, J., Seik, B.; Standardized Terminological Services enabling Semantic Interoperabilitiy between Distributed and Heterogenous Systems; International Journal of Medical Informatics, 64, 2001, 223-240, Reiner, J.; Information-Retrieval medizinischer Daten mit Unterstützung durch einen TerminologieServer, GSF-Medis Institut, 1999.


[4] [5] [6] [7]

[8] [9] [10] [11] [12] [13] [14] [15] [16] [17] [18]

[19]

[20] [21]

[22] [23] [24] [25]

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National Library of Medicine; UMLS Unified Medical Language System, July 2004, http://www.nlm.nih.gov/research/umls National Library of Medicine; Medical Subject Headings; July 2004; http://www.nlm.nih.gov/pubs/factsheets/mesh.html National Library of Medicne, MeSH Medical Subject Headings; Supplement to Index Medicus, Vol. 31, 1990. Karen M. Kudla, MT (ASCP), and Marjorie C. Rollins, DPM, MT; SNOMED: A Controlled Vocabulary for Computer-based Patient Records, Journal of AHIMA; 1998 American Health Information Management Association http://www.ahima.org/journal/features/feature.9805.2.html (last accessed 2001) NOMED international; http://www.snomed.org/ National Center for Health Statistics, Centers for Disease Control and Preventions; A Guide to state implementation of ICD-10 for mortality; July 1998. Duke University Medical Center; Links to coding Systems; July 2004; http://nestor.duhs.duke.edu/DHTS/web.nsf/resources. The International Statistical Classification of Diseases and Related Health Problems, tenth revision ICD10, 2004, WHO, http://www.who.int/whosis/icd10/descript.htm. Canadian Institute for Health Information (CIHI), ICD-10, CCI and Implementation Information; July 2004; http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=codingclass_e The Read Codes, CAMS Computer Aided Medical Systems, 1999, National Library of Medicine; UMLS Knowledge Sources, 12th Edition, January 2001. Clinical terminology, NHS Information Authority, July 2004, http://www.nhsia.nhs.uk/snomed/pages/ct_general.asp ICPM Internationale Klassifikationen der Prozeduren in der Medizin, Friedrich-Wingert-Stiftung, Blackwell Wissenschaft, Berlin, 1994 Ingenerf, J.; Reiner, J., MUSTANG: Wiederverwendbare UMLS-basierte terminologische Dienste., Proc. Medical Informatics Europe MIE 2000, Hannover, 77 (2000): 685-690. Reiner, J.; Ingenerf, J.; Glander-Höbel, C., Terminologie-Server und Informationsbeschaffung als eine exemplarische Anwendung, 43. Jahrestagung der GMDS, Bremen, MMV Medien & Medizin Verlag, 1998, 239-242 Deutsches Institut für medizinische Dokumentation und Information – DIMDI: Operationenschlüssel nach Paragraph 301 SGB V, Internationale Klassifikation der Prozeduren in der Medizin, ICPM Version 2.1 vom 2004, http://www.dimdi.de/de/klassi/prozeduren/ops301/ Baud, R., Natural language processing in the EHR context, in: Contribution of Medical Informatics to Health, Blobel, B., Gell, G., Hildebrand, C., Engelbrecht, R., (eds.) AKA, 2004, 85 Diekmann, D, Peters, C., Diekmann, F., The role of terminology in European HIS, in: Contribution of Medical Informatics to Health, Blobel, B., Gell, G., Hildebrand, C., Engelbrecht, R., (eds.) AKA, 2004, 22-23 Beolchi, L., Telemedicine Glossary 5th edition, EC, 2003 Health Level Seven (HL7), http://www.HL7.org Reference Information Model, HL7 RIM Version 2.02, HL7 2004, http://www.hl7.org ->library Zeng, Q., Kogan, S., Ash, N. Greenes, R. A. A. Boxwala, A. Characteristics of Consumer Terminology for Health Information Retrieval, Methods Inf Med; 41: 289–98, 2002

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2.6. Future trends in Health Informatics - Theoretical and practical -

J. MANTAS Health Informatics Laboratory, Faculty of Nursing, University of Athens, 123, Papadiamantopoulou Street, 11527 Athens, Greece

Abstract. The Health Informatics field is becoming more challenging as the globalisation of economy, the advancement of the technology as well as innovative breakthroughs are being incorporated in the discipline. In Europe as well as in other countries the funding into the research areas of this field is increasing. In this chapter, a brief overview of the field as well the trends of Health Informatics are discussed with respect to the new dimensions that the education of the health care professionals has to tackle in the foreseeable future.

1. Challenges of Health Sector We know that Medical informatics is deals with problems concerning the representation and processing of data, information and knowledge. Computers and technology are just tools, which we often, but not always need. However, one cannot deny that technological advances have often driven the research topics in medical informatics2. Sometimes, because the technology allowed procedures that were not possible before, sometimes the new technology was used, however, to reinvent the wheel. Health sector is facing great challenges in managing the rising costs, growing demands from consumers (patients), demographic changes, aging population, and free market. What is the role of new technologies in healthcare (eHealth) in meeting these demands? We know that Information Technology is a great tool for information intensive sectors. Is the health care an information intensive sector? We know a large number of quite successful applications of Health Informatics. A small number is mentioned :hospital information systems (overall, modular), electronic patient records, dedicated systems, laboratory systems, ECG analysis, radiology, and departmental systems. In research successful areas such as: signal and image processing, decision support, Bayes, pattern recognition, natural language processing, terminology (UMLS), standardization (e.g. HL7, CEN, ISO), Social, organizational and legal aspects of the introduction of information systems. We should note that most of today’s challenges were also challenges 30 years ago. Today we are more involved in the following research areas :electronic patient records, computerized guideline systems, reminder systems, knowledge management, logistics and simulation, knowledge discovery, new ways of developing information systems, (web services, future proof systems via the two model approach), and evaluation2.

J. Mantas / Future Trends in Health Informatics

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Figure 1. The classic model of system development2.

Figure 2. The knowledge-enabled model of system development2.

2. eHealth eHealth applications1 can provide benefits such as improvements in access, quality of care, and cost benefits if applied as an enabling tool for re-organisation accompanied by the necessary skills (training). The main goal and vision of eHealth is the person-centered health systems. To achieve better quality of care, to increase access to the system, and hence increase efficiency we need Continuity of care. This should be done through all the stages of health care - prevention, diagnosis, care, rehabilitation; across all the points of care - hospitals, primary care, lab, pharmacy. To achieve this a new approach in health is required, the Shared Care, among health care professionals - doctors, nurses, paramedics, health managers & authorities, epidemiologists by sharing common data having various views of interoperable Electronic Healthcare Records. 2.1. Past efforts in eHealth From the late 1980’s and during the 1990s the European Union initiated a series of framework programmes that included ICT applications in healthcare. They were known as: Preparatory AIM phase (20 million euros), Main AIM programme (100 million euros), Telematics Applications programme (140 nillion euros), and IST in healthcare (200 million euros). The first two phases were focused on Computer Applications for Doctors and in Telemedicine systems and services. The two recent phases are more on Regional Health

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Information Networks, Home-care systems, and Personal Health Systems. Also they developed real products that can be marketed, and in addition that gave the incentives to initiate a health telematics industry in Europe. Now the first generation of proven and beneficial eHealth applications and services exist and a problem arises to properly implement on large scale. 2.2. Present and future of eHealth1 The European Union (EU) is supporting this effort through eEurope 2005 initiative and of course through structural funds. Technology will influence medical informatics in the future. Nano-technology makes it possible that smart sensors can be used on and in patients or healthy people. We are speaking of body area networks via which the various sensors are communicating with a central station on the body that then sends the information via telecommunication to stations, where the data can be further analysed. Bio-informatics is a new field that gets a lot of attention nowadays. A cooperation between medical informatics and bio-informatics would be very fruitful. New sensors make it also possible that the elderly can stay longer at home, even when they are ill. We speak of domotics in this case. In the area of health information networks we are referring to the successful MEDCOM currently handles over 80,000 messages daily. 100% of hospitals, pharmacies, emergency doctors, 90% of general practitioners, 98% of laboratories, 55% of specialists, and 20% of municipalities are connected to it. MedCom enables hospitals to use electronic referrals, and avoid data re-entry. The professional quality of referrals has risen, and discharge letters are stored directly. The monthly status and number of messages per month can be monitored at www.medcom.dk. First studies suggest that MEDCOM has delivered substantial savings. In terms of human resources, more than 25 thousand person-months are saved. Given the average monthly employee salary of €3,350, this translates into savings of €22.5 million. NHS Direct Online, http://www.nhsdirect.nhs.uk/ established in 1999, provides health information online and access to a 24-hour nurse helpline via telephone. Six million people have accessed NHS Direct Online website in about two years. There were half a million visitors in January 2003. The website has been available since July 2000. It gives information on over 70,000 physical national health service (NHS) sites providing health services to the public. NHS Direct call centres direct people to these physical offices. NHS Direct has also put 200 touch screen kiosks in popular locations, equipped with printers and accessible to wheelchair users. Locations include NHS centres, chemists, libraries, and supermarkets. Around 300 people use each kiosk every month, which adds up to around 60,000 users a year. At the same time EU is launching new 10 year cycle of research focusing on intelligent environment for HC professional and patients as well as new research area “Biomedical informatics where the synergy of medical informatics, bioinformatics and neuroinformatics is sought for advancement of medical knowledge through synthesis of knowledge from the level of molecule (through the level of cell, tissues organ, person) to the level of population. 2.3. Use of the internet eHealth should not be confused with health on the internet - although the internet provides a very significant element of support to both lay people and medical practitioners. Today eHealth is about much more than internet based health information, intent based medical journals and internet based support to patients. But the number of medical practitioners us-

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Table 1. Use of GPs of the Internet and its applications to medicine.

Eurobarometer

2000

2001

2002

GPs with internet connection for continuing education to transfer patient medical data to offer telemedicine services

44% 34% 9% 5%

77% 70% 37% 7%

78% 72% 46% 12%

ing an internet connection in their practices is a good indicator of the rise of eHealth. We can see from this Eurobarometer table (Table 1) than in general, the uptake of internet by medical practitioners is good. The three successive polls show steady rise in the use of eHealth tools. While use of the internet by medical practitioners has reached saturation in many member states now the use of eHealth specific tools in growing steadily. Although the use of telemedicine services, such as home monitoring as well as direct contact with patients via e-mail is still low this is also showing promising signs of growth. It should be noted that much of what is holding back this growth is adjustments in the legal and administrative rules in member states for the provision of healthcare; if a GP cannot be reimbursed for providing home monitoring or for answering a patients questions electronically he or she will not use it. Similarly, if prescription for drugs can only be issued on approved note pads then the role of electronic prescribing will be very slow to grow. 2.4. Towards European eHealth Area1 In the eHealth 2003 Ministerial Conference May 22-23, 2003 it has been demonstrated the benefits of real life eHealth solutions. eHealth systems for Patients/Citizens included Telemedicine services, e.g. for homecare, Wearable systems for health status monitoring, and Systems providing Quality Health Information to Citizens. Regarding the Health Professionals eHealth tools for fast access to vital data anywhere, anytime; collaboration, risk management and research; Support to public health & management. EC is working hard to stimulate wide deployment based on the success of R&D and proven benefits and to provide environment for integration of relevant policies - Communication on eHealth – - Priority topics interoperability and standardisation, electronic health records, regional health networks, on line services (e-prescription, e-referral, telemedicine), health cards - Series of ministerial conferences - Council conclusions on eHealth - Other DG involvement – devices, public health, safety, medical research To achieve wider implementation a number of challenges should be met, such as: Organizational-cultural, National / regional strategy, Industrial issues, Legal - confidentiality and security of data, Technology and standards, User acceptance, The European parliament has issued a number of directives and recommendations, such as: 95/46/EC on the processing of personal data and free movement of such data to be implemented 24/10/98; 96/9/EC on the Legal Protection of Databases, 97/66/EC - concerning the Processing of personal Data and the protection of Privacy in the Telecommunication Sector; Council of Europe recommendation on the protection of medical data (NoR.(97)5) Adopted 13/2/97; New EC Committee on ethical issues –‘infoethics’.

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Figure 3. Biomedical Informatics seen as common ground between Medical Informatics, Bioinformatics, and Neuroinformatics1.

3. Definition of Biomedical Informatics From the original and mostly used term Medical Informatics we have gone to the more generic term Health Informatics that engulfs all disciplines in the field. However, the advent of bio-informatics has pushed again the terminology problem of our field into the front seat. The new term that seems to start dominating our field is Biomedical Informatics. The discussion can go on as the term Health Informatics is still more generic (e.g. it includes Nursing Informatics that Biomedical Informatics seems to forget it; and in addition to most of us Health includes Biology). In the previous figure (Fig. 3) we see that Biomedical Informatics is defined as the discipline that covers the three domains of: (a). Medical Informatics or Health Informatics that studies the applications of electronic patient records, hospital information systems, decision support systems, terminologies, ontologies, telemedicine, and the interoperability of such systems. The field of study is the Medical Sciences or Health Sciences. In this domain the applications of informatics are focused on citizens, patients, and to community (population). (b) Bioinformatics that studies the applications of structural and functional genomics, proteomics, biochip technologies, and computational biology. The field of study is the Biological Sciences. Here the applications of informatics are applied to the level of the human cell, genome and molecule. (c) Neuroinformatics that studies the applications biosignal analysis and pattern recognition, neuro-algorithms, neurocell technologies, human computer interfaces and machine learning. The field of study is the Behavioural Sciences and the Social Sciences. The applications of informatics can range from cell to organ. We can structure the above definitions in a multi-level layer tower (Fig. 4) starting from the lower at a molecule level going to the higher level at community level to depict the levels of informatics applications starting from bioinformatics through the classical medi-


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Figure 4. A Layered depiction of the synergy between the various fields constituting the field of Biomedical Informatics1.

cal/health informatics up to the public health informatics. There are also direct interconnections between the extreme levels such as molecular level and community level, which is the genome epidemiology. Also there interconnections between the two fields of study medical informatics and neuroinformatics that can support the next generation of brain research, which is the Molecular Neuroscience. Another example is the assistance of bioinformatics and neuroinformatics that can lead to the integration of the genomic and neuroscience databases creating the field of neurogenomics. The most common example of the assistance of medical informatics and bioinformatics is the advancement into the molecular causes of the diseases giving ground to the new field of Genomic Medicine.

4. The implementation problems and the new challenges In the previous section we have demonstrated the new field and the era that sooner rather than later will arise. However, during recent year in Europe but also in US and elsewhere we are trying to re-evaluate the shortcoming of our efforts to achieve the goals that had been set up. What we have learned can be summarised in the following1 1) Ensure well thought-out strategy. Most failures occurred due to lack of well planned strategy to tackle managerial problems such as change and crisis management. Usually technical issues had been thought from the beginning but not implementation and managerial issues in applications such as hospital information systems. 2) Break the pattern of large scale all at once implementations. Governments and politicians like very much to announce large scale projects. However, it is safer to progress in step-by-step strategy than in a large scale plan, where there no similarities always even in

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the same health care system or in a region. Small projects can be more successful and can be become successful stories as well that can be copied elsewhere. 3) Ensure commitment of the “leaders”. Since the major eHealth applications are requiring first approval by heads of organisations, hospitals or regional headquartes it is evident to bring those decision makers into the scene from the beginning of the whole process. 4) Keep it up... do not just set it up. In the implementation phase we are requiring every effort to make the application successful and acceptable by the users. But this is not enough the whole effort should continue with the same effectiveness as before in the months and years after. A great number of implementations failed just after we were celebrating great success of their implementation. 5) Ensure (legal and ethical) compliance. The applications should be flexible (parametric) enough to be adapted to any change of the law or the organisational structure of the hospital/regional information system. The system should conform to all local and international accepted recommendations covering the critical issues of security and confidentiality of the citizen/patient. 6) Do not underestimate user acceptance. Most of the well-known cases of system failure occurred because the administration and the company developing and implementing the system underestimated the acceptance of the system by the users. The users in the health care domain are diverse with different backgrounds (physicians, nurses, paramedics, administrators, technicians, etc) and each group can provide different attitudes in favour or mostly against the implementation of the system. According to the experience we had so far the remedy is not simple. What we suggest is: to bring users from the beginning into the design of the system, make the system user friendly, give motivation to the users to take benefit of the usage of the system, and last but not least, especially in budgetary terms, train and educate the users as much as possible not only in the beginning of the implementation of the system but also later providing them continuing education of the advantages and updates of the system. 7) None of the parties (administration, industry, users) can do it alone! The traditional way of thinking was the following: the administration decides to buy a system, the industry develops it and finally the users have to work with it. That was one of most common reasons of failure. For a successful completion of reasonable big implementations all parties must work together from the beginning and throughout all the phases of the life cycle process of system development, implementation and maintenance. The team work is another important challenge of eHealth implementation.

5. Planning for the future in Europe – From Theory to Action The field of Health Informatics usually lacks good demonstrations of best practices. Recently we know of successful stories that can play this role. In European Union during the 6th framework plan and the eHealth action plan it has been demonstrated the willingness to proceed along this path, that is providing real applications to the citizens across member states. In the following sections one can find the communication of the European Commission to the European Council to adopt the agenda for eHealth for the next years to come. Due to the importance of this document we have included some of the important conclusions3. 5.1. Action plan The actions outlined below should allow the European Union to achieve the full potential of eHealth systems and services within a European eHealth Area. There are three target areas:


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• how to address common challenges and create the right framework to support eHealth, • pilot actions to jump start the delivery of eHealth, and • sharing best practices and measuring progress. 5.2. Issue 1: Addressing common challenges 5.2.1. Health authorities leadership European Health Ministers have already shown eHealth leadership in their Ministerial Declaration at the 2003 eHealth Ministerial conference. The ministers welcomed Commission initiatives to explore the possibilities to promote co-ordination at a European level. They proposed to meet the targets and objectives laid down in the eEurope Action Plan and in the Programme of Community Action in the field of Public Health (2003-2008) set out in decision 1786/2002, and liaise with other Community initiatives. The conference also highlighted the importance of monitoring and benchmarking progress by developing an open method of co-ordination in this area. These words must now be transformed into action on the basis of regional and national eHealth strategies. By end 2005, each Member State is to develop a national or regional roadmap for eHealth. This should focus on deploying eHealth systems, setting targets for interoperability and the use of electronic health records, and address issues such as the reimbursement of eHealth services. 5.2.2. Interoperability of health information systems Member States have expressed the need to support actions that cover the development of standards addressing the interoperability of diverse systems and services and to explore in particular the possibilities of open source applications to achieve this objective. In this context, the need for future standards is clearly emphasised so as to solve interoperability concerns in a way which will benefit all stakeholders through the possible adoption of Open Source reference implementations for care services. In addition, an open and more free access to future and existing eHealth standards should be recommended, taking inspiration from models such as the World Wide Web Consortium. The exchange of experience in the use of open standards and open source solutions among health administrations in Member States should be promoted. 5.2.2.1. Patient identifiers The need to identify a person unambiguously is an important component of the interoperability of health information systems. The eEurope2005 action plan already supports the development of standards for a common approach to patient identifiers and electronic health record architecture. The new European Health Insurance Card includes a patient’s personal identification number as part of the data allowing people to use the card to get treatment outside their home Member State. By end 2006, Member States, in collaboration with the European Commission, should identify a common approach to patient identifiers. This should take account of best practices and developments in areas such as the European Health Insurance Card and identity management for European citizens. 5.2.2.2. Interoperability of electronic health records Achieving a seamless exchange of health information across Europe requires common structures and ontologies of the information transferred between health information systems.

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By end 2006, Member States, in collaboration with the European Commission, should identify and outline interoperability standards for health data messages and electronic health records, taking into account best practices and relevant standardisation efforts. 5.2.3. Mobility of patients and health professionals Within the European Union, patients and health professionals are becoming increasingly mobile. The Communication on patient mobility has made a number of proposals to manage the challenges resulting from this development. Recommendations include improving the exchange of information, and establishing specialised reference centres on health information. The Communication on patient mobility is presented as part of an overall strategy on health care together with the present communication and that on the open method of coordination. Work is already underway to improve information on patient mobility and mobility of health professionals at European level, and is being taken forward in particular through the health systems working party under the information strand of the public health programme. 5.2.4. Enhancing infrastructure and technologies Building on eEurope’s focus on accelerating the roll-out of broadband communications, full use should be made of broadband to support eHealth systems and services. Broadband networks carry large throughput and can also save critical time in accessing the network and give sub-second responses to information queries which can often be vital in the context of healthcare. They can bring considerable cost and performance benefits. Availability and affordability are also key to wide deployment. Service level convergence (operators offering services on top of fixed lines or mobile telephony) opens up new possibilities for eHealth applications. Public authorities can play a role in stimulating both supply and demand for broadband, while Community funding may help to support broadband delivery in underserved areas. Programmes such as eTen or the new IDABC programme may also play a role in supporting eHealth applications and health information networks. The Commission actions will enable the deployment of Europe-wide computer-supported networks, based on broadband infrastructures and Grid technologies. During the period 2004-2008, Member States should support deployment of health information networks for eHealth based on fixed and wireless broadband and mobile infrastructures and Grid technologies. 5.2.5. Conformity testing and accreditation for an eHealth market There is need for a set of agreed attributes and norms beyond existing standards that define good quality products and services. Many countries have proceeded with accreditation of eHealth systems that are becoming models for other regions, such as those in the United Kingdom and Belgium. Another example of conformance testing and accreditation is the interoperability guidelines of Integrating the Healthcare Enterprise in Europe (IHE). By mid 2005, the Commission should produce a summary of European best practices as guidance for Member States. By end 2007, a Member States should adopt conformity testing and accreditation schemes following successful best practices. 5.2.6. Leveraging investments A shared approach among Member States to support and boost investment in eHealth is needed. Regional funding structures are already available (for example, INTEREG III re-


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gional funds) in the European Commission, as well as a number of other international collaboration activities. Additional funding that could leverage eHealth developments could be sought at the European Investment Bank. The Bank is currently investing in a very wide range of eligible projects - if they represent cost-effective health policy gain. The World Bank also provides possibilities for funding international eHealth programmes both for the European Union and worldwide. By end 2006, a collaborative approach should be undertaken among Member States to supporting and boosting investment in eHealth. 5.2.7. Legal and regulatory issues There needs to be a baseline set for a standardised European qualification for eHealth services in clinical and administrative settings. Furthermore, certainty of eHealth product and service liability within the context of existing product liability legislation would be beneficial. Information and communication technology developments should contribute to a safer working environment for practitioners; and greater legal certainty with regard to eHealth services within the context of freedom of movement of people, goods and services is increasingly necessary. By end 2009, the European Commission, in collaboration with Member States, should undertake activities to: • Set a baseline for a standardised European qualification for eHealth services in clinical and administrative settings. • Provide framework for greater legal certainty of eHealth products and services liability within the context of existing product liability legislation. • Improve information for patients, health insurance schemes and providers regarding the rules applying to the assumption of the costs of eHealth services. • Promote eHealth with a view to reducing occupational accidents and illnesses as well as supporting preventive actions in the face of the emergence of new workplace risks. 5.3. Issue 2: Pilot actions: accelerating beneficial implementation 5.3.1. Information for citizens and authorities on health education and disease prevention In the context of its Public Health Programme, the Commission is preparing the establishment of a European Union-wide public health portal that will provide a flexible information technology platform to disseminate evidence-based information on public health relevant to European citizens, and to provide a single point of access to information on health. The Commission is also co-funding the development of a set of quality criteria for health related websites (‘webseals’). Its aim is to increase transparency among healthrelated websites in the interest of serious service providers and users, ranging from citizens to health professionals. Strengthening of the Health Surveillance System for Communicable Diseases, with a focus on the real-time collection of clinical and laboratory data and analysis, will enhance the capacity of early warning at national level and Community levels. It will improve the surveillance of diseases of major concern and potential bioterrorism threats. Preparing valid and reliable statistical information on provision of health care at European level as requested by Member States and Commission Services alike will profit substantially from the unique patient identifier, common standards, and protocols. Better information will then be made available to decision-makers and the interested public in a more timely way.

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By end 2005, a European Union public health portal will give access to European level public health information. Health portals shall offer dedicated information on safety at work and workplace health risks. By end 2005, there will be a strengthening of early warning, detection, and surveillance of health threats through enhanced information and communication technologies tools. 5.3.2. Towards integrated health information networks Health information networks link hospitals, laboratories, pharmacies, primary care and social centres. Thus, they communicate in a secure manner. Examples include standardised messaging systems such as e-prescription and e-referrals or the provision of telemedicine services such as teleconsultation (the provision of second medical opinion) or telecare (the home monitoring of patients). By end 2008, the majority of all European health organisations and health regions (communities, counties, districts) should be able to provide online services such as teleconsultation (second medical opinion), e-prescription, e-referral, telemonitoring and telecare. 5.3.3. Promoting the use of cards in health care There are two types of cards that may be used in the health care sector: health cards and health insurance cards. Health cards may carry emergency data (such as blood types, pathologies, treatments) or medical records, or may allow access to these data over a secure network. Health insurance cards allow access to health care and make management and billing easier. In relation to the European health insurance card, decisions have been taken to kick off its deployment as from June 1st, 2004. It will replace all the current paper forms needed to benefit from medically-necessary care while on a temporary stay (for purposes of travel, posting abroad, study, and so on). On the health side, the eEurope 2005 Action Plan states that actions will be taken to build on the European health insurance card. Activities will be launched to support common approaches in Member States that are related to electronic health records, emergency data sets, and electronic patient identifiers. Promoting the use of cards in the health care sector. Adoption of implementation of an electronic health insurance card by 2008. 5.4. Issue 3: Working together and monitoring practice 5.4.1. Disseminating best practices Success in developing a European eHealth Area will draw on sharing best practices and experience across the Union, as systems are deployed and organisations redesigned. The Commission must play a central role in spreading this activity. The experiences could be either bi-lateral or multi-lateral between or among Member States, since Member States may be at very different stages of development and implementation. Attention should be paid to sharing experience in the use and impact of eHealth applications, and approaches to ensuring the interoperability of diverse systems and services, while respecting the multicultural and multi-lingual tradition of European health care systems. Open source applications may play an important role in achieving interoperability. eHealth should be supported by the widespread dissemination of best practices. These should include the impact on access to healthcare and on its quality, assessments of cost benefits and productivity gains, as well as examples of addressing liability in telemedicine services, reimbursement schemes, and accreditation of eHealth products and services.


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In 2004, a high level eHealth forum should be established, the role of which will be to support the Commission services. It should involve all necessary stakeholders, including at national, regional, or local hospital authority levels, thereby enhancing the understanding of the Commission services with regard to the current and planned status of development of eHealth in Member States. Its task should be to follow up the various roadmaps, and to identify further actions including a strong focus on users and access for all to eHealth, as well as to develop a strong evidence basis for the case for eHealth. The work of the eHealth forum will also be closely associated with the implementation of the Community Public Health Programme. During the period 2004-2008, Member States with the support of the European Commission will organise special events such as high level conferences in order to disseminate best practices. In parallel, by the end of 2005, the European Commission, with contributions from Member States, should establish an effective way of disseminating best practices and supporting actions within the European eHealth area. 5.4.2. Benchmarking Progress also needs to be measured. Appropriate benchmarking on citizens’ awareness of eHealth, and how citizens are using eHealth effectively and efficiently is essential for future eHealth measures. This means assessing and quantifying the added value that eHealth is expected to deliver. It also means reviewing how eHealth solutions are contributing to key health challenges, including in employment, access and equity. These measures should be accompanied by proper monitoring of eHealth’s impact on health and health care in the Community. All stakeholders should have a role in this process which should feed in to further improvements in eHealth systems and services. During the period 2004-2010, every two years, the European Commission will publish a study on the state of the art in deployment, examples of best practices, and the associated benefits of eHealth. By the start of 2005, Member States, in collaboration with the European Commission, should agree on an overall approach to benchmarking in order to assess the quantitative, including economic, and qualitative impacts of eHealth. 5.4.3. International collaboration What we do in Europe on eHealth can have an important influence on meeting global health challenges within an information society. This can complement the work launched by the United Nations World Summit on the Information Society (WSIS) held in December 2003, as well as specific initiatives being developed by the World Health Organisation. An assessment of eHealth developments should be completed ahead of the second part of the World Summit to be held in Tunis in 2005.

6. Conclusions eHealth offers important opportunities for improved access to better health systems. It can empower both patients and healthcare professionals. It offers governments and tax payers a means - through substantial productivity gains - to cope with increasing demand on healthcare services. It can also help to reshape the future of health care delivery, making it more citizen-centred.

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The eHealth Area will provide a framework for exchanging best practices and experience. It will allow common approaches to shared problems to be developed over time. This action plan focuses on specific actions to bring this about, so that by the end of the decade: • The European Union as well as other countries will be well placed to measure the impact of eHealth in terms of better access and better, more efficient, services as well as on the overall productivity of the healthcare sector. • eHealth will have become or rather should have become commonplace for health professionals, patients and citizens; and eHealth will be and should be adequately resourced within healthcare budgets, and contribute to boosting wider objectives, such as competitiveness, jobs and cohesion. The widening scope of Health and Biomedical Informatics is also a challenge for the elearning community of this interdisciplinary and multidisciplinary field, which hat to adapt its scope, curricula and delivering methods for effective, quality assured and properly updated education and training having as a vision the forthcoming trends of our area well beyond the year 2010.

References [1]

[2] [3]

Iakovidis I. The real outcome of EU health telematics projects. Proceedings of MIE STC Conference in ‘Contributions of Medical Informatics to Health’, 14-15 June 2004, Munich, Germany, IOS Press Publication. Hasman A. The past and future of Medical Informatics. Proceedings of 2nd International Conference on Information Communication Technologies in Health (ICICTH), 8-10 July 2004, Samos Island, Greece. European Commission. Communication from the Commission to the Council, the European Parliament, the European Economic and Social Committee and the Committee of the Regions. COM (2004) 356, Brussels, 30-04-2004

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Ministerial Declaration at Ministerial eHealth 2003 Conference. http://europa.eu.int/information_society/eeurope/ehealth/conference/2003/index_en.htm. [2] The Role of eGovernment for Europe’s Future, 2003. [3] European Council (2000), Presidency Conclusions. Lisbon European Council. 23-24 March, 2000. [4] COM (2002) 263 final. eEurope 2005: An information society for all: An action plan to be presented in view of the Sevilla European Council, 21/22 June, 2002. Brussels, 28.5.2000. [5] COM (2001) 723 final 05.12.2001, The future of health care and care for the elderly: guaranteeing accessibility, quality and financial viability;(6528/03, 20.02.2003) and Joint report by the Commission and the Council on supporting national strategies for the future of health care and care for the elderly. [6] Braun, A; A. Constantelou, V. Karounou, A. Ligtoet, & J-C. Burgelman (2003) Prospecting ehealth in the context of a European Ageing Society: Quantifying and qualifying needs. Final report. November 2003. IPTS/ESTO: Sevilla, Spain. [7] Decision No 1786/2002/EC of the European Parliament and of the Council of 23 September 2002 adopting a programme of Community action of public health (2003-2008), OJ L 271 of 9.10.2002. [8] Spring Report 2004: Delivering Lisbon, COM(2004), 21.1.04. [9] M. Danzon and M. Furukawa, eHealth: Effects of the Internet on Competition and Productivity in Health Care (2001) In The Economic Payoff from the Internet Revolution, the Brookings Task Force on the Internet, Brookings Institution Press: Washington. [10] Stroetmann K.A. and V.N. Stroetmann (2004) Electronic business in the health and social services sector –Sector Impact Study No. 10-I (draft). The European e-business W@tch 2003/4, European Commission, Enterprise Directorate General: Brussels/Bonn, February 2004. [11] Detmer, D.E., P.D. Singleton, A. Macleod, S. Wait, M. Taylor, and J. Ridgwell (2003), The Informed Patient: Study Report, Cambridge University Health, Judge Institute of Management: Cambridge, UK. March 2003. [12] Communication on eEurope 2002: Quality Criteria for Health related Websites http://europa.eu.int/information_society/eeurope/ehealth/index_en.htm.


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[13] COM(2001) 529. eEurope 2002: Accessibility of Public Web Sites and their Content. http://europa.eu.int/information_society/topics/citizens/accessibility/web/wai_2002/cec_com_web_wai_ 2001/index_en.htm [14] Silber, Denise (2003) Comment améliorer le système de santé? Harvard University Colloquium, August 2003. Espace Européen, October 17, 2003. [15] Communication from the Commission, Adapting to change in work and society: a new Community strategy on health and safety at work 2002-2006, COM (2002) 118 final, March [16] Data Protection Directive 95/46/EC. OJ L 281 of 23/11/1995. [17] Spring Report 2004: Delivering Lisbon, COM(2004), 21.1.04. [18] Rossi Mori. Integrated clinical information systems: an essential resource – an opportunity for international cooperation. Draft in preparation February 11, 2004 for publication in the Swiss Medical Informatics Journal. Spring edition 2004. [19] Employment and Social Dimension of Information Society, eInclusion working paper, 2003. [20] L. Beolchi (editor) (2003) Telemedicine glossary, 5th edition, 2003 working document. Glossary of concepts, technologies, standards and users. Information Society Directorate-General: Brussels, Belgium, September 2003. [21] Deloitte and Touche (2003) eHealth. Health Information Network Europe. Final report. [22] The European e-Business Report - 2002/2003 edition. A portrait of e-business in fifteen sectors of the EU economy - 1st Synthesis Report of the e-Business W@tch. Luxemburg: Office for Official Publications of the European Communities, 2003. ISBN 92-894-5118-1; Empirica, SIBIS, Benchmarking Highlights 2002: Towards the Information Society in Europe and the US, May 2003. See http://www.empirica.biz/sibis/. [23] Applications relating to health. Fifth research and development framework programme 1998-2002. Final report. April 2003 edition. Information Society General-Directorate: European Commission, 2003. [24] Silber, D (2003) The Case for eHealth. Presented at the European Commission’s first high-level conference on eHealth, May 22/23, 2003. EIPA, Netherlands. [25] Eurobarometer 2001-2003. [26] Eurobarometer, 2002 http://europa.eu.int/comm/public_opinion/. [27] Eurobarometer 58.0, March 2003. [28] Iakovidis (1998) Towards Personal Health Record: Current situation, obstacles and trends in implementation of Electronic Healthcare Records in Europe, In International Journal of Medical Informatics, vol. 52, no 123, pp 105 –117. [29] COM(2003) 65 final Electronic Communications: the Road to the Knowledge Economy. [30] Article 23 of the Proposal for a Directive on services in the Internal Market (COM(2004)2 final, WP SEC(2003) 900 on the application of internal market rules to health services. [31] Draft Commission Staff working document, eEurope 2002: Legal issues in eHealth. Unpublished. [32] Directive 2000/31/EC of the European Parliament and of the Council of 8 June 2000 on certain legal aspects of information society services, in particular electronic commerce, in the Internal Market (Directive on electronic commerce), OJ L 178, 17.7.2000, p.1. [33] European Court of Justice, Kohll C-158/96 (1998) ECR-1931 and Decker C-120/95 (1998) ECR-1831. [34] World Summit on the Information Society, Report and Plan for Action, December 2003. [35] eHealth 2003, Ministerial Declaration, Brussels, 22 May 2003 http://europa.eu.int/information_society/eeurope/ehealth/conference/2003/index_en.htm. [36] http://www.w3.org/. [37] OJEU of 27 October 2003. [38] GAO Highlights (2003) Information Technology. Benefits realized for selected health care functions. GAO-04-224, Report to the Ranking Minority Member, Committee on health, Education, Labor, and Pensions, U.S. Senate. United States General Accounting Office, USA. See http://ww.gao.gov/cgibin/getrpt?GAO-O4-224 [39] http://europa.eu.int/eten/. [40] COM(2004) 13 final, 2003/0147 (COD) Common position of the Council on the adoption of a Decision of the European Parliament and of the Council on Interoperable Delivery of pan-European eGovernment services to Public Administrations, Business and Citizens (IDABC). http://europa.eu.int/eurlex/en/com/pdf/2004/com2004_0013en01.pdf. [41] Foster, I. and C. Kesselman (1999) The GRID, blueprint for a new computing infrastructure. San Francisco: Morgan Kaufman.


Section 3 Delivery and Evaluation Methods (Pedagogy and Andragogy)



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3.1. Current and Future Trends in Teaching and Learning Evelyn J.S. HOVENGA and Lisa BRICKNELL Faculty of Informatics and Communication, Central Queensland University, Rockhampton Qld MC 4702, Australia

Abstract. The University of the 21st century provides learning experiences in a new way, using a variety of new technologies, online resources and new educational delivery methods to suit. Flexibility and the adoption of adult learning methodologies are key strategic directions adopted by many. This chapter provides an overview of student learning behaviours, learning styles and the relationship between these and various teaching technologies in terms of changing academic roles and workloads as well as the need for them to acquire new skills and knowledge to teach effectively in these new environments. The variety of teaching and learning options provided by technology allows education to be provided in an appropriate manner to a broader student demographic than ever before.

1. Introduction Increasing competition for students, government funding and research contracts in the higher education sector are leading to greater differentiation between universities as they adopt a stronger strategic focus. Yetton [1] identified a range of strategic objectives being implemented by Australian universities, all of which have important IT drivers - quality of teaching; cost efficiencies; serving multiple campuses; competition for students; different types of students; and inter-university collaboration. The University of the 21st century provides learning experiences in a new way, using online resources, computer-enhanced-learning, new methods of interactivity, self-directed learning, problem based learning and flexible delivery. The tools used by the new generation university include interactive videoconferencing, web-based assessment, video assisted learning, mailing list tutorials and discussion groups and material resources on CD ROM/DVD and the World Wide Web in addition to the traditional printed materials and face-to-face teaching.

2. Flexibility and Adult Learning A number of generic reasons have been identified as to why technology has been and continues to be introduced into Australian university teaching methods. These are:

As a “value adding” tool to enrich a student’s learning experience at traditional established institutions; As a cost reduction strategy by “new” universities, making of these technologies to provide distance education programs to a mass market, particularly overseas; and

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Table 1. Comparison of the traditional (child) learner and the non-traditional (adult) learner [3].

In a combined approach by universities situated over multiple campuses, using technology as a low cost central infrastructure to support learning and teaching in remote locations [1].

Flexibility is a key issue in the strategies of the "new" university approach to teaching and learning. Researchers have, however, found that different universities interpret "flexibility" in different ways:

flexibility in access to courses in higher education, by allowing the time and place of study to suit the learner, removing fixed time and place constraints and removing entry requirements flexibility in delivery to accommodate different learning styles, by providing alternative entry and exit points and accommodating preferences in learning style, pace, collaboration, content and assessment the use of new learning technologies to address the quality of learning [2]

Much work has been done by many researchers into the nature of learning and the adult learner. Adults are more motivated to learn when their own learning needs and experience provide the starting point for learning, and when the focus of their learning is on immediate application to relevant life situations. They also are motivated to learn when their personal experience is used as a resource, and when they direct and assess their own learning [3,4,5,6]. Table 1 provides a comparison between the traditional learner and the adult learner. According to Nichols [7] all university students should be considered as “adult learners”. The traditional approach to teaching at post secondary level has been criticised as ineffective [3,5,8,9,10] for this reason. The online method of flexible delivery is lauded by many as being an ideal instrument for the delivery of education to adults, using selfdirected and problem based methods of teaching [3,5,6,11,12,13,14,15,16]. However, in South-East Asian countries, where much of Australia’s international courses are offered, students are not comfortable with flexibility and making choices about their course of study. These choices are seen to be the role of the teacher, who should know what the best choice is for the student [10]. To date, many courses currently offered electronically are developed for local students and adapted by removing culturally specific content and making materials available online [10]. Not only is simply making existing course materials available online considered to be an ineffective teaching strategy [17], material for international students is more effective if it is designed with culturally appropriate examples [9]. Central Queensland University, in particular the Faculty of Informatics & Communication, delivers many of its subjects in flexible mode with online delivery to international students. Many of these international students are from South East Asia, with a strongly traditional approach to learning. It is important for the teaching academic to recognise that assumptions about learning style should not be made [18] and universities offering culturally flexible online delivery should offer an


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Table 2. Comparison of "low context" and "high context" learning behaviours.

assortment of tools that can be combined in different ways to cater for a variety of learning styles [10,19]. These cross-cultural issues were examined by Morse [19] in his investigation into the effectiveness of electronic communication and asynchronous learning. Morse differentiated students as originating from countries with a “low context” learning culture or a “high context” learning culture. Table 2 reproduced from Morse [19], describes the learning behaviours implicit in these categories, which closely parallel the andragogical and pedagogical approaches described earlier. This author acknowledged a clear link between ethnicity, learning behaviour and communication modes. Based on an analysis of the literature he concluded that students from the United States, United Kingdom, Australia and New Zealand were identified as tending towards low context learning behaviours, while students from Pakistan, China, Taiwan, Singapore and Sri Lanka as being from high context learning cultures. Despite the cultural differences in learning behaviour, Morse’s study found that asynchronous learning networks utilising electronic communication tools provide advantages to both groups, although for different reasons. Students who exhibited low context learning behaviours valued the flexibility and convenience of unscheduled study and the ability to reflect on other students’ contributions. High context students valued the chance to think about an appropriate response. The differences in the aspects of the course that were valued by the two groups reinforce the need for consideration of this issue at the design phase of any course offered on a potentially multicultural basis [19]. It is widely recognised that there is a variety in individual learning patterns and preferences [7]. Two main factors have been used to describe these variations- presentation and process [7,20]. Presentation refers to individual preferences in the way information is pre-

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Table 3. Student learning styles and presentation preferences.

Table 4. Student learning styles and process preferences.

sented, which process refers to the preferred mechanism of learning. These factors and the associated learning styles are described in detail in Tables 3 and 4. The introduction of today’s technology into the academic’s inventory of teaching tools means that this variety of learning styles and preferences can be catered for more than ever before. From the perspective of flexibility, and thus University management, this is a beneficial, given the potential to export higher education to a greater population of students. For


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Table 5. Strengths of commonly used teaching instruments.

the academic, however, the expectation for learning resources provided for a range of learning styles, perhaps in multiple formats, can result in an increased workload.

3. Academic work in the new generation university Today's teaching academic must be versatile. Factors such as the number of students enrolled in a course, the average age of the student, academic ability, basic education, student nationality, English-speaking ability and work status can no longer be assumed as has been possible in the past. Given the potential mixture of these variables in a fee-paying flexibly delivered subject, an academic must utilize a wide variety of teaching methods and tools in an attempt to provide a productive learning experience for all. With the myriad of instructional tools available today, it is essential for the teaching academic to understand the strengths and weaknesses of each one to enable them to choose the most appropriate tool to suit the learning objectives of the subject they teach. Table 5 provides a brief outline for some of the more common teaching instruments. Tables 6, 7 and 8 provide a summary of the available instruments used to present the components of university subjects with respect to the applicability to the modern student demographic. These also identify the associated need for support staff. The actual requirements and the relative benefits of different theoretical learning environments are an issue in itself and are beyond the scope of this chapter. What is clear, however, is that utilizing a range of different instruments to appeal to such a diverse student demographic generates substantially more workload than the traditional lecture format. Some means of recognizing the workload associated with the different teaching instruments would clearly be of benefit, both to academics and to management.

4. Implications for academic workload The new approaches to teaching and learning described earlier will require a shift in paradigm for most universities and academics. The use of technology in teaching requires a substantially different set of skills and resources that that required in the traditional lecture based format [12,17]. To meet the needs resulting from the increasing pervasiveness of

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Table 6. Relationships between resource instruments, applicability to learning styles and implications for support staff.

technology in the university environment, the roles of both general and academic staff are transforming [2,21] and universities are being forced to re-evaluate the provision of staff and student support infrastructure [12]. A number of approaches to the introduction of technology in teaching can be taken.

4. Implications for academic workload The new approaches to teaching and learning described earlier will require a shift in paradigm for most universities and academics. The use of technology in teaching requires a substantially different set of skills and resources that that required in the traditional lecture based format [12,17]. To meet the needs resulting from the increasing pervasiveness of technology in the university environment, the roles of both general and academic staff are transforming [2,21] and universities are being forced to re-evaluate the provision of staff and student support infrastructure [12]. A number of approaches to the introduction of technology in teaching can be taken.


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Table 7. Relationships between two course components, teaching tools (materials), applicability to learning styles and implications for support staff.

Teaching and learning tasks can be integrated with technology. This requires substantial support from the institution for professional development of academic staff members, who must learn how to design learning materials in electronic format. A new multimedia unit

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Table 8. Relationships between two course components, teaching tools, learning styles and need for support staff. Tools available Course components Communication/ student Small group tutorials contact

Assessment

Learning styles/ profiles/ outcomes On-campus students Aural learners Adult learners Activists On-campus students One on one mentoring Low context learners Aural learners Aural learners Telephone Off-campus students Read/write learners Email On & off campus students Bulletin boards/mailing lists Read/write learners Adult learners Low context learners High context learners IRC/web based discussion/ Adult learners Low context learners tutorials Activists theorists Read/write learners Teleconferencing Aural learners Activists Low context learners Videoconferencing Visual learners Aural learners Low context learners Lectures High context learners Aural learners Read/write learners Visual learners Multi-choice exams High context learners Read/write Short answer exams High context learners Read/write Essay question exams Reflectors Theorists Assignments Reflectors Read/write Low context learners Adult learners Practical reports Pragmatists Kinaesthetic learners Online quizzes Read/write High context learners

Support staff no

no no low

medium

medium

medium

high

no

no no no No (medium submitted online)

if

medium high

can be formed to develop learning materials from designs provided by the academic. A single unit would service all faculties across the university. This would require commitment from the institution to employ skilled staff and equip them with appropriate technology and resources. This was done at the Massachusetts Institute of Technology (MIT) to provide their open source course ware via the web [22]. Separate design teams within individual faculties are formed to create multimedia materials for courses offered by that faculty. This exposes many academics to the unusual experience of having to work in a team. Mason [23] notes that what was once a very private


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Table 9. Academic effort to produce one hour of student learning. Medium Lecture Small group teaching (tutorial) Videotaped lectures Teaching text (Book) Broadcast television Computer- aided learning Interactive video Adapted from Boettcher [26]

Academic effort (hours) 2-10 1-10 3-10 50-100 100 200 300

Support staff required? no no no yes yes yes yes

performance for a group of students, becomes a team effort often involving critical comments on drafts of the print or web materials. Such efforts also require adequate funds to employ staff and purchase resources suitable for the individual needs of each faculty member [2]. Messing [24] believes that one of the areas requiring further research is the change that the use of technology makes to the work of the academic. Anecdotal evidence suggests that most university teachers use alternate technologies in their work even though that at least 66% felt that this created more work [25]. This corresponds with other studies conducted locally and overseas that suggest that the workload associated with the use of online tools is considerably higher than with conventional delivery [2,6,12,24]. This anecdotal evidence is supported by the few studies that have investigated the relative workload of traditional and online, flexible learning methods of delivery. Boettcher [26] suggests that it takes an academic an average of 18 hours to prepare an hour of online instruction. This estimate is supported by data collected comparing the hours of academic effort to produce an hour of student learning in different formats [27,28]. Sparkes’ estimates are provided in Table 9 [28]. A certain amount of this increased workload may be attributable to the lack of familiarity and training in the use of alternate technologies and andragogical teaching methods [15]. Given that only a quarter of Australian academics surveyed had engaged in some kind of teaching training at the beginning of their careers as recently as 1999 [25], it is not farfetched to suggest that a lack of training in modern teaching methods and tools causes academics to come to grief when using the new technologies. Many academics will need professional development in designing course material utilising adult learning techniques, how to judge student understanding and mastery of concepts, and to facilitate the selective use of materials rather than constraining students to a comprehensive, linear progression through each of the resource materials provided [5,12,15]. It has also been suggested that teachers, even those with excellent face-to-face skills, sometimes under-estimate the specialist skills involved in taking theoretical printed material and transforming it into an engaging, entertaining and educative interactive learning experience [6,15]. It must be recognised that until academics become comfortable and familiar with the use of technology in their teaching work, in knowing what is appropriate technology to use and when it is appropriate to use it, their workload will be significantly increased. This must be taken into account by management when workload is assessed and assigned.

5. Communicating with Students The teaching of international students is challenging and of greater importance now than ever before. Course material needs to be responsive to cultural differences, although this is

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difficult to achieve. Making a course of study responsive to the needs of international students requires a considerable commitment of time on the part of teaching staff to interact with students and provide culturally appropriate resources. Teachers need to be able to communicate with students in different ways, catering to student diversity and recognising that students will have differing expectations. Local teaching staff in remote campuses play an important role in providing their desired face-to-face contact [10]. This can impact upon the workload of the academic in the role of course coordinator, who becomes a manager as well as a member of the teaching staff. It is well understood that students need communication with their peers and academic mentors in order to learn [29]. The type of communication between teacher and student in the online format differs substantially from the traditional classroom relationship. In a classroom, there are multiple opportunities for interactivity and communication, through watching, listening and sensing, not just between student and teacher, but also between students [6]. In the online classroom, the majority of contact between lecturer and student is one-to-one, which enables the teacher a greater opportunity to learn more about the student's needs and abilities but such close contact greatly increases the teacher’s workload especially when on line classes are very large. Alternative options are available allowing interaction with the class as a group. The use of mailing lists, or shared web based discussion or workspace can be used effectively to achieve this. We know that students learn more from one another as well as through interaction with academic staff. As the use of email becomes more commonplace, students are developing higher expectations about the frequency of contact. If an immediate response to a query is not received, as many as three or four messages about the same issue can be received by the lecturer, student administration and the course coordinator in the space of a day or two. Some students expect their lecturer to be available for consultation on a twenty-four hour a day, seven days a week basis. Academics do have access to their email at home, students may reside in multiple time zones, such that many academics do respond after hours [30]. Email has become a significant source of work for the teaching academic [[6,19,24]. Fee-paying students are becoming more demanding about the learning they are receiving. However these demands are often based on what the student wants rather than what the student needs, and the student is not necessarily in the best position to judge the long-term benefits of the rigour a particular discipline demands. It is our experience that students have a tendency to judge the worth of a subject on what they perceive as "value for money" in terms of passing grades, leading to differing expectations of the purpose of a university education between academics and their students [31]

6. Conclusion It is clear from the literature and our own experiences that the breadth and variety in the work and workload of the teaching academic of today is substantially different from that of academics in previous generations. While teaching academics are often highly motivated, satisfied with their jobs, and have a highly developed sense of professionalism [2,6], the need to acquire new skills and the workload associated with the provision of flexible learning is frequently unrecognized by management. As a result many do not have the required infrastructure and staff support. Academics working in the field of distance education have expressed deep concerns about under-resourcing [2] and overwork [2, 6, 25, 32]. Many academics believe it is unsustainable in the long term [6]. With the emphasis placed by many universities on student learning in their mission statements, the focus for evaluation in the new generation university should be the quality of a student’s learning experience. The variety of teaching and learning options provided by


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technology allows education to be provided in an appropriate manner to a broader student demographic than ever before. The chapters that follow explore in greater depth some of the issues associated with the need to change educational delivery methods to accommodate current student demographics, the trend to lifelong learning and to make better use of available technologies identified in this chapter.

References [1]

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Yetton, P 1997, Managing the introduction of technology in the delivery and administration of higher education, Evaluations and Investigations Program; Higher Education Division; Department of Employment, Education, Training and Youth Affairs, Canberra. Ling, P, Arger, G, Smallwood, H, Toomey, R, Kirkpatrick, D & Barnard, I 2001, The Effectiveness of Models of Flexible Provision of Higher Education, Evaluations and Investigations Programme, Higher Education Division, Department of Education, Training and Youth Affairs. Gibbons, HS & Wentworth, GP 2001, 'Andragogical and Pedagogical Training Differences for Online Instructors', paper presented to Distance Learning Administration 2001, 6-8 June 2001. Kaufman, DM 1998, 'Problem-based learning: using cases to teach about how to deal with ethical problems', Communique, vol. 8, no. 2. Sabatini, JP 2001, Designing multimedia learning systems for adult learners: basic skills with a workforce emphasis, NCAL-WP00-01, National Center on Adult Literacy, Philadelphia. Schofield, K, Walsh, A & Melville, B 2001, Online learning and the new VET practitioner: implications for the organisation of their work, UTS Research Centre for Vocational Education and Training, Sydney. Nichols, M 2002, 'Principles of best practice for 21st century education', paper presented to International Forum of Educational Technology & Society, New Zealand, 15-26 April 2002 Meyer, KA 1998, Faculty workload studies: perspectives, needs and future directions, ASHE-ERIC Higher Education Report Volume 26 No.1, The George Washington University, Graduate School of Education and Human Development, Washington D.C. Walsh, L 1999, 'Encounters with difference: in search of new learning spaces through internationalisation', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane. Ziguras, C 1999, 'Cultural diversity and transnational flexibility delivery', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane. Allison, RD 1998, Faculty obligations and compensation; the necessity of a new approach, US Department of Education. American Council on Education 2003, 'Developing a distance education policy for 21st century learning', Distance Education, vol. March 2000. Care, WD & Scanlan, JM 2000, 'Meeting the challenge of developing courses for distance delivery: two different models for course development', The Journal of Continuing Education in Nursing [H.W. Wilson - EDUC], vol. 31, no. 3, pp. 121-8. Kerka, S 1996, Distance Learning, the Internet, and the World Wide Web, ERIC Digest No.168, viewed 26 February 2003, http://ericacve.org/textonly/docgen.asp?tbl=digests&ID=21 Salter, G & Hansen, S 1999, 'Modelling new skills for online teaching', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane. Sims, R 1999, 'The interactive conundrum I: interactive constructs and learning theory', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane, 1999. Smith, E 1999, 'Learning to learn online', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane. Whymark, G 2003, personal communication, Rockhampton, 28/02/2003. Morse, K 2003, 'Does one size fit all? Exploring asynchronous learning in a multicultural environment', Journal of Asynchronous Learning Networks, vol. 7, no. 1, pp. 37-55. Bates, AW 1995, Technology, Open Learning and Distance Education, Routledge Studies in Distance Education, Routledge, New York. Coaldrake, P 2000, 'Rethinking university work.' in R James, J Milton & R Gabb (eds), Cornerstones of Higher Education: selected papers from the 1999 HERDSA Annual International Conference, Melbourne 12-15 July 1999, Higher Education Research and Development Society of Australasia., Canberra, pp. 12-22.

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[22] Massachusetts Institute of Technology (MIT) Open Course Ware, http://ocw.mit.edu/index.html accessed 24 June 2004. [23] Mason R 2003 The university – current challenges and opportunities in: The Virtual University, D’Antoni S Editor, International Institute for Educational Planning, UNESCO http://www.unesco.org/iiep/virtualuniversity/files/chap2.pdf accessed 24 June 2004 [24] Messing, J 2002, 'Can academics afford to use email?' Journal of Instructional Science and Technology, vol. 5, no. 2 [25] McInnes, C 1999, The Work Roles of Academics in Australian Universities, Australian Commonwealth Department of Education, Training & Youth Affairs. [26] Boettcher, JV 1997, How much does it cost to develop a distance learning course? It all depends ... Boettcher, Judith V., viewed 7 May 2003, http://www.cren.net?~jboettch/dlmay.htm [27] Rumble, G 2001, 'The costs and costing of networked learning', Journal of Asynchronous Learning Networks, vol. 5, no. 2, pp. 75-96. [28] Sparkes, JJ 1984, 'Pedagogic differences in course design', in AW Bates (ed.), The role of technology in distance education, Croon Helm, London. [29] Wigforss, E 1999, 'The role of communication in learning technologies', paper presented to 16th annual conference of the Australasian Society for Computers in Learning in Tertiary Education, Brisbane. [30] Huque, M 2003, personal communication, Rockhampton, 01/03/2003 [31] Sputore, T & Christie, D 2002, Higher Education at the Crossroads - A Review of Australian Higher Education Response from Australian and New Zealand Student Services Association Incorporation (ANZSSA, Inc.), Australian and New Zealand Student Services Association Incorporation, viewed 27 February 2003, http://www.dest.gov.au/crossroads/submissions/pdf/191.pdf [32] CQU 2002, Higher Education at the Crossroads: A review of Australian Higher Education. A response from Central Queensland University, viewed 20 February 2003, http://www.cqu.edu.au/cqutour/crossrds.pdf


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3.2. Cognitive Theories and the Design of E-Learning Environments Bijan GILLANI Professor of Educational Technology California State University, Hayward, U.S. Christina O'GUINN NASA Ames Educational Technology Team, Lead NASA Ames Research Center, U.S. Abstract. Cognitive development refers to a mental process by which knowledge is acquired, stored, and retrieved to solve problems. Therefore, cognitive developmental theories attempt to explain cognitive activities that contribute to students’ intellectual development and their capacity to learn and solve problems. Cognitive developmental research has had a great impact on the constructivism movement in education and educational technology. In order to appreciate how cognitive developmental theories have contributed to the design, process and development of constructive e-learning environments, we shall first present Piaget’s cognitive theory and derive an inquiry training model from it that will support a constructivism approach to teaching and learning. Second, we will discuss an example developed by NASA that used the Web as an appropriate instructional delivery medium to apply Piaget’s cognitive theory to create e-learning environments.

Introduction The explosive growth of the Internet and the dramatic advances in the design and development of online technological tools in recent years have revolutionized the way students and teachers view technology in education. These technical advances have made it possible to produce educational materials and transmit them over the Web. In parallel to these technological advances, the field of instructional design has made phenomenal contributions to curriculum planning. A synergy of these two fields would enable educators to produce effective electronic educational materials. Unfortunately, a great majority of e-learning sites that use online tools lack appropriate theoretical foundations for curriculum content organization. These sites, all designed by highly intelligent and well-intentioned educators, use online technologies without any regard for application of pedagogy to the design of courses. The result is an iceberg-like curriculum where, at best, online technologies have been used to cover the tip of teaching and learning, leaving little time and effort for the students to delve into deeper understanding of curriculum and problem solving. There is a fundamental need for pedagogical approaches to design e-learning environments whose foundations are supported by effective theoretical foundations. One of the most effective approaches to developing appropriate pedagogical models for the design of e-learning is to understand how cognitive development occurs naturally. Cog-

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B. Gillani and C. O’Guinn / Cognitive Theories and the Design of E-Learning Environments

nitive developmental theories attempt to explain cognitive activities that contribute to the learners’ intellectual development and their capacity to solve problems. Once we understand how cognition develops, we can derive a pedagogical model from it and then design effective e-learning environments that are responsive to how people learn naturally. In what follows, we will discuss Piaget’s cognitive theory and derive an inquiry training model from it. Then we will discuss the design of an e-learning environment that is based on Piaget’s model and is adaptive to the cognitive needs of students.

1. Piaget's Cognitive Developmental Theory Piaget [1] argued that children must continually reconstruct their own knowledge through a process of active reflection on objects and events till they eventually achieve an adult perspective. To have a better appreciation of this process, it is essential to understand four other concepts that Piaget proposed. These concepts are schema, assimilation, accommodation, and equilibrium. 1.2. Schema Piaget [1] used the word schema to represent a mental structure that adapts to environmental patterns. In other words, schemata are intellectual structures, in terms of “neuron assemblies,” that organize perceived events and group them according to common patterns. A number of researchers, Anderson & Pearson [2], and Piaget [1], have posited that schemata are the building blocks of intellectual development. During cognitive development, children’s schemata are constantly restructured as they encounter new patterns in their learning experiences. Pearson and Sapiro in the May 1982 issue of Instructor have provided one of the earliest and probably the best explanations of schema theory for instructional purposes: What is a schema? It’s the little picture or associations you conjure up in your mind when you hear or read a word or a sentence. You can have a schema for objects (chair, boat, and fan), an abstract idea of feeling (love, hate, hope), an action (dancing and buying), or an event (election, garage sale, and concert). It’s like a concept but broader. For example, you see the word tree and you conjure up the concept of a tree-trunk, branches, leaves, and so on. Your schema for a tree includes all this, plus anything else you associate with trees -- walks down country lanes, Christmas trees, birds’ nests, and so on. A schema includes behavioral sequences, too. For example, your schema for the word party could include not only food, friends, and music, but also what you will wear, how you will get there, how long you plan to stay, and so on. And, of course, your schema for party is based on your experience at party, which may differ substantially from some one else’s. Schema is an abstraction of experience that you are constantly finetuning and restructuring according to new information you receive. In other words, the more parties you attend the more schema adjustment you’ll make. (p. 46) Schema is not limited to concepts, objects, data, and their relationships. There are also procedural schemata Anderson & Pearson, [2], which are the ways of processing information. For example, students who have acquired the basics of mathematics such as adding, multiplying, dividing, and subtracting have internalized the concepts schemata about these mathematical operations. However, as the students grow, they gain new abilities to solve


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problems that are related to mathematical concepts. The ability to solve problems is a procedural schemata. Both concept and procedural schemata are constantly restructured as new learning environments are introduced to the learner. 1.3. Assimilation, Accommodation, and Equilibrium One of the most fundamental questions about schemata is how are they restructured when new data or patterns are discovered in the environment. Piaget was a biologist by academic training. He was very comfortable with the concept of biological adaptation to environmental stimuli. For example, from a biological point of view the human body is structured to be constantly in a state of equilibrium in regard to its temperature. When the body temperature is raised by a few degrees during exercise, the entire system goes into a state of disequilibrium. The feedback mechanism senses such a state of disequilibrium and internally responds by producing sweat and sending more blood near the skin to cool the body down; thus, restoring a state of equilibrium for the body. Piaget used the same concept of biological equilibrium-disequilibrium states to explain the causes of cognitive restructuring in response to new learning experiences. For example, when students encounter a new learning environment, a state of disequilibrium is created within their brains that must be internally managed. In other words, the new learning environment has placed the brain in a state of disequilibrium. In order for the brain to get back to the state of equilibrium, the learner has to add, modify, or restructure his or her schemata to account for the new situation. The internal mental mechanism or processes that are responsible for the restructuring of schemata so that the brain can get back to an equilibrium state is called assimilation and accommodation Piaget, [1], [3]. Assimilation is the cognitive process by means of which people integrate new patterns, data, or processes into their existing schemata. Piaget argued that, as learners assimilate input from the environment, the new information is not simply stored in the mind like information in files in a filing cabinet. Rather new information is integrated and interrelated with the knowledge structure that already exists in the mind of the person. “Every schema is coordinated with other schemata and itself constitutes a totality with differentiation parts.” Piaget [1]. P.7 For example, in teaching geometry, when a pentagon is introduced to children, the salient features of this geometric shape such as sides and angles are not simply memorized. Rather, it is contrasted and integrated with what is already known about other geometric shapes like rectangles, triangles and squares. In other words, the schemata for a pentagon includes, in addition to its shape, sides, and angles, such related concepts as how its shape compares with other geometric shapes, how its angles compare with other geometric shapes, or how its area and perimeter differ from other geometric shapes. Learning in this manner of relating prior knowledge to new information is said to be meaningful because new schemata in the child’s mental capacity have been formed. Theoretically, assimilation does not result in changes or restructuring of the schemata. Rather assimilation is the process of placing new information into existing schemata. Assimilation can be compared to the air that you put into a balloon. As you put more air in the balloon, it gets bigger, but the shape of the balloon does not change. The actual change or restructuring of the schemata occurs in the accommodation process. The change that occurs in the mental structure of the schemata is referred to as accommodation by Piaget [1]. Upon facing new learning environments, sometimes the learner’s schemata can not assimilate the new information because the patterns of the new stimuli do not approximate the structure of the existing schemata. In such cases one of two things can happen: Either the learner can create new schemata, or he can modify the existing schemata. In either case the structure of schemata is being changed so that it can accommodate

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for the new information. Therefore, accommodation is the creation of new schemata or modification of old schemata. In both of these cases the result is a change in the cognitive structure or the overall structure of schemata. The process of cognitive development is the result of a series of related assimilations and accommodations. Conceptually, cognitive development and growth proceeds in this fashion at all levels of development from birth to adulthood Piaget, [3]. However, because of biological maturation, major and distinctive cognitive development occurs over a lifetime. Piaget [3] posited four major stages of cognitive development that occur over a lifetime. These stages are sequential and successive. According to Piaget, these stages are: • • • •

Sensorimotor (Birth to 2 years old) Pre-operational (2 to 7 years old) Concrete operation (7 years to adolescence) Formal operation (Adolescence to adult)

Sensorimotor refers to the stage that begins with the reflex actions of infants and proceeds through the development of eye-hand coordination to the beginning of symbolic thought. At this point of development, children see themselves at the center of all actions in the world (egocentric). The pre-operational stage is characterized by the development of symbolic thinking. Objects and events in the child’s environment become represented by symbols. Language development is one of the major cognitive developments during this stage. The concrete operational stage is marked by a significant increase in a child’s ability to analyze and to classify patterns according to the attributes of objects or events. Piaget’s extensive research shows that children in this stage learn to reverse procedure and to generalize the outcome of certain experiments. Reversal and generalization are the two essential cognitive abilities that enable children to learn the classification of objects, events and other concepts. The difficulty that children have at this stage relates to their inability to deal with abstraction. Children, however, gradually learn to deal with abstraction, which leads their development to the next stage. The formal operational stage of development generally begins in early adolescence and continues through adulthood. Formal reasoning is characterized by the ability to carry out mental activity using imagined and conditional actions and symbols that are divorced from their physical representation. Individuals at this stage are able to control variables systematically, test hypotheses, and generalize results to future occurrences. This stage, which continues to develop well into adulthood, is characterized by the ability to reason and solve problems. The formal operational stage is the most important stage in terms of application of Piaget’s theory of cognitive development to the design of e-learning. Therefore, I will elaborate more on this stage here. An influential scholar who has continued Piaget’s work in the area of formal operational is Flavell [4]. He has provided a detailed discussion of three operations that young adults gradually acquire during the formal operation of their development. These operations are combinational reasoning, propositional reasoning and hypothetical-deductive reasoning Combinational reasoning refers to the ability of the adolescent to consider several different factors at the same time to solve a problem. This reasoning power provides the learners with the ability to look at problems from an integrated approach. During the earlier stages, children are not capable of integrating several viewpoints to solve problems. They can only deal with problems from one angle at a time. However, as adolescents mature into adulthood, they develop combinational reasoning which allows them to integrate several viewpoints to problem solving. Propositional reasoning refers to the characteristic that young adolescents acquire to reason on the basis of assumption and proposition to solve problems. For example, if a


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child during the concrete operation were asked to assume that coal is white, he would respond that coal is black and can not be white. However, during the formal operation stage the young adults acquire the capability of assumption and proposition to solve problems that he would not have been able to solve during the concrete stage. This ability also extends to abstract thinking that is acquired during the formal stage. Hypothetical-deductive reasoning allows the young adolescent to consider different hypotheses in dealing with a problem. Consideration of different hypotheses also enables the young adolescent to gather data and test different hypotheses to come up with a possible solution. To illustrate how adolescents follow hypothetical-deductive reasoning in everyday life, let’s consider a simple example. Let’s say that there is a young 15 year old girl who is going on her first date. In order to get ready for her date, the young lady goes into her room and gathers several different colored blouses and matching pants. She puts on a blouse and tries it with different colored pants while looking at her choice in the mirror. She may reject this combination and so she tries another blouse with different pants. After several tries she decides to wear the blue blouse with the black pants. This process of selection of what to wear is natural to most young ladies. The instructional implication of such a procedure is significant. What the young lady has learned to do because of her recent development of hypothetical-deductive reasoning is the ability to hypothesize and test a situation. In order to solve the outfit problem, she first hypothesizes something about her taste in what looks good, and then she gathers information (her clothes). She then tests her hypotheses that some colors may go with others. She tests every one of her choices in color. She either accepts or rejects her choices. She makes a final decision, based on her original hypothesis and her testing, as to what looks good for her date. The final selection is the result of careful analysis, testing, and acceptance. The above scenario may be a simplistic explanation of hypothetical-deductive reasoning. However, it is exactly what adolescents and scientists do in the process of solving problems. Both the adolescent and scientist follow an inquiry process when they are faced with a new situation. That is to say, when they are faced with a problem, they use their hypothetical-deductive reasoning to solve it. This process of hypothetical-deductive reasoning can provide a foundation for a pedagogical approach to education and the design of elearning environments.

2. Cognitive Theories as the Bases of Pedagogy Cognitive and developmental psychologists, Piaget in particular, viewed learning as a dynamic process where learners construct their own knowledge by interacting with the world. The role of teachers, they believe, is not to impose steps, procedures, and rigid structure, but rather to be the architect for learning environments that facilitate a process in which students would be able to construct their own knowledge. This radical approach gave rise to a new group of educators and technologists who became collectively known as constructivists. Piaget’s influence upon the constructivist’s movement in the US had a great impact on instructional design, teaching models, and educational technology. The main impact of constructivism can be seen mostly in inquiry-training. Based on Piaget’s theory of cognitive development, Suchmann [5] proposed a constructivist approach for instruction in school which he called an inquiry-training model. The general goal of inquiry-training is to help students develop a sense of the independent inquiry method but in a disciplined way. The process of the inquiry-training model is similar to Flavell’s Hypothetical-deductive reasoning description that allows the young adult to consider hypotheses, to gather data, and test different hypotheses to come up with a possi-

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ble solution in dealing with a problem. The inquiry-training model of teaching has the following five phases of instruction: • • • • •

Phase One: Puzzlement or intellectual confrontation by presenting students with the problem to create a state of disequilibrium in their mind. Phase Two: Students will hypothesize a reason for the puzzlement. Phase Three: Students will gather new information in regard to the hypothesis. Then they isolate relevant information, eliminate irrelevant information, and organize the information. Phase Four: Students analyze the data they have gathered, organized, and then test their hypothesis to postulate a possible answer to the original puzzlement. Phase Five: Students are evaluated to ensure their understanding of the concept(s) in the intellectual puzzlement.

Instruction in inquiry-training begins by the teacher modeling a situation that is puzzling to the students. Such an approach, which can be called an intellectual confrontation, places students’ minds in a state of disequilibrium. After the modeling of the puzzling situation, students make a hypothesis about the intellectual confrontation. During the next phase, students are provided appropriate sources in the environment. Then, students are asked to organize their data in order to provide support for their hypothesis. Next students are guided to carry out experimentation and to eliminate irrelevant information. The final phase of inquiry-training involves an analysis of organized data by the students and the development of a conclusion that provides a possible answer to the original hypothesis that may explain the original puzzlement. Research has provided some answers for the effects of inquiry-training. Research conducted by Voss [6] concluded that the inquiry-training strategy is effective both for elementary and secondary students. The inquiry-training results in increased understanding of science, productivity in creative thinking, and skills for obtaining and analyzing information.

3. Inquiry-Training and E-learning During the 1980’s and 1990’s, influential educational technology theorists such as Papert [7] became interested in constructivism and inquiry-training model. This new breed of instructional designer believed that construction of knowledge through inquiry rather than direct instruction should be the focal issue of teaching and learning. They viewed learning as a process in which children interact with the world to construct, test, and refine their own cognitive representation of the world. Technology is viewed as a tool that allows the development of environments or educational programs in which children through interacting with its elements construct their own knowledge. With the explosion of the Web as a medium of delivery for instruction, the popularity of the contructivism movement and the inquiry-training models of teaching also took a rise in popularity. Proponents of the inquiry-training model often expressed their dislike for the traditional computer-based approach of tutorial and practice and drill. With the rise of the Web and hypermedia, the philosophy of inquiry-training was applied to technology under a variety of different terms such as project-based training, guided inquiry, inquiry-based, problem-based learning, and resource-based education. All of these different approaches to the inquiry-training process share attributes that were first proposed by Suchmann [5]. The vast majority of these methods emphasize the same attributes that can be summarized into how to hypothesize, find, gather, evaluate, and organize information to find a possible answer to an intellectual confrontation. In one form


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Figure 1. Astro-Venture http://astroventure.arc.nasa.gov.

or the other, these steps have been used to design and develop hypermedia-based instructional materials. NASA has developed several successful and effective e-learning sites using the inquirytraining model. One such program is Astro-Venture for students in grades 5-8 where they role-play NASA occupations as they search for and design a planet that would be habitable to humans. This site was developed under the direction of Christina O'Guinn of the NASA Ames Educational Technology Team. Astro-Venture uses online multimedia activities and off-line inquiry explorations to engage students in guided inquiry aligned with Suchman's inquiry-training model. Figure 1 shows the main page of the Astro-Venture Web site. In Astro-Venture , students are first presented with the intellectual confrontation of how to design a planet and star system that would be able to meet their biological survival needs. Students hypothesize about the aspects of Earth and our star system that allow human habitation. As newly accepted members of the Astro-Venture Academy, they are informed that they will be working closely with NASA scientists who will help them in their research to better understand how the Earth meets human biological needs and, thus, the essential elements in designing a habitable planet. Students conduct this research by engaging in multimedia training modules that allow them to change astronomical, atmospheric, geological and biological aspects of the Earth and our star system and to view the effects of these changes on Earth. By focusing on Earth, students draw on their prior knowledge that helps them to connect their new knowledge to their existing schema. Cause and effect relationships of Earth provide a concrete model from which students can observe patterns and generalize abstract results to an imagined planet. From these observations, students draw conclusions about what aspects allowed Earth to remain habitable, and they observe large themes such as the many conditions that play a role in allowing Earth to have liquid water. Once students have generalized needed conditions of "what" we need for a habitable planet, they conduct further research in off-line classroom activities that also follow the inquiry model and help students to understand "why" we need these conditions. These offline activities engage students in explorations that guide them in discovery learning of concepts. For example, after gaining an understanding of the differences between solids, liquids and gases, students hypothesize a cause for changes of matter from one state to another

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and design experiments to test their hypothesis. From this experimentation they "discover" that temperature is a vital condition for changing states of matter, and they conclude that a moderate temperature is necessary for allowing water to remain a liquid on Earth's surface at all times. Students also explore concepts such as systems as they begin to combine different variables symbolically, and observe that many of the required conditions work together and cannot be isolated from others. After students have mastered the "whats" and "whys," they engage in multimedia mission modules that simulate "how" scientists might search for a planet and star system that meet these requirements using the inquiry process. Students then simulate the methods scientists might use to collect data on various stars and planets to deduce whether the star system meets the requirements for habitability or not. After collecting and analyzing these data, students are asked to draw conclusions in comparing their results to their initial hypothesis.

4. Conclusion In this chapter, we have presented a different approach to the design of e-learning environments. While traditional instructional design promotes a structured approach to the development of educational technology programs, the cognitive approach supports guided learning that allows the learner to construct knowledge in the process of learning. Just like any other theoretical foundation for instructional development, there are those who support a cognitive approach to technology Papert [7], and Jonassen, [8], and there are also those who claim that the cognitive approach of unstructured learning is not the best use of technology Laurillard, [9]. The cognitive approach that impacted the development of constructivist e-learning has a stronger basis in learning how to learn than the traditional structured approach. It also provides a new approach to the new attributes, such as hypertext and hypermedia that are found in modern technology. Many of the concepts that I presented in this chapter such as the inquiry-training model and the discovery-learning approach have influenced the development of successful and effective e-learning environments. Because the cognitive approach criticizes procedures, steps, and the rigid design of instructional materials, it is often much more difficult and more expensive to design and develop e-learning environments based on it. However, high cost and difficulties in design should not be the basis of what kind of effective e-learning one should develop. If your research shows that a cognitive approach is the best suited for your project, then it must be implemented.

References [1] [2]

[3] [4] [5] [6] [7]

Piaget, J. (1952). The Origin of intelligence in Children. New York: International Universities Press. Anderson, R. A., & Pearson, P. D. (1984). A schema-theoretic view of basis processes in reading comprehension. In P. D. Pearson (Ed.), Handbook of reading research (pp. 255-292). New York: Longmans. Piaget, J. (1964). Development and learning. In R. E. Ripple & V. N. Rockcastle (Eds.), Piaget rediscovered: A report of the conference on cognitive skills and curriculum development. Ithaca, NY: Cornell University, School of Education. Flavell, J. H. (1985). Cognitive development (2nd edition) Englewood Cliffs, NJ: Prentice-Hall. Suchmann (1962). The Elementary school training program in scientific inquiry. Report to the U.S. Office of Education, Project Title VII. Urbana, IL: University of Illinois. Voss, B. A. (1982). Summary of research in science education. Columbus, OH: ERIC Clearinghouse for Science, Mathematics, and Environmental Education. Papert, S. (1980). Mindstorms: Children, Computers and Powerful Ideas. New York: Basic Books.


[8] [9]

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Jonassen, D. (1991, September). Evaluating constructive learning. Educational Technology, Vol. 32, 2833. Laurillard, D. (1993). Rethinking university teaching: a framework for effective use of educational technology. Routledge.

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3.3. Self Directed and Lifelong Learning Sylvia ALEXANDER, George KERNOHAN & Paul McCULLAGH University of Ulster Shore Road, Jordanstown, Co. Antrim, N. Ireland. BT37 0QB Abstract. Given the many changes that occur in medicine, health care and information technologies we need to prepare all our students to engage in self directed and life long learning. There is considerable opportunity for self-directed and lifelong learning in health informatics bringing together students in exciting global learning environments, where they have much greater freedom and flexibility in their studies and potentially a wider variety of resources available to them. Self-directed learning focuses on the process by which adults take control of their own learning, in particular how they set their own learning goals, locate appropriate resources, decide on which learning methods to use and evaluate their progress. Lifelong learning happens in a variety of formal and informal settings building on both intentional and incidental learning experiences. In a lifelong learning situation the tutor must relinquish the role of expert and assume the role of facilitator, guiding learners to uncover their own knowledge. Against a back drop of rapid advances in technology which can be used to both deliver course materials and provide enhanced learning opportunities, this chapter outlines the pedagogic principles and practices which underpin self-directed and lifelong learning.

1. Background It is evident that a more knowledgeable Health Informatics professional will lead to a more knowledgeable healthcare profession which ultimately will lead to better quality of health care. A number of specialist courses exist at undergraduate and postgraduate level, but health informatics lacks the established career structures of the more established ‘feeder’ professions of medicine, health related disciplines, engineering and computer science. Students are more likely to study health informatics as a second subject, probably in part-time mode. Altman [1] cites continuing education as an area of strategic performance and one of the ten challenges facing medical informatics, if it is to develop and deliver optimal services across the spectrum of health and social care. The desire of the student and delivery of learning material at an appropriate time are key to the success of this mode of learning. As the student will typically be working in a busy and changing environment, Altman concludes that education could be best delivered by building “learning and evaluation technologies directly into the technologies that support the electronic medical record, automated diagnosis, decision support, and patient education” so making optimal use of existing infrastructure. Figure 1 illustrates a model of self directed and lifelong learning. Flexibility of learning is of key importance, enabling students to customize their own programmes, assisted by a single institution or by collaborating institutions. Programmes can include:

S. Alexander et al. / Self Directed and Lifelong Learning

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Figure 1. Self Directed and Lifelong Learning Model showing linkage between Learners, Education Providers and Certification Authority; interacting with each other through units of study or “modules”.

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Short courses, which provide an introduction to the general area of health informatics or to a specific health informatics topic, e.g. decision support. These courses should attract continuing professional development (CPD) credit and may form part of a practitioner’s portfolio which testifies to his/her professionalism. This is illustrated by a single module, designated (a) in Fig 1. Certificate or Degree programmes, which provide detailed health informatics education for those from computer science, medicine or health related background. These programmes should be provided by and accredited by an academic institution or possibly collaborating institutions [2]. They can be delivered by traditional classroom teaching or by a virtual learning environment or a combination of both. It is possible that credit can be awarded for an existing verified short course and that the student can thus seek exemption from elements of the programme. This mode is designated by (b) and (c) in Fig 1. Diploma or Masters programmes, which provide detailed education and training focused toward professional or academic advancement in health informatics, designated (d) in Fig 1. Eligibility would normally require an undergraduate programme in a relevant subject area, followed by a period of appropriate experience in a working environment and would comprise lifelong learning. Research programmes at the doctorate level (PhD) would be available to the academic ‘leaders’ and specialists in health informatics. Traditionally these programmes have required a dedicated period of research at a single institution, typically lasting 3-5 years in full-time mode and up to 7 years in part-time mode. However there is some flexibility in this learning mode with DInf (Doctor of Informatics) programmes offering a combination of advanced taught courses and re-

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search. Additionally the European Union is encouraging mobility of researchers with programmes such as Marie Curie Early Stage Training [3]. The need for a flexible approach to the delivery of HMI has been identified by Recommendations on Education in Health Informatics [4] proposed by The International Medical Informatics Association (IMIA). Section 7.2 states “Besides ‘traditional’ lectures and exercises within universities, and given the explosive growth of the Internet and World Wide Web, different models of flexible, distance and supported open learning should be actively pursued.” This paradigm shift [5] requires cooperation between Institutions supplying modular curricula, supported by a mutually accepted accreditation. In Europe this could be based on the European Credit Transfer System [6]. Globalisation could eventually lead to a single virtual health informatics university, and as a stepping stone, IMIA is encouraging academic membership for institutions. This could assist with harmonization of curricula, standards and practices and address the needs of developing countries, by providing access to pedagogic material authored by leaders in the area. Bridging the Medical Informatics divide and the concept of a virtual university were key themes of KC Lun’s inaugural address when taking on IMIA’s presidency in 2001 [7]. There has already been progress in this area. Van Bemmel and Musen have produced a Handbook of Medical Informatics [8] which provides easy access to the core material required by the HMI student. The handbook is supported by a web site [9], providing ubiquitous access to all the materials (text, figures, tables etc.) and additional quizzes, demonstrations, videos and exercises. Although the breadth of the additional material is limited, it provides a model for future collaboration and delivery. Notes for an Introduction to Medical Informatics course have been provided by Staff at Columbia University [10]. These lecture notes were inspired by Shortliffe et al. [11] and contain much relevant core health informatics material. Educators and other users are free to make copies of the notes and distribute them for teaching purposes without charge providing that their use should be reported to the authors. The notes provide much useful information but are no longer maintained. Massachusetts Institute of Technology provides a free and open educational resource for faculty, students, and self-learners around the world, called OpenCourseware [12], which aims to advance knowledge and education by providing access to high quality learning materials. It does not require registration and is not part of MIT’s degree-granting or certificate-granting activity. Although not specific to health informatics, modules are available in Medical Computing and Medical Decision Support. The European Union has previously contributed to global health informatics education with initiative such as IT EDUCTRA, which provides Information Technology and medical education training [13]. Basic health informatics modules are also being developed as part of the European Computer Driving License [14], which may be required for any IT worker. In the United Kingdom (UK) the number of people working in health informatics is set to increase as a result of political acceptance of the need for ICT in the delivery of cost effective quality healthcare and an associated large increase in funding of education and training in the National Health Service (NHS). The National Programme for IT (NPfIT) has been set up to implement the next generation of record storage and communication infrastructure [15]. This has focused the need for continuing education and training and led to the establishment of a NHS university (NHSU). Learning and development of its staff are key to the Government’s vision of patient-centred care in the NHS [16]. Although this is a UK initiative the need for better trained health informatics professionals is likely to be replicated in many other countries. It is important that the value of learning should be recognized. However, the wide range of health informatics education has required benchmarking of Health Informatics activities to ensure quality and the establishment of UK Council for Health Informatics Professionals (UKCHIP) [17] to promote professionalism and provide a structure for CPD. UKCHIP has only been in existence since Spring 2004 but has attracted


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many registration enquiries from outside the UK, stressing he need for an international structure. Self directed learning also means that the student will depend on ancillary services beyond the traditional tutor (Shown as providers in Fig 1). These include: • • • •

Other practitioners who compile and maintain validated sources of Evidence Based Medicine [18]; Indexers who classify scientific papers and other sources of information [19, 20]; The librarian, who can assist the student with information gathering [21]; Peers and mentors who can share problems and work through solutions.

There are a number of problems in this model of self directed and lifelong learning: •

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Although some health informatics training material has been made available by the WWW, it usually comes without any support or accreditation. Much of the material provides useful information, but is not specifically designed for self-learning. Access to expert (and peer) support is essential to the learning process. Accredited courses will still require a continuous revenue source.. This does not address the ‘medical informatics divide’ and additional proactive measures will be required for disadvantaged regions. Collaboration between institutions is difficult, owing to a long history of competition between them for students and resources, but collaboration is a requirement in this interdisciplinary subject given the shortage of health informatics expertise and resources, particularly in developing countries. A model of successful collaboration exists at a national level [22] but this is the exception at the current time. The question of whether accreditation will be by the institution supplying the majority of modules, the ‘final’ modules or will it be via an independent institution such as IMIA? This can cause friction between education providers, if the terms of an agreement have not been well defined. In HMI, education students are not from a homogeneous background, but may be categorised using: discipline, stage of career and level of expertise. An adequate response to this range of potential learners means that more complex curricula [23] are required than for traditional subjects. Will CPD and professional structures (e.g. UKCHIP) be recognized for career advancement? Will other countries require similar structures? This will be important to encourage uptake among the learners.

These issues require attention if the model is to succeed. Immediately outside health informatics, lies the world of healthcare, which is itself undergoing rapid change, leading to further impact on health informatics education.

2. Changes in the Medical Profession 2.1. Introduction Altman has outlined ten grand challenges for medical informatics [1]: implementation of the electronic medical record with an agreed vocabulary; data capture into medical databases; indexing and representations of medical knowledge; automated diagnosis; decision support and its user interface; patient education and compliance; continuing medical education; evaluation of the effectiveness of theories and technologies; data mining for new knowledge with particular emphasis on bioinformatics, universal access to medical information which bridges economic divides. Although this chapter deals specifically with con-

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tinuing education, the collection, storage and use of medical data are issues that unite all stakeholders whether patient, tutor or student and from whatever discipline. Specific challenges may change over time with technological solutions solving one issue, but probably raising another. We can be sure that change will be a feature of the clinical environment, and that continuing education should continue to update this list of challenges. Clinicians gather, process, store and forward more electronic data than ever before. More patients require more care, with less and less resource expenditure. This section explores how the changing world of healthcare practice acts to drive developments in health informatics, where previously drivers have been largely technical and bureaucratic in nature. This leads to a renewed emphasis on health informatics training and updating throughout the whole professional career pathway. 2.2. Health Technology Developments Health technology is an enigma: it seems to have reached a ‘maturity’, where almost every patient or client encounter is digitally recorded, processed, costed and analysed. Patients notice their doctors spending more time on the PC. Widespread deployment of patient information and administration systems serve to help organise healthcare. Yet changes to health technology continue at a remarkable pace. Health technology is an internationally recognised term that covers any method used by those working in health services to promote health, prevent and treat disease and improve rehabilitation and long-term care. "Technologies" in this context are not confined to new drugs, computers or other pieces of sophisticated equipment. Developments in health technology seem to occur almost at random, all around the world, as clinical researchers investigate, develop and implement new methods to enhance health. New technological interventions; such as statins for cardiovascular disease; combined therapy for some cancers; and orthopaedic prostheses are examples in a traditional medical mould. New policy interventions; such as User-involvement, Healthy Living Centres, Health Action Zones, and Well-person clinics are examples of developments in a new empowerment or social mould. Both types (and many others along the path between) require (demand) advanced informatics support, if they are to be accepted, accessible and effective as valid health technologies. Leading researchers depend on sophisticated information systems that provide details of results from other researchers, facilitate national and international teamwork and provide a vehicle for dissemination of useful findings. Such innovations continue to improve the quality of life and extend life expectancy year-on-year. Again paradoxically, these interventions struggle in vain to compete with the new demands for solutions in areas such as mental health, AIDS, viral infection or man-made disease and injury. Informatics has many new roles in research. One untapped area is in facilitation of closer matches between health needs and research effort. Information systems for priority setting, could close the gap between research effort and globally-effective outcomes. Subsequently, informatics has a role in access to and exploitation of health literature; in performance and analysis of research; in dissemination; in implementation and in audit of practice. This development pathway, from idea conception to problem solution benefits from continuous informatics support. Health technology and health informatics go together, hand-in-hand, from cradle to grave. 2.3. Consumer Developments Informatics is capable of empowering people in ways that are yet to be fully realised for health gain. Those patients with access to information; the ability to understand it and assimilate knowledge might realise that they, themselves, have the potential to be the ‘expert’ in their condition. They also have the motivation to pursue solutions. Health information is


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already a predominant topic for Internet searches. Although this raises the potential for health inequality, it seems vital that the expert patient may be harnessed as a resource to support health gain: to both their personal benefit, and to enhance practice more widely. The introduction of an informatics-based self-directed learning-prescription would allow the potential to be explored still further in this area, thus enhancing the role of professional healthcare workers as learning facilitators in their work with service-users. The rise of consumer-affairs and rights-based public services have all but eroded the traditional ‘paternalist’ way of working, in favour of a partnership approach, where healthcare professional and client share knowledge and decision-making about specific clinical topics, albeit to a limited extent, thus far. In a healthy interaction, the client and professional form a self-directed learning dyad, one assisting the other to learn through the experience of disease. Both parties contribute towards possible solutions to health concerns. Both can make extensive use of online evidence databases using various search engines. 2.4. Evidence as King Evidence-based practice is what we all aspire to achieve throughout our professional lives. Practice that is informed by solid evidence can be depended upon to provide the required outcomes. The approach has an agreed five-stage protocol, starting with the practitioner setting a good (answerable) question; setting a search strategy; and finding, appraising and implementing evidence. As with the development of new technologies through research, a large part of this protocol is supported by computer database management systems. Thus effective evidence-based practice involves effective health informatics, primarily to manage evidence data warehouses but also to deliver advanced programmes of education and professional update. 2.5. Health Developments Health informatics, as a specialist subset of healthcare, is subject to similar influences. Gradual ageing of the populations in western societies has led to renewed emphasis on dealing with diseases associated with older people. Public health concerns emphasise the need for appropriate action to deal with and prevent diseases such as stroke, other cardiovascular disease and Alzheimer’s. Practitioners can expect increased disease associated with older people, for the specific conditions to vary widely amongst the population and across their years of practice. Clearly, there is a need for frequent, if not continual, updates to professional knowledge. Public health itself has re-emerged as a new multi-professional discipline, urging healthy actions amongst individual citizens and communities as well as amongst people defined by their illness, disease or injury. In these endeavours there is a huge need for very effective communication and validated information, delivered to increasingly mobile service users. Such a comprehensive health informatics service has the potential to continuously deliver preventive care. 2.6. Professional Needs As health informatics has moved into the 21st century, it has moved to become the keystone of modern healthcare systems. Demands on the service in turn demand effective and efficient use of information systems. Of course researchers lead the way in use of information for new knowledge acquisition. Indeed, as noted above, health informatics supports health technology from its very onset. But, in order to deliver evidence-based practice, the experiences and expertise of researchers need to be exercised by all healthcare practitioners.

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Changes in the demands for healthcare require ongoing professional development, directed according to individual clinical requirements. The need for life-long learning is compounded by the rapid decline in the currency and content of professional knowledge. Informatics based systems are vital for such life-long learning. Prior learning of informatics skills, attitudes and knowledge is required before embarking on evidence-based practice or indeed any healthcare developments. Management and administration of health and social care has been enhanced by the development of patient information systems and management information systems. These areas continue to offer significant opportunities for further development, not only because of recent and ongoing change to administrative and governance arrangements but also because of a need to manage the increasing complexity of disease prevention, cure and care. Competencies in health informatics have been classified as basic computer skills; organisational and managerial skills; in-depth understanding of the functions and operation of appropriate applications; and in-depth understanding of legal, ethical, social and economic issues [24].

3. Advances in Technology The current quest to use the Internet to support learning and teaching and exploit its benefit to the full has seen a dramatic increase in the uptake of virtual learning environments (VLEs) and e-learning. Whilst the potential benefits such as new methods of assessment, flexible access and new ways of communicating for students and lecturers are to be welcomed, it is nonetheless important to plan for the integration of emergent and future technologies which can further enhance the learning process. Recent rapid growth in the availability and uptake of new broadband technologies potentially remove access barriers to e-learning providing faster, more reliable data transmission rates and fixed price, unlimited access to the Internet for teaching and learning offcampus, whether at work or at home. The introduction of wireless LANs also present a number of interesting new teaching possibilities, as staff and students can use their own equipment wherever it is most suitable whether this be the classroom, laboratory, seminar room or the hospital ward, nursing home, clinic or home visits. Portable devices provide efficient knowledge acquisition; in addition the economic savings in terms of both space and laboratory equipment are significant. Streamed media is also widely available and can be embedded into existing on-line materials to create substantially new and different learning experiences. As increased bandwidth becomes available, streamed media offers the potential to store and forward medical educational video, on demand, providing live audiences of students who are geographically dispersed with a shared learning experience that they can analyse and discuss. Videoconferencing has been around for quite a while and has been viewed with some scepticism. However, decreasing costs, wider availability and increased functionality of the underpinning technology to fully support real time applications such as video streaming is causing institutions to consider it afresh. In particular videoconferencing supports interinstitutional collaboration, allowing convenient sharing of expertise and lectures between students at different venues and as such has the potential to increase opportunities for collaboration on a global scale. Interactive whiteboards, whether the 'virtual' electronic version or the large physical display panel, are also increasing in popularity. Embedded in e-learning environments, interactive whiteboards demonstrate the potential of alternative modes of delivery and enhance presentation content. Lecturers can customise existing content to meet the needs of the class in real time, whilst at the same time enabling learners to work collaboratively on a


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shared task. Interactive whiteboards facilitate group work on graphical topics such as development of decision-trees in diagnosis scenarios, discussions on medical images and annotation of medical videos. The Personal Digital Assistant (PDA) is another important device that can be used to enhance the learning and teaching environment, providing a lightweight and reliable alternative to the laptop and a useful means of creating and accessing reference materials. These are already used extensively for undergraduates in the medical profession where their use has become commonplace. A pocket-sized computer with simplified handwriting entry and voice-command provides better communication and easy access to information and computation at the point of care thus finding use in a multitude of applications [25, 26]. Although not designed for volume data entry the PDA can maintain a portable standalone database of patient records supporting patient management, laboratory results and facilities to track medications [27, 28]. Significant clinical impact has also emerged from PDA-hosted decision-support tools, for example, simple entry of age and gender into a program can predict which screening or preventative measures are appropriate [29]. The PDA also provides a valuable source of reference information with many complete medical and health journals and books available in PDA format for immediate access e.g. SkyScape [30] provides over 20 titles addressing clinical medicine, cardiac abnormalities, infectious diseases, sports medicine and toxicology. Medical calculators are amongst the most popular PDA applications [31]. The Osler Medical Handbook includes over 40 powerful integrated calculators for : Anion Gap-Serum; Body Mass Index; Corrected Serum Sodium; Henderson-Hasselbach Equation; Bayes Theorem-Pre Test Odds; Water Deficit; Glasgow Coma Scale, etc. Treatment guidelines on PDA format from respected organisations such as "The Medical Letter" provide prescribing and formulary recommendations for diseases such as diabetes, asthma, osteoporosis, hypertension, rheumatoid arthritis, heart failure, cancer, high cholesterol levels, epilepsy, pain, depression, as well as treatment of bacterial, fungal and viral infections [32]. Reports can also be written at a convenient location for uploading to the main computer system, saving on duplication of work. Alongside the use of reference materials, the introduction of clinical cases to test competency [33] mean that PDAs clearly have a role in health informatics education. The integration of the PDA into a local network through wireless technology, will provide even greater functionality as healthcare professionals combine the local computing power with the regional network for further professional and remote access to patient data. A more cost effective alternative exists in the form of the mobile phone. Until recently, connections to the Internet via the mobile phone network have been slow and expensive, although much progress is promised with the increasing roll out of 3G services. Already many primary care providers have adopted mobile communication. The term Health has been coined to embrace medical service provision to a roving user [24]. If incorporated appropriately into the learning environment (for managing calendars, task lists and contacts and providing assignment feedback and revision tips) the personal mobile phone, in particular SMS, can enhance motivation. Furthermore as mobile usage continues to migrate to phones which can also receive graphics, the mobile phone is likely to emerge as a powerful educational tool in a blended learning environment. 4. Self Directed and Lifelong Learning In "The Learning Age: a renaissance for a new Britain" [34], lifelong learning is defined as 'the continuous development of the skills, knowledge and understanding that are essential for employability and fulfilment.', (DfES, Feb1998. Cm 3790). This UK government paper emphasises learning for active citizenship within local and wider communities, as well as to develop a 'well-educated, well-equipped and adaptable labour force.'

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Lifelong learning happens in a variety of formal and informal settings building on both intentional and incidental learning experiences. This presents a considerable challenge in creating strategies and practice that enable individuals to access learning where they want, when they want and using the methods most appropriate to them. Lifelong learners are goal oriented and know the purpose for which they are learning new information. Most often, they have sought out a learning opportunity which they can use to better their position or make a change for the better. As such they are not only interested in knowledge but also practical skills which will help them apply such knowledge in their job. They know clearly what they want to attain and require an organised programme with clearly defined objectives. Health professionals require tools for evidence-based practice, such as well developed skills in question formulation, enhanced library skills for database querying, appraisal, guideline development implementation and quality assurance. Health informatics specialists require a wider range of development tools, to support a variety of activities as noted elsewhere, not least to build the tool-set for evidence-based practice. In the lifelong learning situation, motivation is not usually a problem, however, lifelong learners must also balance other life and work responsibilities with the demands of learning. Adult learners bring a wealth of information and prior experiences to the learning situation and generally want to be free to direct themselves in the education process [35] They have already accumulated a wide range of life experiences and knowledge and need to be able to integrate new and relevant information with this existing knowledge base. Self-directed learning focuses on the process by which adults take control of their own learning, in particular how they set their own learning goals, locate appropriate resources, decide on which learning methods to use and evaluate their progress [36]. There is considerable opportunity for lifelong learning in health informatics through the medium of e-learning. If the potential of e-learning is fully embraced, students can be brought together in exciting global learning environments, where they have much greater freedom and flexibility in their studies and potentially a wider variety of resources available to them. In a lifelong learning situation the tutor must guide the learners to uncover their own knowledge rather than simply supplying facts. Given the emphasis on reaching goals the tutor must illustrate how the course will achieve this and provide positive reinforcement to enhance learning. The tutor relinquishes the role of expert and assumes the role of facilitator, seeking student perspectives about what to cover and allowing students to work on projects that reflect their personal interests such that theories and concepts can be related back to a situation with which they are familiar. The tutor must acknowledge the wealth of participant experience, capitalise on this and provide ample opportunity for them to voice opinion and share experiences and knowledge relevant to the topic, thus promoting learning for both tutor and student. By building on current knowledge and providing frameworks to support the learning processes, such facilitation can empower learners to share and develop good practice. For example, students may be asked to identify a current health informatics issue in their experience or work-place, and be supported to specify, build or acquire, test and implement a solution. Such facilitated problem solving in small inter-professional groups provides advanced opportunities for enhanced learning. 4.1. Problem and Enquiry Based Learning In a lifelong learning situation, it is imperative that students develop independent learning skills due to the limited contact hours with the tutor. As such it is important to adopt an appropriate teaching and learning strategy to meet the learning needs of the student. The instruction should be about tasks and not simply memorization of content. Problem or enquiry oriented instruction is ideally suited to lifelong learning. Simulated problem solving


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through the use of case studies helps make the instruction more relevant to the individual learner’s situation. The use of problem based learning (PBL) as a teaching method originated within the medical and health-care context during the 1960s. It represented a major development and change in educational practice and the research literature still remains dominated by medical-based applications. PBL is viewed as an appropriate strategy for professional education and there has been a steady growth in the number of medical programmes that have adopted this approach. The approach has been endorsed by a wide variety of medical organisations including the Association of American Medical Colleges [37], the World Federation of Medical Education [38] and the World Health Organisation [39]. Walton & Matthews [38] present PBL as an educational strategy (as opposed to a teaching approach) where the curricula is organised around problems with emphasis on both cognitive skills and knowledge. PBL provides a rich learning environment. The problems (which may not always have a solution) are used as a tool to achieve both the required knowledge base and the skills to solve them [40]. The focus in PBL is on skills development and motivation. Working in small groups, the students deal with problems and make reasoned decisions in unfamiliar situations. Collectively, they reason critically and creatively, drawing on a variety of prior experience to generate the information necessary to solve a specific task thus simultaneously developing both subject specific and transferable skills. The process helps students develop greater knowledge retention and recall skills and exhibit stronger knowledge application skills whilst at the same time encouraging a student centred approach, active learning and independent study. The PBL paradigm is well suited to health informatics education. Learning in small groups through the use of clinical problems has the potential to make HMI education more relevant and interesting. Jenders et. al. [10] provide some PBL examples in the area of decision analysis. A typical ‘homework’ problem provides cut-off, sensitivity and specificity values for prostate-specific antigen (PSA), a common test for prostate cancer. PSA provides the concentration in the blood of a protein that is produced by the cancer but the same protein is also produced by other conditions and there is concern that the PSA is being overused and does not really give that much information. Given the prevalence (prior probability) of prostate cancer in 60 to 75 year old men, the student is asked to calculate the posterior probability of having cancer given a positive test (i.e., the patient's value is greater than the cut-off) for sets of values of cut-off, sensitivity and specificity. In addition the student is asked to validate the tests (using Receiver Operating Characteristic) and account for any discrepancy in the data. Such examples inform the student as to the efficacy of using tests, depending on appropriate data. Similar examples using decision trees are provided in IT-EDUCTRA [13]. 4.2. Portfolios The use of personal development planning (PDP) in professional training is a well established practice. Irrespective of the name (which can include personal profiling, learning logs and diaries) the purpose is to enable students to see where they have come from, where they are now and where they are going. It provides opportunities for improved learning, improved career development and improved personal development. PDP provides the impetus to encourage skills development and encourage students to take ownership of their learning. Using PDPs as a mechanism for learning in health informatics allows students to demonstrate deep learning through practice and reflection. The challenge is to continue to move to increasingly advanced stages of personal development. However, it is important that PDP development should not be seen as an extra task but be integrated into the curriculum.

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Portfolios and PDP have been widely used by health professionals and have been introduced in the UK to demonstrate and develop learning in order to manage health information [41]. [13, chapter 2] states that all NHS staff should have a personal development plan which supports their learning needs on an individual basis. 4.3. Reflective Practitioner PDP is the main pillar of any lifelong programme, creating a framework for reflective learning. The importance of reflecting on what you do has been emphasized as an important part of the learning process and the degree to which a student engages in reflection distinguished between a deep and a surface approach to learning. Schön [42] suggested that the capacity to reflect on action so as to engage in a process of continual learning was one of the defining characteristics of professional practice. Further, Mezirow [43] sees critical reflection as the major objective of adult education ‘reflecting back on prior learning to determine whether what we have learned is justified under present circumstances’ Reflection is also essential in initiating change. Many practitioners adhere to established methods without taking time to reflect on the rationale behind them. Furthermore, the time necessary for reflection on practice is often usurped by bureaucratic administration thus perpetuating traditional practice. Conventional approaches must be challenged in terms of their suitability and appropriateness for purpose. Encouraging health informatics practitioners to reflect on their practice and evaluate the results provides a sound basis for change. The principle of reflective practice is based on the notion that skills cannot be acquired in isolation from context. Practitioners must use past experiences to make sense of the current situation, critically analyzing one’s actions with the goal of improving professional practice. Reflection provides an opportunity to question what, why and how one does things, seek alternatives, develop an open mind, compare and contrast opinions, view things from different perspectives and become receptive to others ideas and viewpoints. The capacity to reflect both in practice and on practice has become an important feature of professional health informatics programmes. Typically health informatics programmes have a complex variety of students from a variety of professional backgrounds, each with conflicting values and beliefs. These professionals have specialized expertise that they apply to problems in well-defined practice situations. Central to the idea of reflection (and indeed inter-professional education) is the identification of discrepancies between beliefs and actions in order to improve practice. By sharing in the process of reflection and review there is increased likelihood of establishing an informed basis for change rather than creating a polarisation of perspectives. The Department of Health [13] promotes this concept stating that “wherever practicable, learning should be shared by different staff groups and professionals”. The promoting of standards and standing of the profession by sharing of knowledge and experience with their peers is an objective of UKCHIP and part of the Health Informatics Professional’s code of ethics, adopted internationally by IMIA [44] Reflection can be a rewarding and productive experience which has the ultimate benefit of providing a deeper understanding of ones own practice. Furthermore, the reflective practitioner starts to take for granted aspects of practice which initially preoccupied them moving on to reflect on wider matters. 4.4. Mentoring Real reflective practice requires a second person to act as mentor asking appropriate questions to ensure that the reflection does not become a process of self-justification, selfindulgence and self-pity. A successful mentoring relationship can form the cornerstone of professional development. However, the quality and purpose of mentoring can vary tremendously. Mentoring


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requires a certain set of skills and not everyone makes a good mentor. A good mentor provides advice, support and guidance, questions your actions and provides a sounding board for new ideas. Observations, feedback and reflective commentaries are used to raise awareness of current practice. Health related disciplines have systematically used mentoring as a key feature of staff development for some time. Peer review supports formative development by recognizing strengths and suggesting possible areas for attention or alternative approaches. The NHSU has embraced mentoring and has recruited tutors or learning advisers [45]. The advisers make a valuable contribution to the student’s personal and professional development, whilst developing his/her own skills by working with people from diverse backgrounds and with very different learning experiences. NHSU provides training to help the tutor prepare and deliver learning programmes effectively. This comprises: Learning adviser development programme; E-tutor development programme; Mentoring and coaching programmes. 5. Continuous Professional Development Reflective practice and mentoring clearly play an important role in professional development. However there is a need to adopt a more holistic approach. Educational technology (in particular e-learning) can provide suitable environments for CPD activity in health informatics giving a wide variety of health professionals the opportunity to consider responses to questions and input to discussions. Furthermore students have the opportunity to learn from both tutor feedback and other students’ responses. As such, e-learning can break down some of the barriers that arise in “traditional” teaching. It is possible to gain access to a wide variety of tutors, reduce formality of interactions between students and teachers, and provide a friendly environment which helps remove social stereotyping barriers. The challenge facing health informatics with respect to the use of e-learning for lifelong learning and professional development must focus on opportunities for improved student choice and provision of learning material. Linked to this is the challenge of coping with the changes in technology and the associated raised expectations. Murray et al [46] provide a definition of e-learning in health informatics and identify unique features of e-learning in this field including the challenge of competency-based assessment of clinically-based skills and the role of e-learning in client/patient education and the challenge of socializing individuals into the health profession without a degree of face-to-face contact. "Learning objects" have become central to many public and private educational organizations. They are associated with a range of benefits, including resource "reusability". There are many definitions of what a learning object really is but in essence they are engaging digital educational resources which incorporate interactivity and assessment based on a single learning objective. As such they are small and self contained, thus enhancing opportunities for re-use in different courses, institutions and learning situations. Lack of readily available online course content is often cited as one of the major barriers to health informatics education. Nevertheless there are many examples of the use of learning objects in health informatics. HI Collaboratory [47] is a collaborative project established to enhance existing and/or new health informatics education and training programs from participating stakeholder groups in Canada. This consortium is made up of a multidisciplinary project team and stakeholders groups spanning educational institutions, health organizations, professional associations and private sector companies across Canada recognizes that a collaborative approach is needed to build the intellectual capacity in ways that are effective and sustainable. Much of the discussion on learning objects to date has focused on their design and technical development. Orrill [48 ] describes the use of learning objects as support tools in a

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project-based action learning environment. Further, Bransford et al [49] acknowledge that using technology to support learning is not solely a technical matter, drawing out the fact that they ‘function in a social environment, mediated by learning conversations with peers and teachers”. In the UK, the ACETS (Assemble, Catalog, Exemplify, Test and Share) project [50] is involved in investigating pedagogical use of reusable learning objects in a wide range of healthcare educational settings With guidance, a modular structure (incorporating learning objects as appropriate) can encourage students to build their own intellectual connections based on experience and reflective practice thus laying the cornerstone for future CPD activities. Peer assessment, mentoring, reflective practice, teamwork, multi-disciplinary teaching, enquiry or problem based learning, PDP, gaming and simulations and work related skills are all methods to encourage the professional development of the health informatics professional. However, in order to demonstrate professionalism there is a need for accreditation and formal qualification and certification mechanisms that take into account all the settings and learning experiences of the health informatics professional. Accreditation of Prior Experiential Learning (APEL) awards credit for learning and capabilities gained through experiences in work, voluntary, home or leisure environment. It recognises the fact that many students, and particularly mature students, also possess an extensive range of skills and knowledge derived from a variety of professional, vocational, community, leisure and personal contexts. AP(E)L provides students with the opportunity to have this prior learning counted as part of their course. However, it is the ability to state and demonstrate learning, rather than simply having had the experience that is the basis for credit. This usually involves the submission of written evidence (such as a portfolio, containing both commentary and evidence, and including samples of work, and accompanying explanation) and in some instances testimonials from previous employers. Subject experts will be consulted to make a judgement as to the specific value of the prior learning in relation to the proposed award. To be valid, the experiential learning being claimed must be equivalent to learning which would normally be included in the proposed award programme. This means it must be at an appropriate level, be directly relevant, and in a cognate area. Quality assurance processes must also assure that the experiential learning is current, in the sense that the learning must be recent enough to still be valid as some subjects, including health informatics, 'age' much more quickly than others. The process of enabling individuals to gain credit for learning outside the formal system of education and training has developed in the UK over the last ten years in parallel with the introduction of system of National Standards in vocational training and a modular credit system in Higher Education [51]. In the future, these developments may well take on wider potential importance with agreement on a common Framework of Qualifications in Higher Education based on the Bologna Declaration [52].

6. Conclusions Clearly self-directed and life-long learning are vital elements in the process of building a global healthcare service for all citizens. Health informatics represents another part of the infrastructure permitting effective and efficient use of health information of all types. Where these two components meet, to complete the structure, self-directed learning in health informatics is fundamental. In the future, facilitated learning, through internationally-accredited, tailor-made learning objects, will be provided by approved suppliers. It is such learning that will enable health services to cope with increasing demand, while continuing to deliver the optimal quality of care.


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[39] World Health Organisation 1993, Increasing the relevance of Education for Health professionals: Report of a WHO study group on Problem Solving education for Health professionals, WHO, Geneva [40] Barrow, H.S. A Taxonomy of Problem-based Learning methods, Medical Education, vol 20 (1986), pp 481 – 486 [41] NHS Information Authority, http://www.nhsia.nhs.uk/informatics accessed May 2004 [42] Schön D A (1983) The Reflective Practitioner: how professionals think in action London: Temple Smith [43] Mezirow J and Associates (1990) Fostering Critical Reflection in Adulthood San Francisco: Jossey-Bass [44] Kluge E.H. A Handbook of Ethics for Health Informatics Professionals, British Computer Society, 2003: ISBN 1-902505-52-2. [45] NHSU, learning for health and social care, http://www.nhsu.nhs.uk/learning/advisor.html accessed May 2004 [46] E-learning in health informatics: trying to agree what we mean, attempting to determine the research priorities, www.chirad.info/chiradat/imiaeduc2003/chirad%20portland2003%20final.pdf accessed May 2004 [47] A Pan-Canadian Health Informatics Collaboratory, http://hi.uwaterloo.ca/hi/HIC_Project.htm accessed May 2004 [48] Orrill, C. H. (2000). Learning objects to support inquiry-based online learning In D. A. Wiley (Ed.), The Instructional Use of Learning Objects: Online Version. Retrieved May 30, 2004 from the World Wide Web: http://reusability.org/read/chapters/orrill.doc [49] Bransford, J. D., Brown, A. L., & Cocking, R. R. (1999). How people learn: Brain, mind, experience, and school. Washington, D.C.: National Academy Press. [50] ACETS Project home, http://www.acets.ac.uk accessed May 2004 [51] Konrad, John, Accreditation of Prior Experiential Learning in the United Kingdom, http://www.leeds.ac.uk/educol/documents/00001831.htm accessed May 2004 [52] Bologna Declaration, http://www.ntb.ch/SEFI/bolognadec.html accessed May 2004


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3.4. Managing Large Online Classes Across Multiple Locations Kathy EGEA Faculty of Informatics and Communication Central Queensland University Rockhampton, QLD Australia A C Lynn ZELMER Faculty of Informatics and Communication Central Queensland University Rockhampton, QLD Australia Abstract: We now have many different ways of delivering educational offerings, hopefully tailored to the educational environments and student characteristics. Programs vary based on country of origin and delivery location, organisational structures, development and delivery technologies, and the business arrangements made between providers and agents/students. At Central Queensland University (CQU) we deliver the same courses domestically and internationally, often with more than 1000 students per offering, several times per year across 14 campuses located thousands of kilometres apart using faceto-face and/or virtual mode. The students are a mix of Australian distance and on campus plus international on campus. This chapter builds on the CQU experience managing these large classes, particularly within the Faculty of Informatics and Communication, using an evolving mix of technologies. The economic realities of tertiary education require providers to focus on servicing international markets, including an emphasis on student preferences for language of instruction, preferred location (campus or distance delivery) and mode of instruction. Educational delivery requires development and delivery teamwork, maintenance of consistency (quality) in terms of offerings and assessment, appropriate use of technology and cultural awareness.

Introduction Online education is a very recent phenomenon with roots back with the beginning of the modern university. Modern universities were generally organised around lectures and tutorials, ideally face-to-face in small groups, but have always utilised the teaching technologies of the time. Thus demonstrations and practical activities in the early medical and engineering schools, albeit often conducted in the lecture ‘theatre’, led to the use of paper-based student guides and collections of ‘readings’, magic lantern slides and motion pictures, radio and television, telephones and videoconferencing, simulations and games, and computer managed learning with ‘PowerPoint’®, web sites, chat rooms, and online assignment submission with computerised anti-plagiarism checking. Delivery systems change but we are primarily still tasked with delivering a fairly conventional university education, albeit in a [hopefully] more efficient, effective and cost-effective learning format.

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K. Egea and A.C.L. Zelmer / Managing Large Online Classes Across Multiple Locations

Case Note 1. CQU’s Faculty of Informatics and Communication. Central Queensland University (CQU) delivers courses domestically and internationally, often with more than 1000 students per offering, several times per year across 14 campuses located thousands of kilometres apart using face-to-face and/or virtual mode. The students are a mix of Australian distance and on campus plus international on campus. There are several models of delivery, initially developed from elements of distance education with tutor support. Courses typically have a coordinator (manager), several lead lecturers (typically one per campus), and a number of tutors and markers. Some classes are weekly (lectures, tutorials and labs), while others have extended monthly meetings. Distance students might have a total online experience, with staff contact using virtual interaction. The course website presents the weekly activities, including a set of PowerPoint® lecture slides, tutorial and laboratory activities. On large campus sites several staff present the lecture material and provide student feedback. The university uses videoconferencing facilities between local and regional campuses. In some cases videotapes record these sessions and are then available for borrowing. Tutorial and follow-up work is provided by local tutors, who also usually mark assignments and are expected to assist with online (typically e-mail-based) support.

Unfortunately, cost effective is usually defined from the point of view of the administration, not the individuals involved in delivering, or receiving, the newly packaged educational ‘experiences’. Contrary to administrative expectations, organising for and managing the delivery of courses to students, regardless of the delivery mode, is expensive. If the expense isn’t covered by the administration (university, faculty or school), then it will fall on the course development or delivery teams, or the students. Often the reality, at least in the early adoption phase, was and is individuals working extended hours or in their own time, with limited budgets, to prepare and deliver educational resources that can be used repeatedly or in more than one classroom. The question of appropriate course management as one of the primary roles of a course coordinator, underpins the success of the course delivery. Also, the management ability of the lead lecturers at the various campuses varies, with the result that all of the course support activities can fall back onto the course manager. Alternatively, course support can fail; leaving local tutors and students alike without direction or the day-to-day updates and information that can come naturally to a properly managed face-to-face class. This chapter builds on experiences of the authors in their role as course coordinators since 1990, having designed, developed and delivered information technology courses at CQU. In practical terms we are (or have been in the case of one author, now retired) responsible every term for one or more courses with 800-1200 students per term twice a year, although some courses are offered three times a year. While our situation is likely familiar to any educator working with the current and evolving educational technologies, the emphasis in this paper is on the special problems arising from the use of technology to manage large classes across multiple locations. Many authors discuss technology-mediated learning from a pedagogical perspective. We describe the diverse educational technology environment through a number of case notes, the experiences of the authors and others, to focus on the critical issues affecting that environment, primarily from the perspective of the course coordinator cum manager. The issues are course design and development, course delivery, student assessment and evaluation, and technical support. These experiences suggest that: • •

There is a need to design for flexibility and timely delivery of course materials with a reasonable selection of alternate delivery modes and requirements. Both staff and students need appropriate access to the technology tools.


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Case Note 2. Supporting Entrepreneurial Efforts and Technology. Even with the power and capacity of currently available communications technologies such as the World Wide Web and the Internet, adapting and integrating these technologies with existing institutional and departmental strategies and initiatives has not been a priority in many institutions. Furthermore, the fixed instructional budget framework in place at many colleges and universities does not support entrepreneurial activity at the curriculum, department or unit level. Frequently within this budgeting framework, adding students, using learning technologies, and creating new paths of access simply increases the workload without providing significant new resources to the academic unit. Even when funds are added to the departmental resources, they are often at the margin. As a result, faculty and academic departments are hesitant to commit to programs that potentially add workload but few resources. ...It is little wonder that in these settings, the implementation of learning technologies to increase access has met with minimal support, if not direct resistance, from the faculty. [Paragraph breaks added to original] [3, p 26]

•

•

Teamwork, well coordinated, is essential at all levels of the design, development and delivery process. This ensures that staff at all levels of the process have common expectations and equitably share the workload. Functional course management tools are essential for large classes and/or classes delivered online.

1. Course Design and Development Oliver and Herrington [1] describe a sequential process that ‘supports the development of the learning setting in ways that promote and encourage learners’ knowledge construction’. Some of our courses attempt to implement such a constructivist approach, others will continue to follow a more traditional didactic format until time and resources are available for their redesign. This section thus focuses more on those issues that directly affect, or are affected by, the technology rather than the design philosophy. The 1993 CAUT National Teaching Development Grants evaluation [2] indicated a major reason for the slow delivery of learning materials was that staff generally ‘had not allowed enough time for the range of other academic and personal responsibilities which might compromise timely completion of projects’. CAUT grant recipients were highly motivated individuals with external funding and an interest in producing optimal learning materials. While we might hope that all course designers and developers are likewise highly motivated with adequate funding, the reality is somewhat different. The result, though, is the same since many course development projects fall behind schedule and/or fail to meet agreed quality objectives. In our experience this is just as relevant for the basic revision of an existing course as it is for redesigning a course for a new delivery mode or for developing a totally new course. Hanna [3] provides several strategies for developing educational leadership and in the Case Note below explains why staff often resist technological developments. On-campus students are enrolled into courses according to a relatively inflexible timetable. They have an expectation at the start of term that all course development is completed and relevant course materials will be available when required. In the case of courses for distance or online delivery this has often meant the course design and development of materials was done as much as three months to a year in advance of delivery. Many fields of study, however, are changing more rapidly than can be accommodated by such a timeline. In information technology, for example, hardware is constantly evolving, requiring frequent unplanned operating system and software upgrades, especially as students frequently assess the utility of an IT program by the currency of its working envi-

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ronment (hardware and software tools). While these changes can usually be adapted to a campus environment, they are often much more difficult to resolve for distance and online delivery environments, especially when students must provide their own computing (or other work) tools. Perhaps as a result, it now seems more usual for courses within the Faculty to have no upfront study guide. Instead, in some cases, course materials are uploaded to the course website, often week-by-week as the course progresses. Whether this is educationally supportable, rather than just being an administrative convenience is open to question. 1.1. Student Language Expertise and Learning Approaches Academic and technical staff preparing for single location on-campus classes can usually expect a relatively homogeneous group of students to present themselves for any particular undergraduate course. Adding additional delivery locations increases the potential range of student diversity and delivery challenges. Delivering the same course at a distance, across international or cultural boundaries, or to students with differing language capabilities increases the range exponentially. One means to address the broad spectrum of cultural and knowledge backgrounds and to develop student language abilities, is to design courses that engage students in discussion with peers. The virtual environment provides a medium for such communication, for example email, chat room, MSN messenger. Furthermore, Morse [4] found that asynchronous learning with these electronic communication tools was successful in different learning approaches, from those engaged in active internal processing (low context learning) and those reliant on external feedback (high context learning). Low context learners enjoyed the flexibility of unscheduled study and reflected on other students’ contributions while high context learners valued the opportunity to reflect on their own contribution. Other techniques that value the varying learning approaches of cross-cultural student groups are also needed. Here a team approach is recommended where members with a range of skills and backgrounds prepare a selection of materials, sometimes in translation, that meet the variety of needs. Local staff at the varying campus locations can also add local examples to demonstrate the context. At the very least supplementary resource materials (textbooks, journal articles, audio and video materials, etc.) in mother tongues should be available for students who are having difficulty with the primary language of instruction. 1.2. Course Content and Special Requirements Informatics courses frequently require students to have experience with specialised, often expensive, computer hardware and software. While these facilities can be used by other programs in a single campus situation, multi-campus and distance delivery modes add both expense and complexity. Knowing what the students should be able to know/do at the end of the course will help determine essential resource access requirements, as compared to merely desirable resource access or the course designer’s preference. Most academics, course developers and technicians are still primarily print-oriented because of their prior educational experiences and available training resources. It is logical, therefore, that both the course management processes and tools, and the educational materials they produce, are initially designed for print use. If these materials are then simply converted into an electronic format they will likely be cumbersome and ineffective. Historically this provided an inexpensive and easily maintained alternate delivery format [6]. Supplementing this with e-mail or web-based discussion lists added staff and student functionality but at a cost which included the additional time to prepare and update materials, respond to increased student inquiries and coordinate with staff in other locations.


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Case Note 3. Designing the Assessment First [5]. For some it might seem a bit strange to design the assessment before you develop the learning materials, but it is the best way to ensure that we assess the objectives we have developed and ensure that the Course learning materials are targeted to the required learning outcomes. Your assessment needs to be as engaging as your learning materials and be woven into the fabric of the Course. It is always best to make your assessment as authentic as possible and provide opportunities for students to measure their own ability and performance where possible. Assessment can be formative or summative...Once you have written your assessment and confirmed that they meet all of the Course objectives, it is time to design and develop the learning experiences for your students.

Case Note 4. CQU Standard Model for a Programming Course [6]. • •

• • • • • • • • •

a subject home page from which links to all of the other resources can be found, updated on a regular basis throughout the semester; electronic copies in both html and PDF formats of the printed materials despatched [normally on CD] to students prior to the start of semester, including copies of all assignment items; lecture slides in PowerPoint format, as used for on-campus classes, made available for browsing or downloading; additional notes arising from on-campus lectures and tutorials; workshop tasks, with additional notes as appropriate, and solutions; assignment marking guidelines and sample solutions; a feedback ‘barometer’, through which students are enabled to provide anonymous feedback as to how the subject is progressing on a weekly basis; links to full contact details, including email addresses and ‘phone numbers, of the subject coordinators; copies of past examinations for the subject, and hints and tips for the forthcoming examination; links to the electronic mailing list for the subject; a list of recent updates and additions, in date order.

The increased time demands as courses go electronic or online cannot be underestimated. One of the authors received more than 100 telephone calls from students in one afternoon when a delivery error resulted in students receiving erroneous materials and a class of 450-600 students easily generated thousands of e-mails in a week if clear procedures were not in place, and followed, to keep all students updated regularly. As more flexible course delivery at CQU evolves, some students receive a CD disk copy of the course’s web site, current as of the commencement of the current course delivery, when they registered for the course. This allowed students in multimedia and computing courses, for example, to work offline/at home and was particularly helpful for ruralbased students, who often were at the far end of the electronic ‘pipeline’ with slow download and response times, or were international campus students with language difficulties. Increasingly more interactive techniques (see team-building notes below) and tailored materials (eg animations and simulations) are also being used. 1.3. Preferred Teaching and Learning Modes Personal preferences often dictate how individuals react to particular situations. Some students do learn from lectures, others prefer to read, others need a visual explanation and others need ‘to do’. Twigg [7] examines the university’s traditional lecture mode with multi-

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campus delivery (termed multiple section model) while introducing five case studies that use information technology and asynchronous learning strategies. Most lecture courses are notoriously ineffective in engaging students. The lecture format neither encourages active participation nor offers students an opportunity to learn collaboratively from one another. It does not provide adequate tutoring assistance, and consequently, students receive little individual attention. Even though individual help may be available during office hours, only a small fraction of students take advantage of this help. Most students simply study the text, turn in their homework, and take quizzes and exams. The primary alternative structure for large-enrolment courses, the multiple-section model, suffers from problems of its own. In theory it allows greater interaction with students, but in practice, sections are often quite large and are dominated by the same presentation techniques as used in larger courses. In addition, the multiple-section model suffers from a lack of coordination. As a result, course outcomes vary considerably and, more important, are not always consistent with students' abilities. Twigg [7, p.7]

Most educators accept that good course design requires at least some catering to diverse learning needs, and that courses designed for distance or online delivery need viable alternatives to these conventional models. Oliver and Herrington’s constructive framework [1] utilises the online learning environment itself (focusing on learning tasks, learning supports and learning resources) to engage and motivate students. Academics often forget, however, that the availability of particular technology, their own personal preferences, or the preferences of their supporting technical staff, frequently dictate how they design and deliver a course, regardless of the students’ educational or cultural backgrounds, preferred learning styles, or access to technology. Early identification of these preferences and access to resources is a critical component of the design and development process as restrictive designs cannot be overcome at subsequent development or delivery stages. 1.4. In-Advance or Just-in-Time Development Academics can generally provide the intellectual content for a course in written form. They almost always require assistance, however, in editing their materials to meet specific language requirements. Many of our international students, for example, are mystified by Aussie (Australian) slang and narrative examples taken from Australian experience. Most Australian academics are likewise mystified when asked to produce a slang-free and culturally value-free version of their materials. Academics also typically need assistance to produce the graphical materials, animations, and other resources required to post their materials on the web or to use them for a wider audience. This isn’t just a matter of the time required to produce such materials. Educators often lack appropriate design skills and do not have enough experience with computer-based tools to produce an optimum output. This supports the need for multiple perspectives, teamwork and a variety of sources to develop a constructivist approach to the learning environment. There are arguments for and against preparing all of the course materials in advance of the course delivery, rather than just-in-time or post hoc materials preparation for [streaming or videotape] video, CD/DVD or online (e-mail or web) distribution. The quality of materials prepared in advance can be closely monitored and edited, but may not be flexible enough to handle changes in staff (eg illness or death), delivery facilities (eg postal strike), timetabling or facilities. The strongest argument for in-advance preparation is the ability to provide graphical and other support materials, including professional quality animations and video materials. The strongest argument for just-in-time or post hoc preparation (and delivery) is the ability to update and change the materials, particularly important in topical courses. Topical


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Case Note 5. The Missing Textbook. Over a period of roughly 20 years and three different tertiary institutions one of the authors has several times prepared course materials based on a specific textbook, only to have the publisher withdraw the text prior to the course delivery. In each case the publisher had guaranteed that the specified edition of the textbook would be available, but had been forced to withdraw the text at the last moment. In one case the publisher did manage to find sufficient copies for one term through a worldwide search of the company’s warehouses, but generally there was a need to revise the course materials, including lectures and assignments, as the course was being delivered. This is a nuisance but can be handled reasonably with on-campus classes on a single campus. It puts a major strain on other delivery modes, whether to multi-campus or individual students, and can add significant costs.

streaming audio and video may lack the professional quality of prepared materials but provides immediacy. In any event, discussion lists and similar online support services will need to be archived (and promoted appropriately in the course materials) to avoid the need to answer the same or similar queries individually for every student and to provide for individual needs. For example, students who are night- or extended-shift workers, workers in ‘fly-in/fly-out’ remote location mining and similar industries, and members of households with children who also make demands on limited computer resources all require asynchronous and/or delayed access to learning resources.

2. Delivering the Course Materials Current multi-campus and distance delivery practices at CQU encourage a selection from printed and electronic notes (online, CD or DVD), either specially prepared or copies of the lecturer’s PowerPoint slides and handouts, audio or videotaped lectures and/or discussions (tape or CD/DVD), audio or videoconference attendance at classes and/or copies of these materials available online. 2.1. Alternative Delivery Modes Requiring students to be in the same location, or even at various locations, at the same time as the lecturer (synchronous delivery) is simply not feasible for a multi-campus or multimode (on-campus regional, on-shore internationals and/or distance or off-shore) program delivered across multiple time zones. Some courses can be delivered without lectures or other formal input, relying instead on a selection of resource materials, activities and assignments. Others might use virtual study teams where students use computer-based communication tools to collaborate, either synchronously or asynchronously, to access support services and/or deliver and assess student-prepared presentations. The team approach for assessment has the advantage of creating manageable groups within large classes, and at the same time, provide students with a small network to learn cooperatively. A reasonable selection of alternate delivery modes and requirements can reduce the need for every student to have access to the highest level of technology and potentially provide for individual learning preferences. 2.2. Feedback and Student Contact Students expect some feedback on their performance, often delivered in the form of examination or assignment results. This needs to be timely and linked to the assessment criteria.

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Case Note 6. Student-Determined Learning Environments. In this note, Egea and Gregor [8] describe teamwork in an undergraduate HumanComputer Interaction course. Geographically widely dispersed students, both on- and offcampus, were organized into small teams to work collaboratively on course assessment tasks. ‘Students who were aiming for high assessment marks, tended to nurture their working environment by providing supportive and encouraging comments to the other members of the team. They developed a high level of team efficacy and team morale. Personal contact was regarded as essential early in the team interaction. This was done via a phone call or a face-toface meeting, if possible. Being personally friendly with team members created a friendly environment, enabling students to feel comfortable to explain their own thoughts without fear of criticism. It was noted that teams with team members that had prior team experience, including work-mode teams, were more productive and efficient working environments. At the other end of the virtual team spectrum, some students did not contact their teams early in the semester. These students indicated that they had not read the course profile and were quite vague regarding the purpose of the assignment. This caused a lot of stress to other team members. In one case, the team members excluded the third member from the presentation, as his effort was too late to be of use to the prepared seminar. However, overall, 90% of student teams judged themselves as successful and had participated in all aspects of the assignment, including the seminar and the peer reviews. Interestingly, teams were either totally collaborative with the peer review for each week, or were singular, allocating a review to a different team member for each week of presentation. However, in both cases teams indicated general satisfaction with their efforts and the peer reviews that they received. One student asked to be allowed to work individually and not in a team. In the assignment reflection on teams, this student tabled a comparison of positive factors and negative factors of individual work when compared with teamwork. He compared this with his observations of the other teams in his mail group. Positives included: flexibility, no team overheads (team management, team consensus both of which are very time consuming), and no negative dynamics (no stress due to personality differences, no unequal contributions). The negative factors included: work overload, and no team synergy, loss of team expertise and fresh ideas, no feedback from team members, possibility of noncompliance with assignment due to lack of collaboration’. [8, pp 418-419]

Lecturers can sometimes gain some feedback on their performance from students in a lecture or tutorial but genuine student contact and feedback has always required extra work from staff. Accommodating multi-location students requires ingenuity in using available technology (face-to-face, mail, phone, fax, e-mail, discussion list, e-mail, computer-supported discussion groups, etc.). Differing cultural expectations complicate the issue; particularly with our international students as their previous technology use and educational experiences may not have prepared them for class discussion and interaction,

3. Student Assessment and Evaluation 3.1. Differing Expectations Western educators and their traditional students are accustomed to at least some debate during classes and over assessment, deadlines, grades, and course evaluation. Other cultures are more restrained and reaching a compromise that results in optimum learning with useable feedback is not always easy. The degree of ‘hands-on’ or constructivist work, as compared to more academic activities, can also be an issue, both for staff and students. However, our professional and accrediting agencies do see practical skills, experience working in teams, and the like, as very important. This is not unique to IT-related courses and skills. Nursing, medicine, education, science and engineering also struggle to provide


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Case Note 7. Feedback Through Assessment. Student assessment will be discussed further in the following section but Hackett [9] suggests that it is time for learners to take control of their assessment. While her comments are in the context of competency-based English language learning in Europe, they are likely applicable to other areas of skill/competency learning. ‘The recent shift in assessment from norm-referenced testing to a criteria-referenced approach (from comparing performance with other individuals tested to estimating how much content and skills have been acquired by each individual) has broadened our view of what constitutes effective assessment.... [This] has implications for how we can integrate effective learner strategies and best practice through a principled and relevant approach to assessment, valuing what each individual learner brings to the assessment process. It considers assessment as a fundamental, integrated part of the learning programme.... In the run-up to the assessment, learners can be given guidance and scope to evaluate where they are according to the assessment criteria. This gives an opportunity for learners to develop self-awareness about their progress and attainment. It also allows learners to set realistic learning objectives and to direct their learning on a pathway to success. The assessment will tell them how much they know and have achieved rather than how much they don’t know or how much they still need to learn. Giving learners decision-making control over key aspects of their assessment can be an excellent way to encourage and enable them to take responsibility for their learning and assessment of it. One way to do this is by allowing each learner to select and develop the content of their individual test.’

appropriate practical experiences for their students, whether on-campus or at a distance. Our electronic media have the potential to deliver virtual experiences but preparing relevant, challenging and interesting virtual experiences is expensive and time-consuming. Ensuring that staff at all levels of the course delivery have common expectations is an essential beginning. 3.2. Intellectual Property and Plagiarism The technology now exists to reasonably easily determine the source of almost any text; determining the provenance of images and other non-text material is more difficult but still feasible. Unfortunately, as educators we often get embroiled in the technology, and students focus on the presumed loss of privacy and intellectual property, while failing to question the utility of the underlying exercise. It may require more work for a staff member to develop an assessment activity that avoids the potential for a plagiarised response but the result will almost always result in better learning and is often easier to implement. 3.3. Security The information technology in our student computer labs often makes it possible to fabricate student identity cards, capture passwords, transfer files and otherwise subvert normal assignment or exam security. Mobile phones with SMS and digital cameras are even small enough to be used during exams for silent cheating. Of equal concern, students want to be assured that the assignments they submit online actually reach the lecturer and haven’t either been copied by other students or overwritten with bogus, and presumably inferior, substitutes. It is important to have the facility transparent so that students can check and even update their submissions. Anonymity in submitting evaluations of course and staff, as used in the ‘course barometer’ (see Case Note 4), is required to reduce retribution for a negative comment or to ensure genuine responses.

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Case Note 8. Hardware, Software, People or Procedures? Hasan, Verenikina and Vrazalic [10] describe an undergraduate Information Systems course delivery where the online delivery technology both provided for interaction and was a subject for class discussion and learning. ‘Students were given instructions on how to use this facility [WebCT Bulletin Board®], which caused little difficulty, and also rules for appropriate use, including information that messages would be removed if they were offensive to others or were of an individual nature in which case email should be used. Abuses of the former rule came from students who were used to the language of some public forums that were not moderated and they learnt that the use of communication technology in formal organisations imposes codes of responsible behaviour on members. [...A powerful tool for learning occurred] when the systems failed or at least did not work as expected. Students were encouraged to understand the reasons for the failure and to think how they could fix or work around the problem. Not all these system failures were purely technical in nature. From an IS perspective an information system includes hardware, software, people and procedures. One procedural problem occurred when two or more tutors simultaneously uploaded text marks to the WebCT student management database and one set would be lost. This was recognised and an appropriate non-technical solution was imposed on the timing of this task.’

4. Technical Support 4.1. Delivery Course delivery must be an integral part of course planning for external delivery. A single lecturer can support a home grown web site, however an on-line institution must look further and decide on commercial versus proprietary solutions, the type and extent of network access, types of assignment support (including online submission), and day-to-day system maintenance. With 1000 students, for example, even archiving a discussion list rapidly gets beyond a manual solution and dictates the availability of professional technical support. This requires functional support computer-based tools, willing and knowledgeable technical support, and a system for training and managing academic staff. As is also noted elsewhere, technology-based solutions require both staff and students to have appropriate access to the technology tools or the solution fails to deliver the expected results. 4.2. Help Desk Universities are expected to provide on-campus students with an initial introduction to the institution’s electronic technologies appropriate to their level of anticipated use. For IT students this usually extends beyond basic computer operation to the use of sophisticated software for practical work and assignments. Distance students may be expected to have, or acquire, enough expertise to engage in at least the basic communication technologies. Both groups are typically supported by a centralised help desk which offers advice on virus protection and other tools, and provides face-to-face, phone/fax, and e-mail assistance when the computer-based systems or networks fail. Some universities provide their primary telephone and online support with paid professional staff. IC-Assist, described in the Case Note above, was based on what may be a unique system at Athabasca University in Canada, where tutorial staff are located across the country and accessible, on a rostered basis, through a single telephone number. Other support systems include a telephone/fax/e-mail help system staffed by advanced students, peer-


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Case Note 9. Developing a Web Interface to Assist Team Building. CQU’s Human Computer Interaction course, with a typical student enrolment of 450, (regional Queensland 10%, external 10% and international 80%: 4 capital city campuses and 2 overseas), utilizes a web-based interface to facilitate the management of student work teams. Students and staff (some are past students) at CQU’s international campuses tend to have Asian backgrounds, while regional staff generally have Australian backgrounds. Assessment tasks have evolved to develop team skills of goal setting, negotiation skills, research skills, presentational skills, and team cohesiveness using virtual teams. The style of this assessment has developed over a number of years and involved team presentations of ‘set’ seminar topics, team reviews and team reflection to provide currency to the weekly course material. Small teams (no more that four students) are clustered into groups of six teams for interacting through the web site. Detailed instructions are provided in the course profile and a template for the review placed on the course website. Each week, each team is required to present a seminar or complete a review. Seminars are downloaded by reviewing teams, the review template completed and uploaded back to the website. The presenting team then collects the reviews, paraphrases them and documents future presentation improvements. All tasks are to be submitted online at the course website. The 2001 offering included distance students for the first time. While internal teams continued to use live or videoed presentations, distance students were placed in virtual teams (based on locality where possible). The virtual environment made use of email lists and was successful overall in achieving the assignment goals of team presentation and team review. However, staff at the international locations preferred to use a face-to-face delivery and review model. This meant that students could not download team reviews and relied on the tutor transmission of peer reports. Egea and Gregor [8] provide a detailed description of the virtual team evolution through 2001 where face-to-face classes were supported with online submissions via email. Problems noted by the coordinator include the arduous task of manually creating teams and subsequent mail lists, incorrect electronic mail address, and poor linkage between email addresses and student. Initially students found it difficult to understand the actual assignment process of seminar and review. However once they did, there seemed to be minimal problems. To overcome these problems for distance and international students, an in-house dynamic web administrative package was designed and developed to manage both the administration of the teams for all locations and to provide an interactive team website for seminars and reviews. The application would create virtual student teams, of varying size, based on tutorial class in any campus, or postcode group, would send electronic mail to marking staff and students, and would provide an interface for student and marking submissions. Egea [11] indicates that further implementation issues arose from the lack of staff training in using the administration site, while students had few if any problems. In 2003, it was decided by the coordinator, that until satisfactory training could be implemented, the administration of all 400 students in the course into teams by tutor, campus and postcode, would be done by her.

mentoring programs where first year students are individually advised by senior students, optional but scheduled lecturer- or technician-staffed online tutorials and scheduled CHAT sessions. 4.3. Computer Supported Pedagogy Course designers for information technology courses usually decide on a level of required computer support for students, develop their courses to effectively utilise the required facilities and ‘advertise’ this in course promotional materials. Students then either obtain access to on-campus computer labs or are required to provide their own comparable facilities, often in their place of employment or at home. Hardware requirements are often easier to define than software. Software licensing, either by the institution or by individuals, and the perceived need for standardising the assessment procedures to enable online submission, often leads to a demand that students and

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Case Note 10. Structured Peer Support. In the early 1990s the Faculty of Informatics and Communication provided course content support to Queensland-based distance education students through a network of open learning centres. Other external students communicated directly with the course lecturer, typically via telephone or fax, and internal students communicated with their local tutor. The inconsistent nature of the support led to it being replaced by a centralised, student-staffed service currently called IC-Assist. Senior students (undergraduate and postgraduate) on the Rockhampton campus are paid at roughly tutorial rates and rostered for several hours of face-to-face, telephone, fax and e-mail support seven days per week. Responding to telephone queries has the highest priority during scheduled contact hours since on-campus queries can often be handled through course tutors. Voice-mail, fax and e-mail queries are typically responded to within 24 hours, even where it is necessary to contact the lecturer or tutor for further information. Most students adhere to established guidelines for the length and format of programming and similar queries. One of their primary resources is the course material, both the pre-course package of course outline, texts and assignment materials and the archived discussion lists, FAQs, streamed tutorials or CHAT sessions generated during course offerings.

Case Notes 11. Online Assignment Management. Since 2000, the Faculty of Informatics and Communication at CQU has developed and implemented an in-house online assignment submission information system (OASIS) to replace its previous paper or email submission, particularly for those with large classes across the network of 14 campuses. Designed originally to provide timely and personalised feedback to students, it has become an effective management tool for course coordinators in overseeing assignment marking, moderation and detection of plagiarism. The technical support behind the system allocates markers to students, creates downloadable files of the students’ work with empty individualised mark sheets for each marker, upload facilities to accept from each marker, the marked assignment work with mark sheet and a file of student marks. At anytime, the course coordinator can view the state of marking activity at each campus, thus alerting them to situations which may need attention or support. Coordinators can also view individual submissions and the associated marking sheet. The online assignment submission tool provides assignment results in a format that allows for on-going monitoring and easy grading at the end of term. With the previous paperbased system the coordinator relied on physical receipts of assignments for moderation, and staff email responses for assignment marks. Students depended on the markers to return the marked assignments in class or by mail, a process that could take several weeks, and complaints of ‘lost’ assignments (perhaps never submitted) were frequent. One coordinator estimated that the online submission system has reduced his overall marking time by up to 20%. His assignments require physical handling of computer discs, virus checking and hand writing of feedback, which is now replaced by the coordinator’s automated marking system attached to the online assignments. As might be expected, there is a considerable interest within the faculty in the uptake of the tool.

staff work within a defined software environment. At some point, however, it would be well to at least consider whether it’s necessary to use exactly the same tools and procedures for all activities, or whether we can accept comparable outcomes, regardless of the tools (or platforms) used. These days student technology support necessarily includes communication capabilities, typically at least e-mail, Internet access and appropriate antivirus and security software. Not so obviously, at least in practice, is the need for a similar requirement for all staff involved in the learning system. Casual and part-time tutors, for example, are not necessarily provided with access to secure systems for handling their student support and marking duties.


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Case Note 12. Using Local Resources. When CQU opened its international campuses in Sydney and Melbourne it did not have the resources to provide a full-service library outside of its traditional campuses. Instead, the international students were provided with library cards and access to a nearby university library. While students were forced to travel from their normal downtown campus or residence to the library they actually had access to better resources than any Queensland-based CQU students. CQU library now has very good online facilities particular useful with database researching.

4.4. Library and Other Resources While CQU has provided a full range of traditional distance education reading materials, this is no longer adequate for either its far flung campus or distance delivery students. Alternatives include providing an institutional library (with the need for a distribution system for distance students) or using local facilities, inter-library loan, etc. Some courses, especially those developed by our ‘early adopters’ cum experimenters, now our more technologically experienced staff, have gone fully online.

5. Summary The following table (Table 1) summarises the central discussions in this paper. The authors have focused their approach by drawing attention to issues of course coordination and technological usage. Campuses may be thousands of kilometres apart, in different time zones and different cultures. The use of technology is a necessary component of this delivery process for both the teaching material and the assessment design. A key theme is that of teamwork for course design and development in an attempt to cater for diversity in cultural requirements. The overall question though is the issue of course management and its complexities of equitable teaching practices and consistent course grading, assignment organisation, content delivery and ensuring effective student feedback.

6. Conclusion The economic realities of tertiary education require providers to focus on servicing international markets, including an emphasis on student preferences for language of instruction, preferred location (campus or distance delivery) and mode of instruction. Educational delivery requires development and delivery teamwork, maintenance of consistency (quality) in terms of offerings and assessment, appropriate use of technology and cultural awareness. For successful coordination of large classes online across multi-campus model, appropriate organisational infrastructure needs to be in place to recognise the expanded role of the academic. Yet the trend towards larger class sizes at the tertiary level may have been seen as an economic necessity by politicians and administrators. Contrary to administrative expectations, organising for and managing the delivery of courses to large number of students, regardless of the delivery mode, is expensive. If the expense isn’t covered by the administration (university, faculty or school), then it will fall on the course development or delivery teams, or the students. It is therefore critical that academics communicate to their managers these issues of complex and time-consuming delivery to ensure that appropriate academic support is given.

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Table 1. Summary of Central Discussion. Area Course design and development

Issue In-advance versus just-in-time development

Diverse student backgrounds

Delivering the course materials

Assessment, course objectives and content Level of academic familiarity with online technology Broadening the virtual view Academic view of teaching, support and technology influence course design Delivery modes

Student feedback

Accommodating students at many locations

Student assessment and evaluation

Cultural expectations

Plagiarism

Technical support

Security for online submissions Course website Course management Assignment submissions Student support Academic resources

Possible solutions Team approach Technical support Staff workload Allocation of time for development time Allocation of technical support staff to add to written text Use communication tools for student discussion Team approach Local examples Design the assessment before the course is developed Use a minimalist approach for web presence Provide CD disk with website course material Need to identify this early in development cycle

Traditional lecture model Self study program Teamwork activities Divide large student numbers into groups of small teams Detailed mark sheets Criteria based assignment Team feedback Campus set of tutors Coordinator uses extensively communication technologies - course mail lists, personal emails, website updates, telephone Use of communication technologies to stimulate debate

Copy detection software Carefully designed assessment to reduce problem Student education Check integrity of author Student able to update uploads of assignment submissions Commercial vs in-house product Training of staff and students in use Value of standardisation Peer tutoring Technology use Campus library Online facility Other universities

This chapter has presented a number of challenges and potential options for managing large classes across multiple locations. Many of these challenges, and the solutions discussed, would be equally appropriate for any course, independent of class size, using current learning and communications technologies. This would include small classes delivered across multiple campuses or at a distance and on-campus classes with online support. The need to manage large classes across multiple locations simply highlights the needs to resolve these difficulties.


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It is noted that this paper did not discuss all issues that relate to coordination of large course groups at multiple locations. Additional areas include technology management including system failure, result recording and system entry for certification; workload issues for markers as well as students, in particular assignment design and assignment feedback; validation process of academic course work with assessment goals; webpage course design for consistency and ease of use; and the requirement of both technical and administration support. These will be discussed in later papers.

References [1]

Oliver, R. & Herrington, J. (2003). ‘Exploring technology-mediated learning from a pedagogical perspective’, Journal of Interactive Learning Environments, 11:2, p. 119. [2] Hayden, M (1996), Insights from an evaluation of the 1993 CAUT National Teaching Development Grants, Southern Cross University, p.3. [3] Hanna, DE (2003). ‘Building a Leadership Vision: Eleven strategies for higher education’, EDUCAUSE Review, July-August, pp 25-34. [4] Morse, K (2003). 'Does one size fit all? Exploring asynchronous learning in a multicultural environment', Journal of Asynchronous Learning Networks, 7:1, pp. 37-55. [5] CQU Teaching and Learning Portal (2003). ‘Curriculum design‘, http://learning.cqu.edu.au/curric_design.php, downloaded 19 Apr 04 [6] Roberts, TS, Jones, D and Romm, CT (2000). ‘Four models of online teaching’ in Proceedings of TEND-2000, Abu Dhabi. Downloaded from http://cq-pan.cqu.edu.au/davidjones/Publications/Papers_and_Books/, 8 Apr 2004. [7] Twigg, CA (2004) Using Asynchronous Learning in Redesign: Reaching and Retaining the At-Risk Student, JALN, 8:1, February, pp 7-15. [8] Egea, K and Gregor, S (2002). ‘Reflections on communication processes and virtual teams by lecturer and student cohort: a case study’. Conference Proceedings, Informing Science + IT Education Conference, Cork, Ireland, pp 411-425. ISSN 1535-0703. [9] Hackett, S (2004). ‘Exam Action: The time has come to let learners take control of their assessment’, Learning English Supplement (April) to the Guardian Weekly, 170:17, 15-21 April, p 3. [10] Hasan, H, Verenikina, I, and Vrzalic, L (2003). ‘Technology as the object and the tool of learning activity’ in Hasan, H, Verenikina, I and Gould, E (Eds). Information Systems and Activity Theory: Volume 3 expanding the horizon. Wollongong, NSW: University of Wollongong Press, pp 15-30. [11] Egea, K (2003). ‘Managing the managers: Collaborative virtual teams with large staff and student numbers’ in Proc. Fifth Australasian Computing Education Conference (ACE2003), Adelaide, Australia. Conferences in Research and Practice in Information Technology, 20. Greening, T and Lister, R (Eds), ACS, pp 87-94.

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3.5. Evolutionary Epistemology and Dynamical Virtual Learning Networks Umberto GIANI Department of Preventive Medical Sciences Faculty of Medicine University of Naples Federico II Abstract. This paper is an attempt to define the main features of a new educational model aimed at satisfying the needs of a rapidly changing society. The evolutionary epistemology paradigm of culture diffusion in human groups could be the conceptual ground for the development of this model. Multidimensionality, multi-disciplinarity, complexity, connectivity, critical thinking, creative thinking, constructivism, flexible learning, contextual learning, are the dimensions that should characterize distance learning models aimed at increasing the epistemological variability of learning communities. Two multimedia educational software, Dynamic Knowledge Networks (DKN) and Dynamic Virtual Learning Networks (DVLN) are described. These two complementary tools instantiate these dimensions, and were tested in almost 150 online courses. Even if the examples are framed in the medical context, the analysis of the shortcomings of the traditional educational systems and the proposed solutions can be applied to the vast majority of the educational contexts.

1. The multidimensional world According to Morin [1] the paradox of the XX century is that it produced enormous progress in all of the domains of scientific and technological knowledge, but produced a new kind of blindness for global and complex problems. This can generate innumerable mistakes and illusions. The blindness is mainly due to the compartmentalised, mechanics, reductionist “intelligence” that composes the complexity of the world into disjoint fragments, splits the problems, separates what is joined, and unidimensionalizes what is multidimensional. These shortcomings can be faced by setting up new educational models aimed to enable the learners to recognize and manage the intrinsic multidimensionality of the vast majority of problems. In fact, the traditional educational systems are based upon the summation of the specialistic knowledge of different non communicating courses, and the students’ future professional perspective is the specialization in some discipline or sub discipline. In Medicine, for example, the specialist is perceived both by physicians and patients as the highest point of the medical profession, and is the reference model for medical students. As Balint pointed out [2], the students are trained to imitate and reproduce the mental attitudes of the specialist. But, the perspective of the specialist is necessarily one-dimensional, whereas health problems are necessarily multidimensional. So, the mental attitudes and the culture of the specialist can conflict with the patients’ demand for a more comprehensive and person centred approach, and is perhaps one of the reasons of the present crisis of medicine.

U. Giani / Evolutionary Epistemology and Dynamical Virtual Learning Networks

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The fragmentation of medical knowledge also affects the quality of care/cure process, the clinical research, and the education of health professionals. This situation has further got worse since the introduction of the new university professional schools, which, on one hand, enhances the specific competencies in particular professional domains, but, on the other, creates a further fragmentation of medical knowledge because it adds the multiplicity of new health professionals to the great number of specialists yet involved in the care/cure process. Moreover, the education of the different professionals usually takes places in a ‘compartmentalised’ way, i.e. without a real trans-cultural exchange between the learners of the different schools. The progressive and increasing specialization of scientific research in the different disciplines affects in turn the educational contents and creates a vicious circle that increases knowledge fragmentation. The result is that different kinds of knowledge converge upon the patient himself, and often lead to divergent or contradictory diagnostic and/or therapeutic prescriptions. The patient interacts with many different professionals, and is often the sole communication medium between these different professionals, even if normally he has not the cultural competence to integrate different sources of information in a proper way. His choices depend on a complex process of social construction of mental representations of the illness and of the care/cure process [3-5] in which participate the patient’s family, caregivers, members of the social network in which the patient is embedded, and recently the Internet. So, the diagnostic or therapeutic patients’ behaviours are often at odds with the prescribed ones, and lead to a sort of globetrottering among several professionals with a consequent increase of the number of medical tests and treatments, which in turn affects both the costs and possibility of assess the real efficacy of the health system. Patient education is a crucial issue in a new innovative educational model, but it is usually oriented to single diseases and is often aimed at merely obtaining the patients’ compliance according to a paternalistic view of medicine [6]. It is worth noticing that specialistic medicine was born essentially in hospital environments and therefore is centred on health problems of people referred to the hospitals which resemble an immense repair shop with distinct departments for the reparation of the different parts of the human machine. Accordingly, the textbooks and more generally medical knowledge reproduce this organizational structure, also because the textbooks are usually written by hospital doctors, and mainly by professors at university hospitals. The fragmented model of education and training implies also a substantial lack in the historical and epistemological dimensions. As Kuhn [7] pointed out, the educational model by which the dogma-paradigm (the so called Normal Science) is transmitted from generation to generation is based upon the use of textbooks that are written specifically for the students. The student is not encouraged to read the texts of the past because they are considered implicitly as obsolete. This hinders the new generations to appreciate the historical process that led to the present state of the knowledge in a specific area. The textbooks that compete for the adoption in a scientific course mainly differ in the pedagogical level of detail, not in the substance or in the conceptual structure. Students start from standardized problems whose solutions the profession arrived to and are accepted as paradigms. The students are asked to solve only the problems provided in the textbooks. Scientific education remains an initiatory and relatively dogmatic ritual training in a set of pre-established solutions of problems that the student is not invited to appraise, nor are they ready to do so. The Kuhn’s description is perfectly tailored to the features of the traditional educational systems where the rich dynamics of the cultural evolution is transformed in simplified, idealised and standardized situations, and learning is centred upon atemporal abstract notions. For example, medical knowledge is centred on the concept of disease that is conceived as an ideal type instantiated with minor or major modifications in each particular patient.

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The disease picture is usually taught without taking into account that a given medical problem has different characteristics depending on the geographic, social, cultural, organizational and psychological context. Moreover, the concept of disease changes over time and is essentially a temporally qualified notion whilst physicians conceive “disease” as disordered physiological structure and function, set within abstract, medicalized time [8] or as “de-historicized objects in themselves”[9]. Thus, while patients experience “sickness” in the context of life narratives, the lived body, and the diverse forms of social relations and power structures, medicine constructs the objects of therapeutical attention as an ahistorical, atemporal, and non social dimension of the medical body [10]. The holistic or bio-psycho-social approach has been questioned by claiming that it would imply a sort of omniscience, and that it is impossible that a single person has the necessary competence in different domains. This objection is based upon a substantial mistake, because a multidimensional problem is not the sum of several mono-dimensional specialistic problems. For example, it is not necessary that a community or family physician had the competence in all the medical specialties, rather he should be able to integrate the information coming from different specialists, effectively communicate with them, and interact with the patients and their relatives, without being a multi-specialist. In other words, he has to connect several different dimensions in order to manage the variety of aspects of the health problems of their patients, also by taking into account the context within which such problems are located. But, these integration skills cannot be obtained by merely summating fragmented de-contextualized disciplinary notions. There is another way in which the educational models hide the context. For example, the individual centred approach moves in the background the ecological level of disease description. Environmental aspects of health problems are after all a marginal problem in traditional medical education because the attention is focused upon clinical and biological issues concerning single patients. This conflicts with the growing consciousness that environmental issues, such as water and air pollution, climatic changes, population migrations due to wars and climate changes or new diseases linked to new production systems (for example genetically modified organisms, pesticides and so on) play a crucial role in human health. These aspects fall substantially outside the primary focus of medical education. The overall effect is to de-contextualize the patients from the social and ecological system in which they live, reproduce, and die. Moreover, the health of human populations is conceived as the summation of the health of their members. But, even if that is eventually true, this argument is used for implying that the main route to population health is to act on individuals, whilst in many cases global interventions (better preservation of the foods, better housing, drinking water, better nutrition and so on.) are the main route towards the enhancement of the individual health and preserving the health of populations. The recent events of the so-called “crazy cow”, the deadly epidemics of flu due to infected poultry in eastern countries, the recent SARS epidemics, the damages produced by air pollution, the effects on the health of the climatic changes, genetically modified organisms, and of the reduction of the biological variability conflict with a conception of a medicine centred on the biochemical mechanisms-cellular and on individual diseases. In summary, the fragmented de-contextualized mono-dimensional education model is in contradiction with the growing consciousness that the globalization must change the way in which medical education should be conceived because medical professions today must confront with the explosion of technology, the changing forces of the market, the problems of the health services supply, the bio-terrorism and the globalization. The actual educational systems lead to the fact that doctors, nurses and other health related professionals have many difficulties in handling and reinterpreting their responsibility towards the patients and the society [11]


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These issues raise the need to deeply re-conceptualize the teaching-learning process. A symptom that this is an inescapable problem is the overwhelming succession of different medical curricula. It is as if the institutions had a substantial inertia to track the rapid changes that are going on in the society. One of the factors that conflict with the need for continuous change is the “tyranny of the disciplines”. The learning/teaching process should be rethought in a new perspective, that is with a substantial improvement of the contents and of the educational methodologies towards contextualised, non fragmented and multidimensional models. One should also realise that any action is reflected in a myriad of dimensions so generating very complex dynamics. The notion of ecology of action allows conceiving the complexity as the result of the dynamics of the web of the intricate interdependencies between different facets of a given phenomenon. The notion of complexity goes beyond multidimensionality, because it implies the idea that the various dimensions are interconnected and that these interconnections generate new phenomena. From this point of view, the actors of the diagnostic and therapeutic process do form a complex system whose dynamics, which is largely unknown, affects the overall decision-making process and eventually its outcomes. For these reasons the education of health professionals should be aimed at developing to deep attitude to conceive the care/cure process as the effect as well as the cause of the interaction between different kinds of knowledge. The actual educational system does not meet these objectives. A possible answer to this problem is the development of integrated multidisciplinary/multiprofessional education (IME) aimed at the same time to preserve the cultural specificity of each professional and disciplinary area, and to produce a deep trans-cultural education and knowledge integration. This integration should involve both the so-called “medical humanities” and the scientific and technical knowledge. The efficiency and efficacy of integrated models of medical education should be based upon the rigorous analysis of the scientific evidence by means of both qualitative and quantitative research methods. In particular, the analyses should be addressed not only to evaluate the classical cognitive competences, but also to assess the degree in which the educational process induces substantial modification of the learning categories towards the ability of integrating different sources of knowledge.

2. From the centres to the networks In this framework multimedia and distance learning can play a crucial role. From a general point of view, the information technologies can enable us to create new IME models by shifting from the millenary concept of centre to the concept of network, that is a structure that, even if lacks in a central control, nevertheless is capable of selforganization. Some authors claim that the web itself has some mental features. It is the hypothesis of the so-called global brain: Internet has a formative role even in the absence of any centralised control, and the mere navigation over the Internet would produce new knowledge. From another point of view, Internet is an implicit tutor. However, the idea that only an absolute freedom would lead to deep long lasting learning is questioned by other authors who point out some negative effect of web navigation. For example, globetrottering is a typical side effect of web navigation since the navigator can get lost in the cyberspace due to the huge amount of information and news that he can find during the navigation. To resolve this problem some software producers add tracking tools to their applications. But, even if these methods allow reconstructing the sequence of the visited sites, nevertheless they are not able to reconstruct the logic of the choices of the navigator.

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From another point of view, Internet allows the construction of asynchronous learning networks (ALN), i.e. virtual learning communities without any temporal and spatial constraint: learners and teachers can access the network at any time and from any geographical area [12,13]. It can be assumed that ALN can play to crucial role in IME. In fact, in the traditional education settings the students of the different professional schools must necessarily attend the face-to-face disciplinary based lessons and seminars in different teaching rooms. In principle, ALN allows the activation of multiprofessional/multidisciplinary virtual classrooms where learners and teachers with different backgrounds and from different geographical areas can meet without time and disciplinary constraints. Moreover, ALN also allow tracking the learning interactions and are so a valuable and perhaps unique tool for the scientific analysis of the learning/teaching process and multicultural knowledge diffusion.

3. Evolutionary epistemology Learning can be conceived as the interactive social construction of a network of concepts and ideas carried out by a network of cognitive agents where creative and critical thinking interweave in time and in space. The Darwinian metaphor seems very promising for analysing the role of critical and creative thinking in educational models. In fact, mutations occur in an apparently blind and casual way. The environment chooses those mutations that will survive and those that will be discarded from the evolution. The fundamental rule of the evolution is an irregular oscillation between blind variation and selective fixation. Variation is essentially a creative act because the mutations inject variability into the biosphere and are essential for the perpetuation of life in spite of more or less sudden and radical environmental changes. The selection processes can be considered as a sort of anticasuality that contrasts the random occurrence of mutations. From another point of view, natural evolution can be conceived as an attempt made by Nature to solve a problem in the interaction between the organisms and the environment, and to memorize the “best” solutions. If this is true, the entire evolution can be considered as an infinite and immense learning process. Evolutionary epistemologists [14, 15] claim that the metaphor of Darwinian evolution can be applied to the diffusion of knowledge and culture in human communities. In fact, the history of knowledge is characterised by the emergence of new ideas (mutations, i.e. the effects creative thinking) some of which are discarded, maybe temporarily, by the cultural evolution, and some will survive and transmitted to the new generations(selection, i.e. the effects of critical thinking). From this point of view, education can be conceived as the process of knowledge transmission from old generations to new generations. Now, from a certain point of view the traditional educational models are a deliberate, maybe unconscious, action of inhibition of the creativity. This can be appreciated by considering that the term “discipline” is typical of the armies and a well disciplined person is a person with few degrees of freedom. These models are at odds with the need of continuous innovation of the modern societies. In fact, the economical structure of the society has been oriented for centuries towards the production of material goods, but nowadays is oriented towards the invention of immaterial goods, such as software, research engines, information, e-commerce, and so on. The so-called new economy is dependent upon continuous innovation and reinterpretation of old professions and jobs. So, critical thinking has to be conjugated with creative thinking and a new educational paradigm should be set up.


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The creation of a learning culture and the enhancement of human creativity are two pre-eminent topics in the world today. Leaders in business and government world-wide know that the solutions to pressing economic, social and political problems lie not in yesterday's thinking and behaviour, but in entirely new ways of seeing, perceiving and behaving. Learning and creativity are inseparable components of any successful enterprise. So, how do we go about "being creative"? And how do we find a blueprint with which to build a learning culture - in our business organizations, our political and educational systems - in ourselves? Creativity, clearly, will not flourish in an environment which is not dedicated to change. Learning, therefore, is a critical issue [16]

But, the need of creativity generates an anomaly in a society based upon the paradigm of centralized control, and conflicts with the obedient learning/teaching paradigm of the traditional educational systems. The model of centralized control is being transformed into a network based model; the oneness of the truth is being substituted by multi-rationality; there is a troubled search for new models of interpretation of the world; people realise that there is not just one scientific methodology and that the observer is not independent of the observation in any field of knowledge; there is a (re)discovery the theory of complexity. The predictable and stable world of the ancient society is replaced by an intrinsically chaotic and unstable world, i.e. a sort of regularly irregular world. In principle, the inertia of the educational institutions is not a bad thing because a certain degree of stability is necessary. But an excess of stability is dangerous because it leads to a decrease of cognitive variability and eventually to a cultural impoverishment, whereas a substantially interconnected, complex and multidimensional world requires a fair dose of critical and creative thinking. So, the educational process, which is too much oriented towards selection and fixation (preservation), has to be corrected by stimulating the process of variation (creativity) not only in connection to the contents of knowledge, but also to the way in which these contents are generated and transmitted. This correction can be obtained by moving the focus of the education from the individual learner to the network of coevolving actors of the learning/teaching process. In this perspective, the ritual of the academic lesson, which is self reassuring for the teacher and passivizing for the learner, and the concept of program itself should be deeply rethought because the teacher is confronted with the fact that knowledge is limited and that the students must be induced to create new knowledge. The student is transformed into a sort of researcher, and the teacher into a facilitator who helps the student to learn how to learn, critically appraise the quality of the information, avoid informative overload, choose the right information at the right moment, and create new knowledge. So, the two actors of the formative process become co-learners and co-teachers and the task of the tutor shifts from teaching to enabling to think in a creative and critical way. The model of vertical transmission of knowledge should be replaced by a horizontal model where the learner is a partner of the process of knowledge creation. From the evolutionary epistemology point of view, traditional educational models are unbalanced towards the selection process, whilst the problem is to balance the process by injecting into the system some mechanisms aimed at increasing variability in order to enable the students to create new ideas, new concepts, new models, and new theories, and critically appraise them in order to select the most promising ones. In other words, one should support the development of creatively critical thinking. 4. Enigmas and learning Distance web based education would have a fundamental role in this direction. A learning environment that is well balanced between the processes of blind variation and selective fixation could be based upon the induction of the cognitive dissonance [17] arising from the need of taking a decision when the information upon which such a decision has to be based

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is ambiguous, uncertain, incomplete and/or difficult to be gathered. So, the tutor should engage the students' curiosity starting from real or realistic problems and drive them to realise the problems can be solved by a careful retrieval and analysis of the information stemming from many sources. At the beginning the students should be involved in the process of creating meanings, formulate questions, sharing ideas without being overwhelmed by the need to solve the problem. Moreover, they should be told that there is not just one “correct” solution, but that the same problem can be shaped in many different “correct” ways. The virtual learning environment should engage the learners in typical research settings where several actors with different expertise and level of knowledge are involved. The research process is triggered by an ‘enigmatic situation’ (ES) which needs to be analysed. One can distinguish between problem solving, that is the solution of given well shaped facets of the ES, and problem finding, that is the process of structuring the ES. Problem finding is the first and, maybe, most important phase, and usually it is carried out via translation by means of metaphorical reasoning the new situation into to a more familiar one, that is into a situation for which the solution is known or can be, hopefully, easily found [18, 19]. At the beginning, a sort of negotiation among the experts occurs aimed at exploring different aspects of the ES. When the problem is well defined, problem solving starts aimed at defining a clear research design, planning data gathering, finding or producing the most suitable software or computational tools, taking into account objective constraints, such as the available or forecasted resources in terms of time, money, personnel, other competing lines of research, ethical issues, and so on. Usually, both in the problem finding and in the problem solving phase, the need arises of consulting experts and the literature so leading to the accumulation of a selected bibliography which forms also the reference starting knowledge with which the results are to be eventually confronted. Also, seminars or lectures are given in order to highlight some aspects of the problem. All these activities lead to a continuous tuning of the research plan in order to focus upon realistic and objectives of interest. The main consequence of this turbulent dynamics is that not all the aspects of the ES are analysed with the same deepness and extent. So, at each step of the process there are aspects (problems) of the ES that are well defined and others that are merely sketched and their analysis postponed. Also, some data analyses are simply outlined, whilst other facets are more deeply analysed, others are abandoned because they led to unfruitful lines of thought. Eventually, some of the research lines leads to significant results and are submitted for publication. The paper is evaluated by independent referees, whose comments lead to further modifications of the original analysis, and so on. One can easily see that this complex process produces an ensemble of ideas, data, computations, reports, evaluations with different degrees of completion. All these conceptual objects form a dynamical network from which one can continuously gather further insight into the nature and into the several facets of the ES at hand. Figure 1 shows an abstract model of this process, where knowledge is conceived as a transformation operator which allows the transformation of data into information (that is giving a form and structure to the raw data), information into plans and actions, actions into results, results into evaluations, and evaluations into revised or new data and so on. The double arrows indicate that the knowledge is in turn modified by the effects of these transformations. According to this model the entire process produces a dynamic network of more or less sketched ideas, computations, problems, data, plans, literature studies, more or less definitive reports, and so on. Teaching should be based upon involving the students in this hopefully exciting turbulent process aimed at developing creative and critical skills for the discovery of the scientific knowledge needed for coping with ESs. In this respect, the Problem Based Learning (PBL) approach can be regarded as the starting point for activating both critical and creative thinking [20, 21]. A ‘problem’ is in


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Figure 1. The process of knowledge construction.

fact an ill-structured, enigmatic, intriguing and real life like situation built by the tutor. At the beginning the ES contains only a limited amount of information. As the learning session proceeds, the students, with the help of the tutor, are driven to define a list of learning issues that they have to learn in order to cope with the proposed ES, i.e. in order to structure it. For each facet of the ES they must decide what kind of information is needed, how to gather it, what is the best analysis to be performed, what are the expected results, how to evaluate them, and so on. As one can see, PBL is based upon a sort of creative ‘strip-tease’ procedure where the tutor does not give all the information to the student, but faces him with a poorly informative situation in which the information is to be actively searched and structured. This structuring activity, i.e. finding relationships between data, information structures, pieces of knowledge, and so forth is the core of the learning process. If PBL is oriented to the production of a research project one can build up an educational model that mimics real situations. In this respect the role of the teacher-tutor is similar to the role of the leader of a research group, and the whole PBL session realistically mimics what happens when a research problem is set up. 4.1. From PBL to M_PBL If, in order to cope with the ES, it is necessary to involve and integrate different disciplinary competences, an IME model is set up. This model implies a radical change of the concept of assessment because one must now assess whether the student developed a critically creative way of thinking, are able to integrate knowledge coming from different sources and collaborate with other students in order to produce a multidisciplinary project. In fact, knowledge integration does not merely mean sharing factual and disciplinary knowledge, but mainly a way of conceiving health problems in a multifaceted way. This educational model can be the basis for “producing” professional subjects oriented to the so-called research based practice [22]. In fact, each professional subject should be considered as a potential knowledge producer and researcher. In other words, health professionals should be able to analyse scientifically the results of their diagnostic and therapeutic behaviours and choices, conceive knowledge in a critically constructive way, express scientifically relevant questions, communicate with colleagues of their own disciplinary area or of different disciplines, cooperate with the patients in identifying their problems and their possible solutions, comprehend

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how the mental representations of the actors of the diagnostic and therapeutic process affect the entire care/cure process, and so on. This should not be disjoint from an attitude to integrate technical and scientific notions with medical humanities and environmental sciences. In Multiprofessional / Multidisciplinary Project Based Learning (M_PBL) groups of learners with different backgrounds can be induced by the tutor/facilitators to discover trans-disciplinary connections, and create multidisciplinary and complex projects. So, M_PBL is a generalization of the so called multiprofessional learning [23]. In this respect, conceptual maps, i.e. networks of conceptual nodes connected by links, allow to represent graphically the way in which people conceive a given argument or concept, and seem able to grasp at least one of the meanings of knowledge integration. Multimedia and interactive versions of the classical cognitive maps, such as Dynamic Knowledge Networks (DKN), add new possibilities to the classical scientific and statistical analyses of the learning processes because they allow capturing deep aspects of learning [24-25]. Cognitive maps have been used also as a powerful tool for patients’ education. Moreover, it is well known that the assessment criteria do influence directly the way in which the students learn. So, if one of the objectives of IME is to stimulate a new way of learning, then new models of assessment must be developed. These models should not be simplistically oriented to the evaluation of the cognitive competencies or surface aspects of learning. Instead, they should allow analysing the degree in which the students developed a genuine capacity of integrating different dimensions of a given topic within a dynamical and complex perspective. This situation leads to important methodological issues, because the classical statistical approaches, such as for example the “before-through-after” statistical analysis of predefined questionnaires, are too simplistic in order to assess whether a student is able to synthesize intelligently different kinds of knowledge. In this respect, DKN also can be considered as a tool for assessing the degree of connectivity of the students’ mental representations. However, even if concept maps and DKN capture deeper aspects of learning with respect to the classical assessment approaches, they are not able to represent the complex social dynamics of knowledge construction. Distance-learning networks could fill the gap, and play a crucial role in multiprofessional education in health sciences because they allow creating virtual communities of learners and teachers with different backgrounds (e.g. physicians, nurses, informaticians, statisticians, psychologists, educators, managers, and so on). Moreover, these systems allow tracking the interactions between learners and the system. So, they are a valuable tool for the scientific analysis of the learning/teaching process and of knowledge diffusion in human communities. From this point of view, the asynchronous distance learning networks (ALN) allow not only forming multiprofessional/multidisciplinary virtual classrooms, but also assessing the process of social construction of knowledge. The e-learning system Dynamic Virtual Learning Networks (DVLN) was implemented in order to meet these desiderata [26]. 4.2. Towards tolerant thinking However, the information technology and software is just a small part of the issue. In fact, one should honestly recognize that there are several obstacles to the development and application of a new educational paradigm. Among these there are psychological and personality factors that can affect the extent in which a given person can develop a critical and creative way of thinking. According to Allport [27], one can recognize essentially two types of personalities: authoritarian and tolerant. Authoritarian persons need clear and simple behavioural rules, consider the ancient knowledge coming from an authority (a teacher, a book, a leader, and so


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on) as a guide. They do not tolerate fuzzy situations, disregard abstract thinking because it leads to uncertainty, and tend to dichotomise the reality into couples of opposite polarities: e.g. strong-weak, friend-enemy, correct-incorrect, good-bad, and so on. From the cognitive point of view they use stereotypes, and are not able to see different aspects of a problem, i.e. they are narrow minded. Tolerant people have a greater mental flexibility, do not dichotomise, and tolerate ambiguities, uncertainty and frustration. They admit their ignorance, have a greater insight and social intelligence, and are able to see and connect several aspects of a given situation. From the studies carried out up to now it is not clear whether tolerant persons are also more intelligent, but certainly they are on average more cultured because the culture softens the feelings of insecurity and of anxiety. Probably the Allport’s dichotomy is too schematic and the two typologies, authoritarian and tolerating, can be considered as the extremes of a continuum between opposite polarities: each individual is placed somewhere between these extremes. Moreover, it is reasonable to suppose that being authoritarian or tolerating is also a function of the specific task and that human beings are authoritarian in an area or in some circumstances and tolerating in other circumstances, other tasks or other contexts. From the pedagogical point of view, the transition from authoritarian to tolerant thinking should be one of the main objectives of the IME models because flexibility, critical and creative thinking would enable people to deal with multidimensionality, contextuality, and complexity. 4.3. Critical thinking Probably personality factors underlie the individual cognitive style, i.e. the way in which people capture and represent external and internal “reality”, and therefore the way in which they learn and teach. The learning styles (LS) [28-30] can be considered as the network of cognitive, emotional and psychological factors that can be used for describing the relatively stable way in which people perceive, interact and respond to the learning environment Some authors claim that LS are personality traits that cannot be easily changed, whilst others conceive them as relatively stable ways of thinking which are susceptible to evolve over time. LS also can be used to predict which methods and formative strategies would be the most effective for a given individual and/or objective of learning. A general recommendation could be that IME models should be aimed at enlarging the repertoire of cognitive styles of the community of learners in order enable them to appraise the situations according to a multiplicity of points of view and contexts. Moreover, one should orientate this enlarged repertoire towards critical and creative thinking. According to Nelson [30] there are four phases in the development of critical thinking 4.3.1. The knowledge as truth This is the most primitive level of critical thinking. At this level people think in a dichotomized true-false way and are convinced that the scientific theories are absolutely true, and that any pertinent question has always one and only one certain answer. They see the world in white and black. These persons passively accept the point of view of the authority rather then activating personal elaboration, and feel comfortable in applying simple predefined rules. At this stage knowledge is an objective and eternally true “discovery” of the truth. Since the authority knows all the answers, the role of the student is simply to reproduce what the authority says. This stage could correspond to the authoritarian thinking.

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4.3.2. Knowledge as opinion When the persons realize that the authority does not always know the answer to specific questions, they also realize that the truth is not “objective” and enter in a phase of big trouble. In this phase the individuals split the “reality” into two worlds: one in which the truth exists and in which the authority knows the right answer, and the other where each person is free to think the way they want. The respective amplitudes of these two worlds are variable from subject to subject and from one area of knowledge to other areas of knowledge. To the first world people apply the dichotomies of the previous stage, while for the second world the persons are convinced that their point of view is superior with respect to other people’s ideas. However, in an obscure way people at this stage are beginning to think with their head. 4.3.3. Contextual relativism The transition to the contextual relativism stems from the awareness that also the personal opinions are insufficient. The thinking style, at this stage, is characterized by a sort of withdrawal in non-evaluation. The students cynically choose to say to the teacher what they suppose (s) he wants and opportunistically considers the answers to be given as a sort of cynic game. As a consequence they claim that teaching should be based on such logic: the examinations preferably should be in the form of multiple choice questions with only one correct answer, the questions themselves should be circumscribed to explicit arguments of the program, and so on. Nevertheless, they do not succeed, in seeing the relevance of the connections and interrelations between different disciplines nor can they say what are the best criteria for choosing a theory or a model with respect to another. In summary, they are not able to take the responsibility for the construction of their knowledge. Often the teachers themselves maintain the students in this “childlike” stage of dependence from the authority 4.3.4. The responsible knowledge The transition to this stage derives from the awareness that the problems can be conceived from different points of view and contexts, that other individuals can conceive the things in different ways and that there is a sort of multi-rationality. The persons at this stage can describe the advantages and the disadvantages of the different approaches. and are able to argue the reasons for the approach they prefer. They are also sceptical on simplistic answers and realize that the answers are context dependent, are able to argument and defend their thesis, learn with enthusiasm, and see the education process as an enhancement and not as an obstacle to be overcome. In few words they became tolerant persons, responsible of the construction of their knowledge. The Nelson’s evolutionary stages describe the long and difficult way from authoritarian to tolerant thinking and introduce an evolutionary dimension that is absent in the studies on the cognitive styles and on multiple intelligence. The result on the pedagogical side is that, the tutor should understand what the stage of development of their students is in order to facilitate their development towards responsible knowledge. From a more general point of view, several definitions of critical thinking were suggested • • • •

the ability to analyze facts, generate and organize ideas, defend opinions, make comparisons, draw inferences, evaluate arguments and solve problems [32]; a way of reasoning that demands adequate support for one's beliefs and an unwillingness to be persuaded unless support is forthcoming [33]; involving analytical thinking for the purpose of evaluating what is read [34]; a conscious and deliberate process which is used to interpret or evaluate information and experiences with a set of reflective attitudes and abilities that guide thoughtful beliefs and actions [35];


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Table 1. Difference between ordinary and critical thinking.

Ordinary thinking Prefer Grouping Believing Inferring Concept association Note relations Suppose Offer opinions without argumentations Formulate judgments without explicit criteria •

• •

Critical Thinking Assess Classifying Assuming Logically inferring Grasping principles Note relations between relations Hypothesize Offer opinions supported by rational argumentations Formulate judgments with explicit criteria

active, systematic process of understanding and evaluating arguments. An argument provides an assertion about the properties of some object or the relationship between two or more objects and evidence to support or refute the assertion. Critical thinkers acknowledge that there is no single correct way to understand and evaluate arguments and that all attempts are not necessarily successful [36]); the intellectually disciplined process of actively and skilfully conceptualizing, applying, analyzing, synthesizing, and/or evaluating information gathered from, or generated by, observation, experience, reflection, reasoning, or communication, as a guide to belief and action [37]; reasonable reflective thinking focused on deciding what to believe or do [38].

People with critical skills are constructively sceptic and open-minded, appreciate evidence, rigorous reasoning, clarity and precision, But at the same time they are able to explore the things from different view points, and are ready to change their minds when a sound argument is suggested. They also identify and construct complex argumentations, to carefully listen to the others’ argumentations, formulate questions without the fear of showing own ignorance. The following table shows the main differences between ordinary and critical thinking. So, a deep change of the way in which the contents are conceived and taught is needed in order to orientate the education in the direction of the development of the critical thinking so that the students go beyond simple memorization and passive reception of the “transmitted” notions towards deep understanding, take the responsibility of the construction of their personal knowledge, develop the ability of questioning, critically appraising the literature, and so on. 4.4. Creative thinking A creative person is curious, is in search of problems and takes pleasure in the challenge; looks at the problems not as obstacles, but as opportunities; perceives problems as interesting and emotionally acceptable and as a fundamental tool for the enhancement of knowledge and culture, has no fear to express his(her) own ideas, also in contrast with the authority; lives in the permanent state of constructive dissatisfaction; is substantially an optimist and believes that whatever the problem, it can be resolved; has the capacity of suspending judgements and to refrain from immediately stating that a thing is right or wrong; has a deep capability of observing and listening; feels free to also express strange questions; does not blame the limits and incongruence of the knowledge; is constantly in search for solutions; feels comfortable with imagination; believes that the mistakes are not to be censored; has an horizontal thinking and is able to see connections between very different fields.

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Creative thinking is mainly based upon the ability of provisionally suspending critical judgments by focusing of attention in a fluctuating random-like way. The word “serendipity” probably captures some crucial aspects of this way of thinking. Creative thinking involves several dimensions: 4.4.1. Inventivity is the capability of creating new ideas by suspending for a short time critical judgment and building up clarifying analogies and innovative metaphors 4.4.2. Connectivity is the capability of connecting ideas belonging to different cultural areas, comparing alternative views, introducing new elements in a discussion, finding and synthesising new information. 4.4.3. Introspection is the capability of insight into the personal cognitive processes and emotions, drawing the objectives of personal learning, formulating personal projects, taking the responsibility of the learning process 4.4.4. Collaboration is the capacity of working in group, accepting and expressing one’s ignorance, asking pertinent and intelligent questions, taking one’s responsibility of tasks within the objectives of the group, organizing the personal work and connecting it to that of other members of the group, respecting other people’s opinions. Some mental attitudes can block the creativity. Symptoms of inhibition are thoughts of the type: It’ crazy! It’s childish! Oh no! A new problem! I‘m not able to do the job. I do not have the necessary skills. I’ll be considered as mentally insane. So, while critical thinking is analytic, converging and vertical, creative thinking is synthetic, diverging and lateral. Creativity will not flourish in an environment that does not encourage thinking freedom. As we saw, culture is a fundamental factor for the shift from authoritarian to tolerant thinking and therefore to creativity. In particular, since creative thinking is often based on linking ideas from apparently different areas, it is necessary to provide a learning environment aimed at increasing the students’ general culture. This can be achieved by providing many cultural stimuli, including the so-called humanities, and particularly the history and the philosophy. So, even technical notions should be embedded into a rich context of related social, economical, organizational, psychological, historical, and epistemological issues. 4.5. Union of the differences and collaborative intelligence Different studies show that the creative attitudes of the students increase if they work in groups because the differences between people are the driving force of change. Historically the differences have been perceived as "the enemy", i.e. something to avoid. In fact different and contrasting views generate a sense of discomfort and impatience. Our unconscious refusal to cope with inconsistencies and our unwillingness to integrate them into a common dialectic framework substantially weakens our ability to create long lasting solutions to our problems. Instead, the union of differences is the seed from which new ideas stem. Only when the creative power of the differences is appreciated, we made the first step towards educational models aimed at developing a collaborative intelligence focused on the process of social construction of knowledge. These models are not teacher centred nor student centred, but are social network centred. This environment can be facilitated by providing suitable cooperative distance learning environments. 4.6. Flexible learning The concept of flexible learning (FL) probably has many meanings [39-40]. According to some authors in FL the learners have something say on where and when to learn. Other au-


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thors claim that FL is an approach to teaching focused on student responsibility so that he is involved in learning activities that are in agreement with his(her) actual needs and/or with those of the group of whom (s)he is a member. Finally, others claim that FL is a philosophy that puts the student at the centre of the scene and recognize that learning is a process that endures for life. FL requires that the student have a greater freedom of negotiating the choice of the arguments, the educational tools, and the formal procedure of assessment and so on. FL is an answer to crucial questions. 4.6.1. When to learn. The student has greater freedom of choosing when to learn in opposition to the rigid organization in semesters or years: the obligation to attend the courses is replaced with the possibility of a greater personalization of the timing of learning. 4.6.2. Where to learn. Not necessarily the students should attend the same lessons, in the same classes, at the same time. They can study at home, in a class, in a library, in a study centre. 4.6.3. What to learn. The students have the opportunity to negotiate what aspects of a given area should be learned. In this respect, the learning contracts are an extreme version of this kind of flexibility. 4.6.4. How to assess learning. Since the assessment procedures are the most powerful driver of learning, a wide range of assessment procedures should be available and negotiated with the students. 4.6.5. How to build a learning environment: In order to promote active learning, the institutions involved in FL should provide a wide range of facilities. 4.7. Social negotiation of knowledge In summary, the tutor-facilitator should have the ability of understanding the cultural interests of single students, their cognitive styles, and their way for interpreting the learning process itself. In opposition to the individual based approach, more attention should be given to socialization of knowledge. From this point of view, the actors of the learning process must develop the capability of intelligently negotiating knowledge and to communicate with each other because the creation and diffusion of innovation stems from a suitable communicative environment. The focus of attention should be shifted from the contents of learning to a set of interrelated learning methodologies that allow the learner to comprehend, integrate and assess knowledge coming from several cultural domains. The negotiation of knowledge leads to the construction of a learning community which elaborates its own social cognitive style, language, set of pertinent knowledge, that is its own way of thinking. 4.8. Constructivist vs. objectivism The classical educational model is based upon the concept of program, i.e. a sequence of predefined arguments that is implemented during a semester or an academic year. The programs are defined at different levels: States, Universities, Faculties, and so on. The role of learners in the definition of the arguments and their sequence is practically nil, and often also the teachers’ freedom to introduce a new argument is limited. This philosophy roughly corresponds with the objectivistic model and is based upon the standardization of content and procedures: the authority defines the objectives of learning and creates a systematic approach to the content.

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On the epistemological view the objectivistic approach is based upon the assumption that the world is composed of objective entities and relations: knowledge is objective and independent of the knowing subject. It follows that learning means to capture this objective structure of reality that the authority knows. The differences between individuals depend on the fact that their knowledge is partial and limited. Given these premises, according to the objectivistic model, teaching must transmit the “correct” conceptual structures and enable the development of the competence in the objective knowledge. On the pedagogical side, this approach leads to behaviourism and cognitivism. The extreme version of the objectivism is the so called instructionism that is aimed at instructing people to do a well defined job. Objectivists believe that knowledge is outside of the learner truths exist and learners must memorize them. The objectivist model is best seen in behaviourist methodology such as in direct instruction, where the goal is usually to have the student acquire and repeat factual information. Most textbooks are designed for, and most teachers are trained in, this type of model. Students either read or are told factual information, and then they are to repeat this information as a part of assessment to see if they "learned" it. This type of model is fine when the objectives to be met are for that type of informational memorization [41].

The constructivist approach stems from a deep criticism to objectivism: passive (objectivist) approaches to learning assume that the students learn by receiving and assimilating knowledge individually, independently of others. In contrast active (constructivist) approaches present learning as a social process that takes place through communication with others. The learner actively constructs knowledge by formulating ideas into words and these ideas are built upon through reactions and responses of others. In other words, learning is not only active but also interactive [42].

From the epistemological point of view, the constructivist approach subsumes that the meaning is imposed to the world by the knowing subject: each individual builds up his own knowledge. It follows that learning is conceived as a continuous process of construction, interpretation and modification of the individual mental representations of the “reality”. So, knowledge and understanding are essentially processes of conceptual change and are activated by discussing, re-elaborating, and restructuring previous knowledge. This leads to what the constructivists call the shift from learning to thinking: the students should be enabled to think in an autonomous way and not merely to learn what other people thought for them. In this perspective the learner’s objective is to construct or reinvent his knowledge. ordering and re-ordering knowledge, testing it out and justifying this interpretation is the underlying principles of constructivist practices… learning is the search for meaning [43]

In this perspective, knowledge is constructed by human beings and is not merely a set of facts, concepts or natural laws to be discovered; it does not exist independently of the knowing subject, it is inherently conjectural and fallible. It is not stable and is always incomplete and provisional. This approach implies that the learning/teaching process should take into account the learners’ previous conceptions and knowledge. From the pedagogical point of view, the constructivist approach goes from the concrete to the abstract, in contrast with the objectivistic model that goes from the abstract to the concrete. “constructivist environments start with observations within a world of authentic artefacts rooted in authentic situations. Students, while accessing various materials, construct ongoing interpretation of their observations, and collaborate with their peers. Finally, students serve as coaches and teachers to each other to show their mastery of what they learned [44]. The objective of the tutor-facilitator is to create a learning environment which is rich of cultural stimuli and information, socially significant, help the learner to create authentic


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learning objectives, integrate the comprehension of multiple perspectives, personalize learning, and facilitate the individuals’ construction of knowledge. This is a contextualized, situated or anchored learning environment. The strategy for the activation of a constructivist learning environment can be synthesized in the following steps. 1. Activation of previous knowledge. The so called prior knowledge should be elicited before learning new concepts. 2. Knowledge acquisition. The acquisition of new knowledge should not be based upon assembling elementary packets, but should start from realistic and complex problems. The PBL approach is based upon such principles. 3. Knowledge exploration. The students should be allowed to explore all the facets of new knowledge and to share them with other students and the teachers. 4. Meta-learning. The student should be induced to reflect upon the steps made for gathering the new knowledge, and abstract from concrete situations to theoretical models in order to transfer the knowledge to other fields. The development of an attitude to metaknowing is the basis for learning to learn, that is meta-learning [45].

5. Re-conceptualising the assessment Some authors claim that the assessment procedures play a key role because they orient not only the contents but the entire learning process. The assessment procedures can be analysed according to the needs they satisfy. From the point of view of the student, the assessment is aimed at providing means for appreciating the degree in which the required standard were achieved, and to obtain a final certification. From the point of view of the teachers, the assessment is aimed at understanding whether the students achieved the learning objectives, the usefulness of didactic materials, and to certify that the students reached the predefined standards. From the point of view of the institutions, the assessment gives evidence of the degree of accomplishment of the institutional goals, the efficacy and efficiency of the didactic programs. From the point of view of the community, the assessment is oriented to understand whether the institutions are efficient, the students are adequate to the objectives of their careers, whether the educational process satisfies the long term needs of the society, and justifies funding As we saw, the traditional assessment procedures can be questioned because the type of student that they produce is inadequate with respect to the emergent needs of a complex and rapidly changing society. The negative aspects are the following. o Infallibility. The evaluator is infallible and the results of the assessment cannot be discussed o Inscrutability. The criteria and the logic underlying the assessment procedures are rarely explained to the student and often are not known even to the evaluator himself: an oral examination can give different results depending on the teacher. So, the assessment process is a sort of mysterious object. o Injustice. The inscrutability generates in the students a deep sense of injustice o Teachers’ convenience. Often the so called written standardised tests (multiple choice and so on) are adopted for the convenience of the teacher when the number of students to be assessed is high.

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o Surface learning: the final goal of the students is to pass the final examination rather then to develop a genuine curiosity for the arguments. Moreover, it is not clear whether written examinations select deep and motivated students. The overall effect of the traditional assessment methods is the so called cultural cynicism that produces students who are not able to integrate different aspects of knowledge: the success of the student depends on his (her) ability to recognize what the teacher wants in order to reproduce the teacher’s preferred theories at the examination. In summary, learning becomes a cynic game without deep learning. Plagiarism is part of this perverse game. One of the main consequences of this type of assessment is that the content is rapidly forgotten because learning is oriented to the compliance with the authority and not towards a genuine comprehension. Another side effect of the traditional assessment procedures is that teachers and students are at two opposite sides and several opportunities for productive sharing of knowledge are definitely lost. So, the old standards of simply being able to score well on a standardized test cannot be the sole means by which we judge the academic success or failure of our students. Formative assessment as opposed to summative assessment is oriented to help the student to achieve root learning, and is based upon learning activities aimed at motivating the students and increasing the deepness of their comprehension. In IME models it is also necessary to develop new assessment procedures aimed at evaluating whether the students developed the attitude to integrate knowledge coming from several fields and to think in a critical and creative way. One should not underestimate the resistance to change of the educational institutions, resistance that not necessarily has only negative meanings. There is also resistance coming from the students themselves because they are accustomed to years of passive and reproductive thinking and have a natural inertia to change, because thinking in a critical and creative way is by far more complex and demanding then just repeating what the teacher or a textbook says.

6. Education and research An educational model should also include tools for scientific research on the learning/teaching process itself. Usually the research on education is carried out by means of before-through-after questionnaires aimed at exploring several aspects of the learning /process. Traditional vis-à-vis educational models are not able to capture at runtime the interactions between the actors of the learning/teaching process unless they are video or tape recorded. But even in this case the tape or the video must be played back in order to have a transcript of the interactions, and this takes a long time to be completed. Moreover, one must take into account that most of the learning activities take place outside the classroom. The student-student, student-teacher and teacher student verbal interactions, the relationships among the students are definitively lost for the analysis, whereas these social interactions are probably the driving force of the learning process. Also, the way in which the students use the didactic materials, the timeline of learning cannot be tracked and analysed. Moreover, the students’ learning style is usually collected by means of classical paper and pencil questionnaires, and it is very difficult to track the evolution of the learning styles in order to assess whether the students evolved from passive to active learning, developed the capability of working in groups and connecting different domains of knowledge. All these issues can be partially solved by distance learning tools, provided that the elearning platforms are explicitly implemented with the intent to meet these desiderata.


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7. Dynamical knowledge networks (DKN) and Dynamical virtual learning networks (DVLN) and the re-conceptualization of education and learning The constructivist approach, flexible learning, knowledge negotiation, formative assessment, learning by discovery, critical thinking, contextualization, multidimensionality, complexity, creative thinking and connectivity can be conceived as the dimensions that should characterize distance learning models aimed at increasing the epistemological variability of a given learning community. DKN e DVLN, are two educational tools implemented at the University of Naples “Federico II” that represent an attempt to develop a distance educational model aimed to allow the students to: a. b. c. d. e. f. g. h. i.

Generate new ideas Reflect upon their own cognitive processes Design scenarios for pursuing personal learning objectives Being responsible for their learning Being able to express and accept the ignorance Connect ideas from different sources Being able to perform multidisciplinary collaborative projects Assume responsibilities within a group. Show the capability of introducing new elements that are not part of the arguments proposed by teachers. j. Being able to synthesize new information k. Being able to construct clarifying analogies and metaphors l. Being able to suspend judgement and to postpone the application of critical thinking after the production of new tentative ideas. Concept maps are considered as mind tools for pictorially representing the individuals’ network of concepts connected to a given argument. At the beginning they were introduced for grasping the so called naïve knowledge, i.e. the prior knowledge of each student. Dynamic Knowledge Networks, DKN, is a multimedia extension of the concept maps, and open new possibilities to the analysis of the individual and group learning processes, and allows grasping deep aspects of learning because they provide a set of non-traditional statistical tools for assessing the time evolution of the entire structure of the students’ knowledge. Moreover, DKN allows setting up a network of interconnected elementary multimedia objects (PowerPoint presentations, movies, simulations, and so on). The learner can be enabled to browse these materials and to modify the original network by adding or cancelling nodes or links. Also, the concept maps can be displayed on the classroom screen in order to trigger a public discussion within the classroom, and eventually to set up a collaborative map. DKN was used in several contexts: PBL, decision making, nursing informatics, medical statistics and so on. Now, structuring an ill-structured situation can be conceived as the active construction of a network of concepts as the result of the social interaction between the actors of the learning process (ALP). So, a PBL can be translated into a DKN. The e-learning platform DVLN allows constructing a dynamic network of the actors of the learning/teaching process, so facilitating the simultaneous participation of different specialists to the social construction of knowledge. DVLN is a distance learning platform that provides a set of built-in online interactive “objects”, such as brainstorming, PBL, collaborative projects, critical thinking, web sites, new terms, and so on. Also a variety of communication tools are available, such as discussion forums, chats, videoconferences, and so on.

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Figure 2. Final common DKN of factors affecting the intensity of childbirth pain produced by students of the school of obstetrics and midwifery.

Each DVLN object is an active agent which, according to the evolutionary epistemology paradigm, tries to survive. One of the survival strategies of each object is to induce the students to produce a new instance of the object itself. For example, if a web site about a given topic is uploaded then the web-site agent can send a message to the classroom inviting the students to find and upload other web sites on the same topic. In this way, DVLN allows setting up different kinds of dynamic networks. Network of web sites: Students and teachers can post the URLs and brief descriptions of web sites related to the topics discussed during the face-to-face lessons and/or in the forum. Network of terms: the ALPs can post the definition of new terms learned during the face-toface lessons and/or during the on-line activities. This allows creating a knowledge base that can be easily accessed by the whole community; Network of discussions: the forum is available to both the students and the teachers which can suggest a new discussion topic, post comments on existing topics or reply to comments posted by other ALPs Brainstorming Networks: brainstorming sessions are aimed at stimulating the student’s creative thinking. The session starts by posting a problem and/or a situation (actually only the teachers are allowed to post a brainstorming session), and the students have to formulate short sentences that describe their point of view on the problem. Then, the students are invited to express, using a 7-levels Likert scale, their agreement on each statement. The results analysis of the statements can suggest new topics to be discussed for example in the forum. FAQ Network: this section puts up the Frequently Asked Questions of students. The questions as well as the answers given by teachers are accessible to the whole community Communication Network. DVLN allows exchanging of messages between the actors of the learning/teaching process, and studying the dynamics of the communication process.

These networks can be linked so that a meta-network is created. A built in text mining algorithm allows analyzing these networks and in particular their temporal evolution. Moreover, the track of the students’ and teachers’ DVLN actions can be analysed by means of a set of built-it qualitative and quantitative tools. DVLN can also diagnose the students’


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learning styles by taking into account the way in which they interact with the system. Three distance learning styles were found [46]: 1. Lurker: these students just look around in order to see what happens on the platform without being involved in the virtual classroom activities. 2. Opportunist: these students finalise the online activities to the examinations, and use the system just for downloading the didactic materials, and answering multiple choice questions 3. Socializer: these students do actively participate to the forum discussions, post interesting web sites or new terms; suggest books, and so on. The combination of online concept maps (DKN) with distance learning networks (DVLN) could provide an educational environment suitable for the development of IME. In fact, while DKN allows constructing a network of concepts, DVLN provides a network of persons and processes. For example, the DKNs produced by each student can be uploaded to DVLN so that they can be accessed online by the virtual classroom. This provides a powerful didactic tool because the students are confronted with the perturbing evidence that each person views the same situation in very different ways. DVLN can extract the common features of the set of DKN uploaded by the students. Figure shows the final common DKN of factors affecting the intensity of the childbirth pain produced by the students of the school of obstetrics& midwifery. This common DKN was used for triggering a learning process about the usefulness of qualitative and quantitative methods in health sciences. From a more general point of view, the intrinsic connectivity of the notion of network, which underlies both DKN and DVLN, could represent a unifying starting point for a new paradigm for the analysis and assessment of the learning processes in human groups.

References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14] [15] [16]

Morin E.(1999) La téte bien faite. Seuil. Balint M. (1957) The doctor, his patient and the illness. Pitman, London Hunt L, Jordan B, Irwin S. (1989) Views of what's wrong: diagnosis and patients' perceptions of illness. Soc Sci Med 28: 945-95 Toombs SK.(1993) The meaning of illness. A phenomenological account of the different perspectives of physician and patient. Dordrecht: Kluwer Academic Publishers. Mabeck C, Olesen F. (1997) Metaphorically transmitted diseases. How do patients embody medical explanations? Fam Pract. 14: 271-278 Baker M. 2003) The Autonomous Patient: Ending Paternalism in Medicine; The Resourceful Patient BMJ 326: 1338-1339. Kuhn T. (2000) Dogma against critic: Possible Worlds in the story of the science. Curtain Frankenberg R. (1988) “Your time or mine?. An anthropological view of the tragical temporal contradictions of biomedical practices. Int. J. Health Services 18:11-34 Young A. (1982) The anthropologies of illness and sickness. Ann. Rev. Anthropology 11:257-85 Mattingly C., Garro L. (2000) Narrative and Cultural Construction of Illness and Healing. Univ. California Press Davidoff F., Catherine D. et al. (2001) Sponsorship, Authorship, and Accountability. Ann. Int. Medicine 135:463-466 http://www.aln.org/publications/jaln accessed May 2004 Aviv R. et al. (2003)Network analysis of knowledge construction in asynchronous learning networks JALN 7 Radnitzky G., Bartley W.W.(Eds) (1987) Evolutionary Epistemology, and the sociology of Knowledge. Open Court Popper K. (1987) Natural selection and the emergence of mind. In Radnitzky J. Evolutionary Epistemology and the Sociology of Mind. Open Court, La Salle, Illinois Feldman DH., Gardner H. (1994) Changing the world: A Framework for study of creativity, Praeger

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[17] Harmon-Jones AND., Mills J. (Eds) (1999) Cognitive dissonance: progress on a pivotal theory in social psychology. Am. Psicol. Assoc. 59. [18] Samples B. (1976) The Metaphoric Mind, A Celebration of Creative Consciousness, Addison Wesley Publishing Co. [19] Benzon W., Hays D. (1987) "Metaphor, Recognition, and Neural Process." American Journal of Semiotics 5: 59-79 [20] Blake, J.M., Norman, G.R., Keane, D.R., Mueller, C.B., Cunnington, J., & Didyk, N. (1996). Introducing progress testing in McMaster University problem-based medical curriculum: Psychometric properties and effect on learning. Academic Medicine 71: 1002-1007 [21] Schwartz P. , Mennin S., Webb G.( 2001) Problem-based learning : case studies, experience and practice. Kogan Page, London. [22] Pearcey, P.A. (1995) Achieving research based nursing practice. Journal of Advanced Nursing 22: 3339 [23] Owens C., Goble R., Percira G. (1999) Involvement in multiprofessional continuing education: a local survey of 24 health care professiona. J. of Interprofessional Care 13(3) 277-288 [24] Giani U.; Martone P. (1998) Dynamic knowledge network, problem based learning and distance learning. Int. J. Medical Informatics 50: 273-278 [25] Giani U. (2000) Learning Health Informatics and Telematics by web-DKN based knowledge construction and discovery in J. Mantas (Ed) Health and Medical Informatics Education in Europe, IOS Press, Amsterdam [26] Giani U.(2004) Dynamic Learning Networks. Liguori, Napoli [27] Allport G. W. (1973) The nature of prejudice. [28] Boyd R., Kuhn T. Metaphor and Theory change: what a “Metaphor“ a metaphor is? [29] Felder R.M. (1993) Learning and teaching styles in College Science Education. J. Coll. Science teaching 15: 48-60 [30] Merrit SL.(1973) Learning style preferences of baccalaureate nursing students. Nurs. Res. 32: 376-72 [31] Nelson C. (1994) Critical Thinking and collaborative learning New Direc. Teach. Learn., ,59, 45-57 [32] Chance P.(1986) Thinking in the classroom: A survey of programs. New York teachers College [33] Tama, 1989, Critical thinking has place in every classroom. J. ofReading 33: 64-65 [34] Hickey, 1990 Reading and social studies. The critical connection Social Education 54: 175-179 [35] Mertes (1991) Thinking and writing Middle School Journ. 22: 24-25 [36] Mayer R Goodchild F. (1990) The critical thinker. Brown NY [37] Scriven m. Paul R. (1992) Critical thinking defined. Handout given at Critical Thinking Conference, Atlanta, GA [38] Ennis, 1992 Critical Thinking: What is it? Proc. VIII Ann. Meeting of Philosophy of Education, Denver, Colorado [39] Collis B., Jef Moonen Flexible learning in to digital world: experiences and expectations. London Kogan [40] Race F. (2000) The Opening Learning Handbook, Kogan Page, London [41] Rayan S.(2003) Objectivism and the corruption of rationality. Writers club Press [42] Sanford G. (2001) Constructivistic Approach to Online Training for Online Teachers. JALN,5 [43] http://www.doit.gmu./Archives/Oct99/rfischer_11.html accessed May 2004 [44] B. Wilson (Ed.), Constructivist learning environments, New Jersey, Educational Technology Publications, pp. 25-32, 1996 [45] Bateson G. (1991) Sacred Unity: further steps to an ecology of mind. Harper Collins, NY. [46] Giani U., Bruzzese D. (2003) Cognitive styles, PBL and distance learning. Proceeding of the National Conference on Knowledge Information and Decision, Brescia pp 209-211


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3.6. The Role of Evaluation in Web-Based Education Kaija SARANTO, Johanna LAMMINTAKANEN & Kristiina HÄYRINEN University of Kuopio, Department of Health Policy and Management P.O. Box 1627, FIN-70211 Kuopio, Finland Abstract. The use of web-based education has increased significantly. As a result there is a need to focus on methods, employed to evaluate teaching and learning outcomes, when technology is used to enhance learning. This chapter provides an overview of what, how, and why to assess, test and measure learning. The use of technology facilitates a combination of different perspectives within an evaluation process. Not only the knowledge and skills of students but also the learning arrangements are the focus of assessment. Evaluation generates information which can be used for different purposes e.g. planning, implementing and guiding teaching and learning processes timely and for the future as well. Based on experiences of teaching health informatics, an evaluation model for web-based courses is described. The risks of dishonesty and misbehavior related to web-based education are recognized.

1. Introduction The concept of evaluation is broad and widely used, and in many studies, it functions as a culminating term for the sub-terms measurement, test and assessment [1, 2]. With regard to education, evaluation is often used as a synonym for assessment. In general, evaluation may include testing or measuring, for example, teaching and learning outcomes when using qualitative or quantitative methods. In many studies, students’ and health professionals’ knowledge and skills have been measured using questionnaires, in which they have usually been required to assess their own abilities [2]. Evaluation can be completed systematically, or unsystematically when learning arrangements are assessed [3]. It has many different goals, and can be approached from different perspectives, for example, that of student, teacher, peer, self, teaching, learning, etc. The temporal aspect of evaluation is not fixed; it provides information on what has passed, describes the state of art, and is also carried out with a view to guiding the future. [1.] Based on the timing and needs of a particular teaching process, assessments can be diagnostic, formative or summative. Diagnostic assessment takes place prior to teaching, and should provide information about students’ knowledge and skills, and in some cases, also about their attitudes before the learning process. It can also be used to explain obstacles and difficulties in teaching and learning. Formative assessment means analysing (following) students’ progress during the teaching and learning process, while summative assessment is used to describe the teaching and learning outcomes. This may close a short episode or learning module, or come at the end of an education programme. Summative assessment may generate information for further studies. [1, 4.] The purpose of this chapter is to describe what new web-based education brings to evaluation. A web-based course has several advantages, but there are also disadvantages. The advantages are found in such aspects as freedom from place and time to study, but

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these are offset by the increased opportunity for cheating or plagiarism. Such negative issues can also be viewed as challenges for the delivery and evaluation of the course. Most problems in a web-based course occur not because of technology per se, but because of people who are the critical element in the learning process. [1, 5- 6.] Web-based education often makes use of course management software packages (platforms), which provide various functions for discussions and the organization of material. Another format is to create a virtual learning environment through the Internet. Both options facilitate access to material which may not be valid or reliable, and which may result in temptation leading to dishonesty. This paper pursues the issues involved in assessing, testing and measuring web-based teaching and learning (what is to be assessed, why and how), and addresses the role of technology in this. In addition, it discusses some of the challenges in avoiding plagiarism and cheating, and ends with the presentation of a case study as an example.

2. Evaluation as a process in education Evaluation is usually seen as process. The fundamental phase is, however, initially to decide why the evaluation is being done – what or who is the focus of interest (e.g. teaching and learning or students and teachers)? Learning objectives or criteria defined for teaching are frequently of interest in educational settings. The objectives can be determined by authorities and organizations, but are more naturally defined through interaction between teachers and students. The next phase – how to evaluate – should determine which strategies and measurement tools are to be used. Should the evaluation be external, e.g. done by administrators and the faculty, or internal, e.g. by peer students or self-evaluation by the students themselves? Furthermore, tests and assignments can be conducted individually or in groups, synchronously (at a given time) or asynchronously (time-independently). The evaluation process also includes a phase for distributing information about the results, which can be disseminated either formally or informally. Formal information includes credentials and grades, while discussions with students are considered as informal information concerning the learning outcomes. Without the last phase of evaluation, focussing on analyses of the implications for the future, the process would not meet the goals and implicit importance of evaluation in providing feedback, motivating, developing and improving learning. [4-5.] The use of Information Technology (IT) in health care has created many teaching and learning activities, of which one example is the Recommendation of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics launched by the Working Group 1 [7]. These recommendations, together with the guidelines for the European curricula in health informatics by the EU-EDUCTRA consorted action or results of the Nightingale Project, have defined the learning outcomes for informatics education [8-9]. Although these three documents provide detailed information on how to build learning modules, they fail to offer advice on how to assess learning outcomes. As educational objectives often describe outcomes as cognitive, affective and skill-related, the terminology used in the objectives of the guidelines steer assessment or measurement in the direction of ascertaining whether or not the learning objectives have been achieved. [7-9.]

3. Technology in educational assessment The use of technology has improved the integration of the different phases of the evaluation process. In web-based education using course management software, it is possible both to


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link the different phases of evaluation, and to provide students and educators with prompt feedback. For instance, if learning objectives are of interest, they can be linked with measurement tools that facilitate the recording of results. Therefore, the feedback is more accurate and prompt for students and teachers. The use of technology can also be seen from the perspectives of different learning theories, inter alia behaviourism, constructivism, problem-based learning or andragogy. Webbased education is believed to promote a constructivist approach by allowing all-round interaction, transferring the responsibility of learning to the student, and enhancing the construction of knowledge by interaction. [4-6, 10.] Technology easily combines qualitative and quantitative methods to evaluate the outcomes of teaching and learning. From the behaviourism point of view, the software’s log files provide information about the students’ performance during the course; however, tracking students’ records affords only the quantitative information on their activity. From the constructivism point of view, educational software usually has search options that allow the following of messages posted by various criteria. These options provide more in-depth information for the assessment. The possibility of analysing students’ discussion threads in discussion forums provides teachers and tutors with information on how the students have made progress in their studies. The students are able to use self-reflection in the discussion forums. Adult students also often have personal learning objectives which they like to have assessed, and individual reflection on content with the help of a tutor provides opportunities for achieving knowledge and skills beyond the course. [4-5, 11-12.] Hasman (1998) highlights the importance of the teaching methods used when selecting the measurement strategies. For instance, problem-based learning needs specific methods to measure students’ achievements. In addition to thinking and acting, the system of assessment should be concerned with knowledge and skills. [13.]

4. How to assess learning? Several studies indicate that the validity of assessment should be clear and accurate. If it is the students’ knowledge that is of interest, the level of knowledge should first be defined, for instance, based on the learning objectives. Assessment should also focus on the teaching content, and the methods used must be reliable and objective. Students must be aware of the grading systems; they need feedback regarding how they are progressing in their courses, and whether they are meeting their module and course outcomes. [5,11.] Assessment should always be fair, and based on equality. An open and confident feedback of results improves the interaction between students and teachers. Assessment results also provide a response to the teacher’s performance, e.g. have the teaching arrangements enhanced learning or should they be replaced? [1,14.] In web-based education, students prefer online convenience for learning and performance assessment. Asynchronous learning via the Internet creates possibilities for using learning materials and methods in various ways. Aggarwal (2003) classifies the use of sites for assessment into web-based, take home and on-site test with supervision. Web-based assessment includes tests, presentations, demonstrations, and interviews. In web-based courses, students can have exams and assignments to do in asynchronous mode without supervision. One-on-one synchronous interview can be conducted in the discussion forum, messaging area or chat room. [6, 15.] Some studies have made the criticism that it is not possible to assess all learning objectives in web-based education. Critical thinking is often cited as a highly valued learning objective [16], and with regard to web-based education, mention has often been made that it

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is not possible to measure this. Conversely, the opposite has been found in recent studies [5, 11]. For instance Ryan et al. found that the analysis of web-discussion forums revealed a very high level of analysis and critical thinking skills among students. In addition to discussions, critical-thinking activities may include brainstorming and role-play, which can be used to complete assignments. These can be done individually or in groups. [11.] Informal interaction has been seen as problematic in web-base education in which the student is unable to observe the behaviour of peers. However, a structured calling for responses to case studies or questions has yet to be proved an efficient method for measuring informal interaction. The discussion is also more focused when each student responds independently. [11, 15.] Free-timing of studying may sometimes cause frustration in discussions, because the student does not necessarily receive an on-line response to arguments within forums. The beginning of a course may even create barriers to starting a discussion. Examples of motivational activities may include the use of restricted amount of words to introduce oneself, or sharing a link. [11.]

5. Management of web-based courses A review of the literature indicates that the transition from traditional classroom teaching to web-based education involves many changes [2]. With regard to evaluation, many studies have focused on the development process of different courses, i.e. teaching methods, materials, and target groups. Furthermore, many studies highlight the transition in the role of the teacher, which is more like one of a leader, coach, judge, or referee facilitating learning and group processes. [12, 16-19.] The use of software in education challenges course management. In web-based education, course management may become crucial during the period of realisation if it is not properly planned beforehand. The course needs to be managed on a daily basis, and this involves the management of discussion forums, assignments and exams, and student progress as well as emails. Previous studies indicate that difficulties with hardware, software and Internet connections occur, and are most prevalent at the beginning of the course. This highlights the additional need for technical support in order to minimalise frustration. [5-6, 11.] Aggarwal (2003) emphasizes forum management as one of the most significant areas of course management, as it requires behaviour management. One key purpose for the use of discussion forums is to create a community of learners. As the virtual nature of forum communication may provide a false sense of anonymity, students need monitoring and guidance, and there are several situations under which the learning objectives risk being turned on their head because of misbehaviour. Disruptive behaviour and discussion control are matters that usually occur in one form or another during the discussion forums. Although generally, argumentation is considered valuable in discussion, it may also lead to offensive behaviour or even, at its worst, a hostile situation. Furthermore, instances may occur in which the discussion can be directed in a single direction and dominated by one student, with the result that alternative views are inhibited. Both types of situation must be alleviated immediately. Another common challenge for education is knowledge heterogeneity among adult learners; those who already have knowledge sometimes tend to monopolize the conversation. Conversely, if not stimulated enough, they may be frustrated and lack the motivation to continue. [6, 15.] It appears that sometimes there is difficulty concentrating on the given discussion topic, and this may be due to asynchronous discussion. When there are several discussion threads available, it is possible to go in many directions, and often students need to be encouraged to participate in the discussions. Periodic assessment of student input may even be neces-


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sary to reinforce the importance of active participation. Students sometimes express difficulties in writing publicly; to be able to demonstrate the level of one’s knowledge in a written format needs encouragement. With regard to this, the size of the discussion groups is crucial; an optimal size of eight to 12 students should prevent discussion overload, and keep the students on the track of the discussion threads. [6, 15, 20.] It is the faculty’s task to ensure that the clarity of goals and objectives is high. Course materials, content, policies and procedures, and logistics must be predetermined and managed. All assignments should also be returned within a reasonable time period. [5.] When these criteria are addressed and in place, this creates a fruitful learning atmosphere.

6. Case study – Introduction course to health informatics A web-based course on health informatics is available for students from six different universities in Finland. The course is run by the University of Kuopio in the Virtual University Network, and uses constructivism and problem-based learning methodologies to enhance the students’ knowledge and skills. It consists of four modules and has a weighting of 4.5 ECTS 1 for the master’s degree programme [21]. Each module has learning objectives to be realised through assignments such as independent presentations, tests and case analysis. The modules are built on a cumulative knowledge perspective – basic, advanced, special and expert level. Each module has an optimal duration by which time it is preferred that students have done their assignments and carried out their duties. However, it is still possible to pass the course without acknowledging the timetable. The students are randomly divided into subgroups, each with its own tutor to guide and support the learning process. WebCT is the software used as the virtual learning environment. This includes sites for course management: objectives, contents and materials; forums for module-related subgroup discussions, and for tutors; as well as a help forum for general questions and answers. The tutors help students to start off their discussions with ice-breaking activities; one activity that is used regularly is introducing oneself. All participants are also encouraged to use the email-option and chat room for learning support. The evaluation of the course is based on each module, which students need to pass separately. The first module acts as a basic introduction to the field of health informatics, and it also provides instructions on how to proceed with the course. As the student cohort consists of adult learners, the students are advised to compile their own learning objectives in addition to the general ones. They are required to visit several sites, e.g. www.imia.org, and respond to questions concerning these sites. As mentioned previously, several technical problems usually occur during this first module, which causes frustration. However, the module is highly valued by students, and they have voluntarily started several discussion threads. Thus, this module acts as a diagnostic assessment of the students’ knowledge and skills, and sometimes even of their attitudes towards health informatics. When first accessing the course the students are told, that their responses are marked according to their activity and the content of the responses. The second module is two-fold. Based on problem-based learning, students are initially required to choose a topic from the given material, and formulate a discussion theme for their peers. Each student must act as a moderator for two weeks, and guide the discussion by responding to the comments and questions made by the others. To pass this assignment, each student must be both a moderator, and take part in the discussion of topics set by the other students. 1

European Credit Transfer System 1 ECTS is 40 hours of work

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The second part of this module is a test in which students must visit National Development Centre for Welfare and Health (Stakes) sites, and seek information about statistics. To pass the test, students must answer the given questions. This module has been criticized by students for two main reasons. Firstly, they feel that the workload is too heavy, and secondly, the task of following responses on peers’ discussion topics is exhausting. Although the number of students per subgroup is 12, the amount of messages sent remains relatively high. The evaluation type of this module is formative assessment, which provides information on the interaction between peers and tutors, as well as that on working patterns. The third module also has two parts. First the students must analyse information on given websites; these analyses are based on the National Data Security Act. After this, they must respond to their peers’ analyses and make comments (a minimum of three comments). This module is actually based on the students’ self-assessment, and its assignments create a need for advanced knowledge; the students themselves notice the lack of critical knowledge. The fourth module consists of visiting sites containing educational material, and to be able to pass this module, students must analyse the quality of these sites. They must also summarize how they would apply the sites in their work as health professionals. Students’ case studies of the educational on-line material often reveal their knowledge requirements, and thus, this module helps them to reflect upon their own knowledge and skills. At the end of the final module, students are required to make an assessment of their learning process, and give summative feedback on the course management.

7. Challenges for course evaluation based on experiences A web-based course requires constant evaluation. Figure one sets out an evaluation model for web-based courses. The components of the model are based on the informatics course described above. The purpose of the model is to answer the questions – with regard to learning, what is to be assessed, why and how? The aim is to focus on students, and on both the learning process and outcomes. All evaluation types (diagnostic, formative and summative) have their role to play in web-based education. (Figure1.) In the case study, the access and logging procedure on the informatics course has proved to be a diagnostic assessment. It provides information about the level of IT abilities, and in many instances, also about attitudes. The results are used to focus guidance and technical support on the students’ needs at the beginning of the course. As is the case with learning objectives, at the beginning of the course, learning deficits can also be classified into the groups cognitive, affective and skill-related. For many students this may be their first experience of the infrastructure and using management software, and they are not necessarily aware of how to use the filing system, are unable to use the email options, or are too hasty and frustrated, e.g. with the slow connections of their PCs. Formative assessment focuses on objective achievement, and provides information about the interaction in discussion sessions. The students’ activity is also graded in the different learning modules. This type of assessment also provides information about the participants’ working patterns. Based on the experiences of the case study, students have a flexible way of studying; for instance, on a recent course, one third of the messages were sent during the weekend. The variation in the times the messages were sent was also extensive; nearly half of the messages were sent between 6 p.m. and 2 a.m. The faculty usually operates during the daytime, and from Monday to Friday. Being able to respond to students’ comments and questions instantly would require tutors to be available on-line 24 hours a day, seven days a week. The only way to get around this problem is to point out the working hours of the faculty to students. However, if a student has


Figure 1. What is to be assessed, why and how? [2, 4].

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been experiencing difficulty, for instance during the weekend, this has sometimes resulted in the fruitful interaction between peers, who also can help and guide each other. One solution is also to organize virtual office hours [6]; students are able to contact given faculty members at a designated time. The information from this formative assessment can be used to analyse the reasons why students do not make progress in their studies. Summative assessment should provide information about the whole teaching and learning process. Ultimately, it should answer the question as to whether or not the participants have finished the course, and reserve grades or credentials. Evaluation methods used in summative assessment should also generate information to be used for the future, thus case analyses and questions stimulating reflective discussions, comments, and critical thinking are often used. One useful way of summing up the learning process is to create a digital portfolio. The use of digital portfolios in healthcare in Finland is still in its infancy [22], but generally, the contents of the portfolio are gathered over a period longer than just one course. Thus students familiarized with the system will have the advantage of being able to present their competence and abilities, as well as displaying their level of knowledge and skills in their field of expertise. 8. Successful evaluation It is often argued that web-based education should be a faculty concern in all its phases beginning with: 1) how to define learning objectives for a course; 2) finding materials; 3) methods for compiling a successful learning and teaching process; 4) technical support; and 5) ensuring that the evaluation of the course is valid, reliable, objective and fair. [4-6, 17.] A sole educator has nowhere near this type of scope. Web-based education offers a multitude of possibilities to use on-line material at various sites. From the cultural point of view, the greatest obstacle may be the language, as most Internet sites tend to be in English. In a learning process, this can usually be valued as a strength, in that material can be shared worldwide. For an educator planning a web-based course, the challenge to find accurate knowledge to enhance learning is extensive [18]. Data privacy is one concern which must be taken into account when planning webbased education with management software. In Finland, the Ministry of Education recommends that educators and students always make an agreement on the material produced during a web-based course. This agreement creates a confident learning atmosphere in which everyone is aware of what will happen during the course. Furthermore, if the log files are used to follow students’ performance, the participants need to be aware of and agree on that. Teachers and students should also know the logistical way the access control functions in management softwares. Usually it only shows if a student has accessed the environment, thus, when the activity of students is graded for the assessment, this should be based on certain tasks or duties, not merely by accessing the learning environment. The learning theories and methodological perspectives adopted for a course often remain concealed for students. Adult students with working experience may find it helpful to be able to combine new knowledge with earlier learning experiences [12]. This procedure is also challenging for course evaluation as well. Designing a course for students with heterogenous backgrounds, and providing personal feedback on individual progression are complex tasks for an educator or tutor. The clarity of learning objectives and the criteria for assessing them are crucial for a fair and objective assessment. [6.] Fair assessment is also a concern for students. Cheating and plagiarism are the risks most often mentioned for assessment, in web-based as well as in traditional classroom teaching. Born (2003) highlights the taking of a proactive rather than a reactive approach to prevent academic dishonesty and misconduct. The technology used for on-line convenience


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has its off side in making the plagiarism easy through copying material from websites or even from other students’ assignments. Students’ papers are not products per se but learning processes [1], and one way to avoid cheating is the monitoring of students’ work in progress. One method to avoid plagiarism from other students on a certain course is to use the software’s email option for the assignments, although this procedure hinders the contextual learning process by isolating the assignments from the discussions. The different experiences and expertise each student brings to the course should be shared with peers, and to avoid plagiarism, students can submit their assignments within a given timeframe. A limited period of time can be used for tests, and everyone can be required to take the test at the same time. If the assessment is based on questions, different questions can be assigned to different students, and questions should generate an answer requiring discussion rather than something that can just be memorized. Working in groups randomly compiled by tutors has a proactive effect on cheaters; students are more likely to report dishonest behaviour when they experience it. [1.] Effective web-based education requires both active participation and feedback. Mandatory participation is recommended due to the need for engaged participants in an assessment process. Participation also enhances two-way communication between students, peers, tutors and educators. Participation as a part of graded process is often likely to create higher participation [6]. The instructions for assessments should be clearly stated, and timing is crucial when delivering feedback. Born (2003) suggests that the feedback should be sent to students no later than a week after the submission of their work. A lag in feedback has the potential to decrease motivation, and can even be the cause of some participants dropping out of the course. An automated feedback function in course management software aids tests by providing the correct answers, however it cannot assess written answers or essays. Nevertheless, students, tutors and educators should have a joint agreement about the timing of feedback. 9. Conclusion Web-based education facilitates the combination of different evaluation perspectives within a course (e.g. self-evaluation, peer evaluation, teacher or student evaluation). Although the choices made during the planning process determine whether the web-based education is based on constructivism or other learning theories, constructivism is usually closely related to web-based education. In particular, constructivism emphasizes the role of assessment from the end of the learning process (summative assessment) to continuous (formative) assessment. It also promotes student’s self-reflection and self-evaluation, therefore, students can gain a more holistic ‘picture’ of their learning. From the faculty’s perspective, assessment in web-based education requires new ways of thinking. Usually, the teacher’s role changes when web-based teaching is adopted. The teacher’s new role can be described as a learning catalyst and knowledge navigator, or as tutor acting as a facilitator for learning and group processes. Moreover, the tutor’s duty is to maintain a safe environment for learning, and encourage novel problem solving processes. Therefore, crucial elements in the tutor’s role are continuous assessment and timely feedback on them. However, as described earlier in the text, these changes in the tutor’s role may even require changes in working patterns and also working hours, if the core idea of web-based learning (timely feedback, etc.) is maintained. Web-based education provides good opportunities to make use of the many information sources available via the Internet. The problem is, however, the quality of knowledge; how to select appropriate information from amongst the mass, and how to avoid the use of misinformation. At its worst, the Internet is a tool towards fabrication, falsification and plagia-

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rism. Through formative assessment, some of the misbehaviour related to web-based education can be avoided or at least, minimised. When students’ learning processes are assessed both by the tutor and peer students, the risks of plagiarism and cheating can be minimised. Finally therefore, although there is perhaps an increased temptation towards plagiarism with regard to web-based education, the principles of evaluating learning and teaching remain largely similar to those of the traditional classroom context, with the added bonus of the possibility of rapid feedback, and the systematic accumulation of assessment material via the log information in the web-based learning environment.

References [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11]

[12]

[13] [14]

[15] [16] [17]

[18] [19] [20] [21] [22]

Born, A. D. (2003). Web-based Student Assessment. In Aggarwal, A. Web-based education: Learning from experience. Information Science Publishing, Hershey, pp. 165-188. Saranto, K. & Hovenga, E. (2004). Information literacy – what it is about? Literature review of the concept and the context. International Journal of Medical Informatics 73(6), 503-513. Saranto, K., Leino-Kilpi, H. & Isoaho, H. (1997). Learning Environment in Information Technology. The views of student nurses. Computers in Nursing 15: 324-332. Brown, G., Bull, J., & Pendlebury, M. (1997). Assessing Student Learning in Higher Education. Routledge, London. Nagia, S. A., Hodson-Carlton, K. & Ryan, M. (2004). Students’ Perceptions of Online Learning. Implications for Teaching. Nurse Educator, 29:111-115 Englebardt, S P. (2002). Technology and Distributed Education. In Englebardt, SP & Nelson, R. Health Care Informatics. An Interdisciplinary Approach. Mosby, St.Louis. pp. 267-284. IMIA WG1 – http://www.imia.org/wg1 Hasman, A. & Albert, A. (1997). Education and training in health informatics: guidelines for European curricula. International Journal of Medical Informatics 45: 91-110. Mantas, J. (ed.) (1997). Health Telematics Education. IOS Press, Amsterdam. Jefferies, P. & Hussain, F. (1998). Using the Internet as a Teaching Resource. Education + Training, 40(8), 359-365. Ryan, M., Hodston-Carlton, K. & Ali, N. S. (1999). Evaluation of Traditional Classroom Teaching Methods Versus Course Delivery Via the World Wide Web. Journal of Nursing Education 38(6), 272277. Saranto, K., Korpela, M. & Kivinen T. (2001). Evaluation of the Outcomes of a Multi-Professional Education Programme in Health Informatics. Patel, V. & al. (Eds.) Medinfo 2001. IOS Press, Amsterdam. p. 1071-1075, 2001. Hasman, A. (1997). Challenges for medical informatics in the 21st century. Internationals Journal of Medical informatics 44(1), 1-7. Salminen, L. & Leino-Kilpi, H. (1997). Evaluation of the professional Teachers – The requirements for a Nurse teacher. In Lasonen, J. (ed.) IVETA ’97 Conference Proceedings. The Challenges of the 21st Century for Vocational Education and Training. Kopijyvä, Jyväskylä. pp. 247-251. Aggarwal, A. (2003). Guide to eCourse Management: The Stakeholders’ Perspectives. In Aggarwal, A. Web-based education: Learning from experience. Information Science Publishing, Hershey, pp. 1-23. Mallow, G. E., Gilje, F. (1999). Technology-Based Nursing Education: Overview and Call for Further Dialogue. Journal of Nursing Education 38(6), 248-251. Covvey, H.D. et al. (2001). The Development of Model Curricula for Health Informatics. In: Patel, V.L, Rogers, R. & Haux, R. (Eds.) Proceedings Medinfo. 2001. London, IOS Press: Amsterdam. p. 1008 – 13. Calvert, P.J. (1999). Web-based misinformation in the context of higher education. Asian Libraries 8(3), 83-91. Volery, T. & Lord, D. (2000). Critical Success Factors in Online Education. The International Journal of Educational Management, 14(5), 216-223. McFazdzean, E. & McKenzie, J. (2001). Facilitating Virtual Learning Groups. A Practical Approach. Journal of Management Development, 20(6), 470-494. Information Management in Social and Health Care, http://www.uku.fi/laitokset/tht/tiha/english/english.htm Lammintakanen, J., Saranto, K., Kivinen, T. & Kinnunen, J. (2002). The digital portfolio – a tool for human resource management? Journal of Nursing Management. 10, 321-328.


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3.7. Student Support Infrastructure Christian NOHR Virtual Centre for Health Informatics Department of Development and Planning Aalborg University, Denmark Abstract. The development and diffusion of distance learning programmes has made it possible for students to choose their preferred location to study and consequently, they are expected to be able to use new technologies in order to gain the necessary support in a wide range of areas. When universities implement distance learning a number of complex issues have to be considered. This chapter presents a framework for identifying the most important issues. Furthermore, it examines some of the options and problems, which are necessary to consider.

Introduction Infrastructure is commonly used as a term to describe physical facilities in society, which are constructed and managed by a public institution to support the general interest of many. It is of a kind, where it is difficult to both measure and place the cost and responsibility for its management. Infrastructure can also be used in other contexts to cover different tasks and considerations, which are to be taken care of, in order to perform a specific activity, e.g. a university education programme. Hence, it is not limited to the physical facilities, but refers to a wider range of immaterial issues [1]. The development and application of distance education activities has been primarily technology driven. New technological solutions and facilities have been applied as soon as they have become available on the market. However, to create a distance education programme works as educational infrastructure is a rather complex task and it requires a finely balanced correlation and integration of a number of issues. During our 18 years of experience with computer supported distance learning, 10 of these years, by running a master programme in health informatics at Aalborg University, and by activities in the VIRT project1 [2,3] we have identified three essential elements:

Planning of study activities Interaction between students, teachers, and administration Management of learning material

These three key elements can all be considered from an organisational aspect, a pedagogical aspect and a technical aspect. This suggests the matrix, which is shown in figure 1. In the following each cell in the matrix are elaborated further. 1 The VIRT project has it origin in the concept “the virtual learning environment” and contributed to the development of a theoretical model for the virtual learning environment at university level, including a multitude of concepts for technological support.

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Organisation Pedagogics

Technology

C. Nøhr / Student Support Infrastructure

Planning Division of labour Coordination Student environment Seminars

Interaction Flexibility Continuous inter and intra communication between, students, teachers and administration

Material Information

Teacher resources Learning cultures Subjects - courses Research projects Project management Study planning Result access On-line enrolment

Construction of virtual learning space Differentiated didactics

Textbooks Reading instructions Computerised material “Intelligent” material Databases Internet access Virtual libraries

Asynchronous communication: e-mail Synchronous communication: “Skype” NetMeeting Telephone

Figure 1. A model for development of virtual learning space.

Organisation and Planning As traditional education programmes, distance education requires daily management by a coordinator or director. Additionally, an organisation to administrate and schedule the students' activities, exams, material etc. is required, as well is support staff for the technical infrastructure. Faculty Teachers, lecturers, instructors or professors with the necessary expertise within the main areas of the programme can in principle be recruited from institutions worldwide. Nevertheless, it is essential to appoint one person to be in charge of the daily management and coordination of the different teachers. This person holds various titles in different institutions, such as director or co-ordinator. In this relation, he/she must have a multitude of competences in the organisation, both with regards to the pedagogical issues as well as to the technological aspects of the distance education programme, in order to integrate and coordinate the planning, the interaction and the material aspects. The so-called co-ordinator will be the main contact person for students and staff as well as for the faculty, for instance, when relating to questions about admission criteria, courses, assignments, and exams etc. Perhaps, it will not be possible or even desirable to have the co-ordinator handle all the enquiries exclusively, but paths of delegation should be planned for. The recruitment of adequate faculty can be a considerable task – especially when recruited worldwide. Finally, the co-ordinator will be in charge of evaluating the distance learning programme and responsible for initiating important improvements. Administrative staff Any educational programme requires administrative support to contact the students, provide information material, and offer a basic service to the faculty. It is important that administrative staff hold basic computer skills; additionally, language qualifications are recommendable, in order to communicate professionally with international students and faculties.


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Figure 2. Communication between the three stakeholders.

Computer support staff It is evident that the technology must be up and running 24 hours - 7 days a week. Hence, so much work depends on the servers, meaning that they must be continuously maintained and updated, mainly to avoid technical faults and loss of data. In case of incidents, it is essential that the support staff can act immediately and solve the problems rapidly. The support to students will often be extended to also including technical computer problems in their homes. While students often work from home and use their own Internet connection, it is important for them that the various user applications are up and running. It is often rather difficult to determine, whether the server at the university, the Internet connection, or the student’s own computer can cause specific technical problems. With that in mind, it may cause frustrations, if the students are to determine themselves, who to ask for support – the Computer store, the Internet provider or the University.

Organisation and Interaction Flexibility in the university organisation is a key issue. The specific activities of the students are performed outside normal working hours and by recruiting students worldwide, the activities will take place around the clock - due to the span of several time zones. An international education programme often relates to a number of different universities and institutions, each having different administration practices. A result of this will be the demand for a higher degree of flexibility at the participating partners. The three key stakeholders in an education programme: students, faculty and administration must dispose of communication facilities that enable them to communicate with each other as well as within their own group (cf. fig 2). The different modes of communication should be independent of the system administrators. The students should be able to open their own forum within the educational software and control the access autonomously.

Organisation and Material Institutions commonly have a lot of information material for students and staff, which is important to keep accessible at anytime. Much of this material is available in different ver-

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sions and is often paper based. Therefore, all of the material must be converted into electronic forms and made available directly from the e-learning software. In addition, the material should also be placed in a single database to avoid redundancy and to ensure easy update procedures. The learning material for the students can be organised in many ways, for instance in accordance to the subject and the didactics. It will however be necessary to agree upon the policies for availability, as it is subject to the copyright regulations and due to the fact that these regulations may vary from country to country.

Pedagogics and Planning In virtual learning environments, the faculty can be recruited from institutions worldwide, as long as the appropriate technology is at hand. Taking the long geographical distances in to consideration, they will, however, inhibit physical meetings. Instead, various teleconferences can substitute for parts of a physical meeting, but experiences show that the outcome of a teleconference can be enhanced significantly, if the participants have met each other physically beforehand. In that connection, it may be a great advantage to recruit teachers from the best institutions, in order to assemble the best possible team of expertise within each subject area. On the other hand, one should be aware of the potential conflicts between different learning cultures, values and norms. Hence, it may take considerable time to synchronise teaching practices or even just to gain acceptance of the differences within the teaching practices. When recruiting staff for the faculty, it is therefore preferable to recruit teachers with a special interest in e-learning and distance education who have the required enthusiasm to go through a readjustment into a virtual teaching environment. Teaching the subjects In a traditional learning environment at the university, subjects are usually organised in a number of units (or courses) each carrying a specific load – in Europe measured in ECTS (European Credit Transfer System). Lectures, where the teacher presents a subject followed by discussion, reading and assignments are a traditional structure of these units. In virtual learning environments using distance education, there is still a need to organise subjects in units, whereas the contact between teacher and student must be organised in a new way to maximise the output within each subject. Although, the responsibility of learning partly belongs to the student himself, it remains the teacher’s responsibility to provide a framework to enhance the individual learning of each student. In this relation, two issues are important to notice: 1. There is a tendency to focus on the professional knowledge within the subject, but while teaching there is a need to focus on the students experience, because learning is a psychodynamic process. 2. There should always be a set scene for the learning process. It is the teacher's responsibility to set a scene, which can work as the context for the learning in the virtual learning environment. In distance education, it is even more important to have a precisely defined aims and objectives for each unit. These must be clearly worded and presented at a central place in the applicable learning system. It should also stand clear that the involved parties play different roles, and it must be properly stated what the demands and expectations are to the teachers and the students.


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These demands and expectations will vary from one university to another and therefore, it is important to state them very clearly. Particularly, the students have to adjust to changes from earlier studies or from the role, which they play in a work place environment. Research projects It is very common that the students learn from doing their own research projects under guidance. Distance learning is very suitable for this approach, as long as the different stages of progress are organised and as long as the mode of guidance is adapted to the specific stage of the project. As in the case of teaching subjects, the guiding teacher is expected to set a scene for learning. Defining milestones and deadlines for deliverables can help the students to focus on work tasks relevant to the particular stage of the project. It is also important that the guiding teacher adopts his mode of teaching to the particular student and the stage of the research project. It would for instance not be good idea to present the students with completely different ideas for a new study design, whilst they are analysing their data, with another deadline in mind.

Pedagogics and Interaction The students in a global programme will be characterized by a great diversity in background, experience from previous education, work situation, age, language and culture, just to mention a few. Flexibility in the programme is consequently very important, but economy will enforce some limitations. For instance deadlines for assignments and dates of exams or tests will be the same for everyone and should therefore be decided and announced well in advance. As the students will be physically situated over a large geographical area, they will be isolated from the university to which they enrol. Consequently, they will not have the traditional possibility to communicate with older students and they will also be isolated from other fellow students, which means that they don’t receive the same social and psychological support. The contact between students can to some extend be re-established in the virtual environment, but it is essential to pay special attention to this issue. It is a well-known experience that the dropout rate for distance education programmes are higher than for traditional programmes, but the dropout rate can be limited by improving the interactive links between students. It is a great challenge to maintain the enthusiasm of the students, when they work alone with the subjects most of the time. Even an intensive dialogue in the virtual learning space, is more demanding and cumbersome than in a normal classroom, simply because of the written form. Faster computer facilities and higher bandwidth to the Internet might bring a solution to this problem – Internet video conferencing etc. It has not been possible to find any documented experience with online teleconferencing for distance education with respect to student contact and social interaction. During the interaction with students, the teachers must be acquainted with the background of the students, because in their daily lives, they are often confronted with problems related to the subjects. It is important to notice that the content of the subject need not to be adapted to the specific backgrounds of the students, because an important point in university studies are to get new inputs and sometimes even better unexpected inputs. On the other hand if you teach a course in clinical decision support systems, it may be relevant to know, whether the students are physicians or nurses in order to adjust the communication according to their qualifications and demands.

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Communicating learning level A major problem when guiding the students in their reading is to communicate the level, to which they are expected to read the literature. Some students with learning experiences from their education as a health care professional may have developed a habit of studying all the material in great depth, almost learning long sentences by heart. This way of reading clearly cannot exist in a modern university programme. The amount of pages, which the students have to read in a unit, takes aim at a differentiated reading speed and depth. Certain references will have to be studied very carefully to gain a deep understanding, while other references are speed-read, just to get acquainted with an idea or a principle. A workable tool for communicating learning depth to students is Blooms Taxonomy for learning in the cognitive domain [4]. The taxonomy is a logical hierarchical system with six levels of complexity: Level one - knowledge is the ability to reproduce a subject matter e.g. facts, figures and procedures. Level two - comprehension is the lowest level of intellectual abilities. Comprehension means that you are able to apply your knowledge, but not necessarily having a deep understanding or being able to relate it to other areas independently. Usually, it is reflected, when a student is able to communicate abstract theory in own words or give an example. Level three - application is where the student can apply general theories, principles, procedures, or methods to a specific situation or concrete problem. Level four - analysis is the process, which breaks down and reveals relations between entities in a case. Level five - synthesis is the process of aggregating the broken down and analysed parts to a new whole. Level six - evaluation can in principle be done in two different ways: as a judgement based on internal evidence, or a judgement based on external criteria. Blooms taxonomy is general and as such it gives the possibility of guiding the students in any subject. In some subjects the students are only expected to familiarize themselves with the content, i.e. learn at level one, whereas in relation to other subjects, they are expected to study in depth. For instance when studying knowledge representation techniques, the students should be able to apply the different techniques on a range of specific health informatics areas.

Pedagogics and Material Learning material for distance education programmes exist in innumerable different ways – a coarse categorization can have the following classes: New textbooks, reading instructions, computerized material, and “intelligent” material. The classification is not exclusive, there are a lot of overlapping examples, but here it can serve as a framework for discussing the different approaches. New textbooks New specialised education programmes, such as health informatics, often lack adequate references that cover the entire area. Instead a number of different textbooks each covering parts of the area are used to provide the overview of the entire area. Writing textbooks in health informatics takes a long time and the lifespan is only limited due to the rapid devel-


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opment of new knowledge and new technologies. As an alternative faculty often write notes for the students - notes that digest and transform general knowledge to the health informatics area. This material is often adapted to the student’s particular level and experience. Reading instructions Reading instructions are used by students to guide their reading and can comprise a description of the aim of the subject, formulation of the learning goal, reference to additional literature, case descriptions, hints, questions and answers, and assignments. Furthermore, reading instructions can include a schedule for when each reference are expected to be read, how long time it should take and which level of knowledge the student is supposed to reach after studying the subject. Computerised material Computerised material comprises all kinds of material that are accessible by a computer. It can be distributed via the Internet, CD-ROM or other media. The use of hyper links will make it easier to follow up on various tracks, investigate sources and clarify details. Intensive use of hyper links also has the potential of introducing a lot of breakaways and makes the reading incoherent. A great number of scientific journals are now available in computerized form, some of them in hypertext versions, which makes it possible to link directly to referenced papers. Working with hypertext documents introduces a new media for reading. Most students prefer to read from paper. It has a lot of advantages, you can write notes directly into the text, bring it everywhere, and there is a very easy brows-ability etc. however, when reading hypertext documents you are tied to a computer. It is still unclear, how the hypertext media influence the learning outcome, but it has added a new modality to the spectrum of learning material, which can contribute to the clarification of complex matters. Video demonstrations of software products and various video instruction programmes are also an element in this category, which becomes widely diffused. “Intelligent” material Intelligent material is often thought of as automated tests, where the student work through a number of quiz questions on a computer and where the programme immediately responds to the answer – if wrong with an explanation on why it is wrong and hint on how to answer the question correct. In connection to their textbook: “Handbook of Medical Informatics”, J.H. van Bemmel and M.A. Musen have set up a web site containing a “questions and answers” section, where students can test their knowledge after having read the corresponding chapter in the book [5]. Simulation programmes can also be seen as a kind of intelligent material. They react according to a pre-programmed behaviour based on a model of real world parameters. Simulation programmes can be of great value in virtual learning environments because the students' access to laboratories is limited. Choice of material There is no “best choice” of which form the learning material should take. It depends in many occasions on the availability of the material, and in addition on, what is practical

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achievable. In that relation, educational considerations should also be taken into account – such as, what will help the students to reach the learning goal, and what is the student’s background and former experience.

Technology and Planning There are several issues, where information technology can support distance education, and several programme packages exist on the market to choose from. H. Tolsby et. al. have surveyed a number of these programs [6], where after they conclude that it is rather confusing and difficult to understand the potential of the different systems. They are all based on different technologies and they support different learning strategies. To give an overview of the systems, they have suggested organising the systems in following categories: Content delivery systems. Systems where the main function is organisation and publication of teaching material. Such systems have dominated the market with the consequence that most e-learning is organised as traditional classroom instruction. Examples of systems in this category are Lotus Learningspace, WebCT and Blackboard. Conference systems. Systems to provide dialogues in asynchronous (text) media. These systems have root in bulletin board systems (BBS), which existed before the World Wide Web. Systems in this category encompass FirstClass and Virtual-U. Groupware systems. These systems provide facilities to coordinate group activities. The purpose of the activity can either be production oriented or just socially motivated. There are several Internet Service Providers (ISP) providing free access to functional groupware systems e.g. Yahoo−Groups, Groupcare, and iGroups. Examples of commercial groupware systems are Lotus QuickPlace and Communispace. The categories are not fully exclusive and exhaustive. Many systems have functions across the categories, but the above-mentioned systems have a dominating functionality that justifies the placement in a category. Here is not the place to discuss the different categories or to evaluate the systems against demands for establishing distance education. The systems are too complex to do so in this context. Instead there are a number of functionalities important to consider in the planning of study activities. On-line enrolment Some systems have facilities to support the students to sign up for various activities, such as specific subjects, assignments and exams. Sometimes it can also be convenient to monitor the progress of each individual student. Firstly, it can hereby be determined, when and how to progress, when teaching a subject. Secondly, in cases, where a student is close to dropout, it can eventually be prevented by using adequate measures in time. Result access To keep track of all the students' achievements can be a difficult and complicated task, but some systems have facilities, in order for the students to access their own results. An example is that the teachers can enter marks from exams into the system, and thereafter the secretariat is able to keep individual student records.


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Study planning The general activity plan for each semester is often difficult to keep updated and accessible, but most of the systems available have facilities to support this task. In some cases it is possible for each user to access the planning system as their own diary, and this will automatically synchronize with the schedule from the education programme. Project management In situations, when research projects are a fundamental part of the study activity, as is the case in most problem-based programmes, some of the systems will include facilities to maintain project management. Project management appears to be a very difficult task for students. Many programmes within health informatics teach project management as a subject – focusing on the management of health IT projects. But when it comes to managing the students' own research project, it often causes significant problems. Therefore, it may be a great support to the students to have the facility integrated into the conference or groupware system. Implementing distance education systems As soon as it has been decided to use a distance education system, the ones responsible for system administration and those who are to be involved in operations of the system should be included in the planning work. Everybody involved must be concerned about the choice of specific vendors, in order to ensure that all the educational demands as well as the technical requirements which are necessary to make the system run satisfactory can be met. The system has to be installed well ahead of the launch of the programme – at least six month – to make sure that it will work. It is very important that the system is well tested by the teachers and the technical staff. It can be complicated to test the system running full load i.e. with a realistic high number of users logged on at the same time, but it is a crucial test to perform, especially if common on-line exams are planned for [7]. When the system is running, it is an advantage to get the technical operation and the user support provided from the same office. Not necessarily the same people, but in situations with errors, it is most efficient that the error is reported only to one place and to have it corrected at the same place. Technology and Interaction Distance education requires communication in two modes: asynchronous and synchronous communication. The asynchronous communication is required because of the request for freedom in time. The students want to work whenever they have the possibility, and the teachers may want to pass comments to the students when all of the students have completed the reading of a specific reference, or have turned in their assignments etc. This kind of communication is well known to everybody who uses ordinary e-mail. By using the distance education system, there is the possibility of sorting the communication in the relevant files, and also to perform threaded discussions in a flexible way. A couple of issues are worth considering, when choosing the system: Firstly, it is important to look for systems which can provide a dynamic environment, where students can furnish their own virtual learning room i.e. autonomously create areas where they can control the access e.g. a conference where they can discuss their teachers without any intruders listening.

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Secondly, it is convenient to be able to see a log of the activities concerning a specific document i.e. What time it has been send, who has read the document, and when did they do it. Has it been forwarded etc. Thirdly, it is appropriate to be able to check the time, when a specific student was logged on last time. There might be several reasons for students to become inactive in the programme, but sometimes it is helpful, if the institution, where they are enrolled, can follow up and discuss difficult situations, agree on postponing a critical deadline etc. instead of dropping out of the programme. The synchronous communication is needed where immediate feedback is required. In situations where two or more people have to come to an agreement, or where a group has to stimulate progress in their learning it is necessary to facilitate the immediate response to issues raised. One solution to this demand is a chat function within the distance education system. It can be a very inexpensive way for students to communicate, and one of the great advantages is that the minutes of the meeting is automatically documented during the meeting. A second solution can be IP-telephone. A freeware programme “Skype” [8] is already in use by close to one million users worldwide. It has a very simple user interface, which can be learned by everybody within minutes; now, it also comes with a conference facility for up to five people. When used over extreme distances – between continents – IP telephoning still has a little delay in full duplex mode that requires a disciplined communication. A third solution is using videoconferencing. Commercial systems are available and used quite intensively, but free software products such as “NetMeeting” and “MSN Messenger” also works satisfactory. These products not only have the capability of normal chat via keyboard and a common whiteboard where the “pen” can change hands, but they also allow one user to take over the control of specific software programme on another users computer. A fourth solution is the use of the conventional telephone. It is often neglected because everybody is so focused on using computers in distance learning. Technology and Material The use of fast Internet connections has provided remarkable access to learning material, but the wealth of information available can cause an information overflow that is difficult to digest for students of a new field. It has sometimes been compared to drinking water from a fire hose, and it necessitates the structuring of a limited and more targeted selection of material. A key issue in the access to learning material is the library. Some university libraries have developed excellent virtual library facilities for the enrolled distance students. This means connection to efficient search engines and access to full text on-line journals. To get access to the on-line journals that the university subscribes to usually requires that the user request access from within the university Internet domain i.e. from behind the university firewall. Therefore it is important to arrange for VPN (Virtual Private Network) connections. Conclusion The most important point made above is that the development of distance education infrastructure involves a wide range of considerations that all are woven closely into complex interrelations. This means that there are no generic best solution – it will depend on many local, cultural and indigenous relations.


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The paper presents a framework for discussion of the most relevant issues and suggests a number of considerations as seen in the perspective of our current experience with many years of running a master programme in health informatics at Aalborg University.

References [1] [2] [3] [4] [5] [6]

[7] [8]

Jens Müller (Ed.): Infrastruktur og samfundsudvikling. Aalborg Universitetsforlag, 1989. T. Nyvang: VIRT-håndbogen, Aalborg Universitet, 1998. (in Danish) L. Dirckinck-Holmfeld (Ed.): VIRT-projektet. Erfaringer fra teknologistøttede uddannelser ved Aalborg Universitet. Aalborg University, 1998. (in Danish). Benjamin S. Bloom: Taxonomy of educational objectives: the classification of educational goals. New York, 1964. J.H. van Bemmel and M.A.Musen: Handbook of Medical Informatics. Springer-Verlag 1997 H. Tolsby, T. Nyvang, L. Dirckinck-Holmfeld: A Survey of Technologies Supporting Virtual Project Based Learning. In Proceedings of the third international conferenceon networked learning edited by Banks Sheena et al. University of Sheffield, 2002. C. Nøhr, A. Bygholm, O. Hejlesen: Courses and Examinations in a Distance Learn ing Curriculum in Health Informatics. In: J. Mantas (Ed.): Health Telematics Educa tion. IOS press 1997. www.skype.com

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International Medical Informatics Association (IMIA) Working Group on Health and Medical Informatics Education WG1 Objectives: To disseminate and exchange information on Health and Medical Informatics (HMI) programs and courses. To promote the IMIA HMI database on programs and courses on HMI education. To produce international recommendations on HMI programs and courses. To support HMI courses and exchange of students and teachers. To advance the knowledge of: (1) how informatics is taught in the education of health care professionals around the world, (2) how in particular health and medical informatics is taught to students of computer science/informatics, and (3) how it is taught within dedicated curricula in health and medical informatics Recent activities: The recommendations of the IMIA on Education in Health and Medical Informatics which can be found also in this book, have now been translated into Spanish, Chinese, Italian, Turkish, Czech and Japanese. Anyone undertaking further translations must (1) formally seek permission from Schattauer, the publisher of the recommendations, (2) notify Dr Reinhold Haux at ([email protected]) and (3) forward the URL to Steven Huesing so that a link can be established on the WG1 website. IMIA HMI has a mailing list and anyone interested is able to join this list by sending a message to Dr. Evelyn Hovenga <[email protected]>.· WebPages are accessible via the IMIA homepage at http://www.imia.org or directly via http://www.imia.org/wg1/ A three day conference with the theme: Teach Globally, Learn Locally: Innovations in Health and Biomedical Informatics Education in the 21st Century was held April 23-25 2003 in Portland, Oregon, hosted by the Oregon Health and Science University. This event was attended by around 80 registrants from 10 countries. Issues associated with the globalisation of health informatics education were discussed at a number of workshops. A number of papers and posters were presented; the proceedings were made available on a CD-Rom. A selection of these were published in a special issue of the International Journal of Medical Informatics Vol.73 No.2 18 March 2004. Future Activities: Identified issues associated with the globalisation of health informatics education will be further explored. The business case and a strategic plan regarding how to best overcome these issues to enable the establishment of the Virtual Health Informatics University now needs to be developed by the steering committee consisting of Professor John Mantas, Dr. Jim Turley, Dr. Umberto Giani, Dr. William Hersh, Dr. Yu-Chuan (Jack) Li and Professor Evelyn Hovenga. This entity will in the first instance consist of a web-based portal to all programs on offer by the 29 IMIA academic institutional members once funding is secured.

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A glossary of terms describing the many data elements used to describe various aspects of programs and courses is being compiled. A number of members are contributing to this effort The next meeting will be held during September, 2004, in San Francisco, in conjunction with the Medinfo2004.

For further information please contact: Professor John Mantas Chairman IMIA WG1 University of Athens Health Informatics Lab 123, Papadiamantopoulou Street 11527 Athens, Greece Tel: +30-210-7461460 Fax: +30-210-7461461 e-mail: [email protected]

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Recommendations of the International Medical Informatics Association (IMIA) on Education in Health and Medical Informatics International Medical Informatics Association, Working Group 1: Health and Medical Informatics Education Abstract: The International Medical Informatics Association (IMIA) agreed on international recommendations in health informatics / medical informatics education. These should help to establish courses, course tracks or even complete programs in this field, to further develop existing educational activities in the various nations and to support international initiatives concerning education in health and medical informatics (HMI), particularly international activities in educating HMI specialists and the sharing of courseware. The IMIA recommendations centre on educational needs for health care professionals to acquire knowledge and skills in information processing and information and communication technology. The educational needs are described as a three-dimensional framework. The dimensions are: 1) professionals in health care (physicians, nurses, HMI professionals, ...), 2) type of specialisation in health and medical informatics (IT users, HMI specialists) and 3) stage of career progression (bachelor, master, ...). Learning outcomes are defined in terms of knowledge and practical skills for health care professionals in their role (a) as IT user and (b) as HMI specialist. Recommendations are given for courses/course tracks in HMI as part of educational programs in medicine, nursing, health care management, dentistry, pharmacy, public health, health record administration, and informatics/computer science as well as for dedicated programs in HMI (with bachelor, master or doctor degree). To support education in HMI, IMIA offers to award a certificate for high quality HMI education and supports information exchange on programs and courses in HMI through a WWW server of its Working Group on Health and Medical Informatics Education (http://www.imia.org/wg1).

1. Introduction 1.1. Why Do We Need Health and Medical Informatics Education? Throughout the world, health care professionals often lack knowledge of the possibilities and limitations of systematically processing data, information and knowledge and of the resulting impact on quality decision-making. They are often asked to use information technologies of which they have limited appreciation, in order to enhance their practices through better use of information resources. However, for systematically processing data, information and knowledge in medicine and in health care, health care professionals who

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are well-trained in medical informatics or health informatics are needed1. It will only be through improved education of health care professionals and through an increase in the number of well-trained workers in health and medical informatics that this lack of knowledge and associated skills can begin to be reversed. Health and medical informatics education is of particular importance at the beginning of the 21st century for the following reasons ([8], p.17): 1. progress in information processing and information and communication technology is changing our societies; 2. the amount of health and medical knowledge is increasing at such a phenomenal rate that we cannot hope to keep up with it, or store, organise and retrieve existing and new knowledge in a timely fashion without using a new information processing methodology and information technologies; 3. there are significant economic benefits to be obtained from the use of information and communication technology to support medicine and health care; 4. similarly the quality of health care is enhanced by the systematic application of information processing and information and communication technology; 5. it is expected, that these developments will continue, probably at least at the same pace as can be observed today; 6. health care professionals who are well-educated in health or medical informatics are needed to systematically process information in medicine and in health care, and for the appropriate and responsible application of information and communication technology; 7. through an increase in scope and the provision of high quality education in the field of health and medical informatics, well-educated health care professionals worldwide are expected to raise the quality and efficiency of health care. 1.2. IMIA-Recommendations for Health and Medical Informatics Education There are different opportunities world-wide for obtaining an education in this field. In some countries there are extensive educational components in health and medical informatics at different levels of education and for the different health care professions. Many other countries have not, or at least not sufficiently, established such opportunities until now, with all the consequences concerning the quality and effectiveness of health care. According to its aims and because of the situation just described, the International Medical Informatics Association (IMIA, [9], [15]) felt the need to develop international recommendations in health and medical informatics education. These recommendations shall help to establish education in this field, to further develop existing educational activities in the various nations and to support international initiatives concerning education in health and medical informatics. Because a variety of educational and health care systems exist all over the world, programs, courses and course tracks in health and medical informatics may vary in different countries. In spite of this variability, basic similarities in health and medical informatics education can be identified and used as a framework for recommendations. Such recommendations are also necessary for enabling an international exchange of students and teachers and for establishing international programs. 1 The meaning of the terms health informatics and medical informatics varies within and between different nations. Both terms will be used here interchangeably in a broad and comprehensive manner, in terms of the discipline dealing with the systematic processing of data, information and knowledge for optimal decisionmaking in medicine and health care. In order to recognize this point of view, the term health and medical informatics (HMI) will normally be used.

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The IMIA recommendations, presented here, have taken into consideration the various existing, mainly national recommendations in health and medical informatics education (e.g. [1], [2], [4], [6], [12], [13], [14]). The IMIA recommendations should be regarded as a framework for national initiatives in health and medical informatics education, and for constituting international programs and exchange of students and teachers in this field. They shall also encourage and support the sharing of courseware.

2. General Considerations 2.1. Key principles of the IMIA-Recommendations In order to provide good quality health care, training and education in health and medical informatics is needed ([16], p. 537-547): hh for various hhealth care professions, ee in different modes of eeducation, aa with different, aalternate types of specialisation in health and medical informatics, and ll at various llevels of education, at respective stages of career progression. There must be tt qualified tteachers to provide health and medical informatics courses which lead to hh recognised qualifications for hhealth and medical informatics positions. heeaalltthh’ means: In more detail, ‘h hh Practically all professionals in health care should, during their studies, be confronted with health and medical informatics education: e.g. physicians, nurses, pharmacists, health care managers, health record administrators, and also health and medical informaticians who are graduates from specialised programs in health and medical informatics. Computer scientists/informaticians and other scientists (e.g. engineers), who intend to work in the fields of medicine and health care also need health and medical informatics education. ee Various education methodologies are needed to provide the theoretical knowledge, practical skills and mature attitudes that are required. In addition to traditional classroombased models, there are many different models of flexible, distance and supported open learning to be considered. The explosive growth of the Internet and World Wide Web are additionally having great impacts on all educational methodologies, and in particular will favour flexible and distance learning. Interuniversity collaborations might also facilitate curricular choice. aa Alternate routes to different types of specialisation in health and medical informatics will depend on career choice. The majority of health care professionals (e.g. physicians, nurses) need to know how to efficiently and responsibly use information and communication technology, but only a few will choose to have accredited specialisation in this field. They should, however, also be able to acquire an additional specialist qualification in health and medical informatics as part of their chosen career development. Health and medical informatics specialisations may be different to suit the various types of health care professionals. Finally, it should also be possible to acquire specialist qualifications in health and medical informatics via specific health and medical informatics programs leading to accreditation at different levels, e.g. master or Ph.D. ll Every profession in health care even at an early stage needs some core health and medical informatics knowledge. Different levels of education, respectively stages of career progression, (bachelor, master, doctor, ...) have different health and medical informatics education needs according to experience, professional role and responsibility. A junior pro-


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fessional uses information differently compared to a senior professional. As well as there are specialised health and medical informatics university programs, health and medical informatics instruction should be integrated within other professional educational programs (medicine, nursing, informatics/computer science etc.). Thus educational components will vary in depth and breadth to suit specific student groups. Subsequent continuous education programs in health and medical informatics also need to be available. tt The content and delivery of health and medical informatics courses and programs must be of good quality. Teachers of health and medical informatics courses must have adequate and specific competence in this field. hh There must be recognised qualifications in health and medical informatics for positions in this field. Accreditation of educational content and competence in health and medical informatics is required, to eventually have recognition on an international basis. The IMIA recommendations concentrate on the ‘dimensions’ hh, aa and, to a certain extent, ll Comments on the other components ee, tt and hh, are given in sections 6 and 7. 2.2 Structural Outline of the IMIA-Recommendations The IMIA recommendations centre on educational needs for health care professionals to acquire knowledge and skills in information processing and information and communication technology as it is needed and used in medicine and health care. The educational needs are described as a threedimensional framework with dimensions ‘professional in health care’, ‘type of specialisation in health and medical informatics’ and ‘stage of career progression’ (figure 1). For these various educational needs learning outcomes are suggested (see section 3), either for courses1/course tracks2 in health and medical informatics as part of educational programs (see section 4) or for dedicated programs3 in health and medical informatics (see section 5). Figure 1 shall point out, that if one is studying a certain discipline (e.g. medicine to receive a bachelor degree), then the IMIA recommendations suggest, that in their study all these students should get a minimum of education in health and medical informatics, so that they are able to efficiently use information and communication technology (IT users). This education will be formulated in table 1, section 3, in the form of learning outcomes. On the other side, candidates may want to prepare for careers in health and medical informatics (HMI specialists). Table 1 in section 3 will indicate, which education should be given to them to become an HMI specialist. The study of HMI is somewhat different. Here we have to interpret figure 1 in the sense, that learning outcomes (also being given in table 1 and further explained in sections 4 and 5) are defined to get a bachelor, master or doctor degree in HMI. Per definition this predefines an HMI specialist. There are obviously different ways to become a qualified HMI specialist.

3. Recommendations for Learning Outcomes It is not possible today to refer to standard curricula, but rather interesting differences exist both within and between countries. A clear trend however in curriculum design is the com1 Course: Unit of study consisting of a set of lectures, exercises, ..., dedicated to a certain field, e.g. ‘introduction to hospital information systems’, ‘medical decision making’. 2 Course: Unit of study consisting of a set of lectures, exercises, ..., dedicated to a certain field, e.g. ‘introduction to hospital information systems’, ‘medical decision making’. 3 Program: An organised, structured set of course offerings aimed at preparing participants for specific career paths and culminating in a degree, diploma or leaving certificate, e.g. program in ‘medicine’, ‘medical informatics’ (as dedicated program).

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ing together of competence requirements in information processing, information systems and technologies and competence requirements in information management, i.e. how to effectively use information and communication technology to support appropriate decisionmaking and evidence based practice. This trend also relates to the evolution of concepts of the multi-disciplinary information sharing that is needed for successful decision-making and quality management both in health care and in other domains. For education in health and medical informatics two kinds of major learning outcomes can be identified. They specify the 1. Learning outcomes for all health care professionals in their role as IT users: Enabling health care professionals to efficiently and responsibly use information processing methodology and information and communication technology. These learning outcomes need to be included in all undergraduate curricula, leading to a health care professional qualification. On the other hand there are: 2. Learning outcomes for health and medical informatics specialists: Preparing graduates for careers in health and medical informatics in academic, health care (e.g. hospital) or industrial settings. These learning outcomes need to be included in all curricula, leading to a qualification as specialist in health and medical informatics. Clearly for the health professional gaining knowledge and skills in health and medical informatics, various levels can exist concerning depth and breadth of educational components. The learning outcomes define the levels of knowledge and practical skills needed. The desired outcomes determine the educational components either in courses/course tracks in health and medical informatics as part of educational programs or as dedicated programs in health and medical informatics.


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recommended for health records administrators

Table 1 contains the list of learning outcomes, recommended by IMIA. These are specified as levels of knowledge and practical skills. There is a distinction between three levels of knowledge and skills: 1) introductory knowledge/skills, 2) intermediate knowledge/skills and 3) advanced knowledge/skills. Knowledge and skills which are described as optional are recommended if the research profile of the university/school offering a program includes these fields and if it fits well into a program. The knowledge and skill levels are classified into three domain areas of knowledge and skill:

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P recommended for physicians P,SP recommended for physicians and for HMI professionals X Minimum knowledge and skills in medicine, health and biosciences, health system organisation,recommended e.g. for students of dedicated HMI programs, of health record administration programs and of computer science/informatics students at bachelor and master level.

1. Methodology and technology for the processing of data, information and knowledge in medicine and health care. 2. Medicine, health and biosciences, health system organisation. 3. Informatics/computer science, mathematics, biometry.


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B/M recommended for bachelor programs in HMI, based on an informatics-based approach to HMI (see section 5), necessary knowledge and skills for entering a master program in HMI, based on an informatics-based approach to HMI

All health care professional graduates should, in their role as IT users, have the levels of knowledge and skills mentioned for IT users. Analogously, those professionals in health care, being health and medical informatics specialists, should have the levels of knowledge and skills specified for them. In order to achieve the learning outcomes mentioned above, their educational components should be considered for inclusion into the respective educational programs. The levels of knowledge and skills mentioned may particularly work well for developed, industrialised countries, with high levels of access to, and use of, information technology, and which have highly developed health care infrastructures. Developing countries may at the beginning have the need to adapt them with regard to the level of technology. The principles of health and medical informatics, however, can still be taught, applied and developed in the absence of high levels of information and communication technology. Recommendations, either specific for certain courses or course tracks in health and medical informatics as part of educational programs or specific for dedicated educational programs in health and medical informatics, are mentioned in sections 4 and 5.

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4. Recommendations for Courses/Course Tracks in Health and Medical Informatics as Part of Educational Programs 4.1. General Remarks Educational course components in health and medical informatics should be tailored to the student's advancement and where possible be made relevant for and used to support a given stage of student progression. For example, teaching about the patient record for students of medicine should be introduced after the student has gained some clinical experience, but not too late so that students can benefit from this knowledge in the latter stages of their clinical training. Due to the afore-mentioned large variety, there exist different perspectives for health and medical informatics education. For health and medical informatics specialists we especially can distinguish between a more informatics-based and a more health care-based approach to health and medical informatics education, with a variety of combinations inbetween. The objective of an informatics-based approach to health and medical informatics is to focus on the processing of data, information and knowledge in health care and medicine with a strong emphasis on the need for advanced knowledge and skills of health and medical informatics, of mathematics, as well as of theoretical, practical and technical informatics/computer science. Health care problems, however, can be treated cooperatively with physicians and other health care professionals. In such an approach to health and medical informatics education knowledge and skills of informatics/computer science predominate. The objective of a health care-based approach to health and medical informatics is to focus on the processing of data, information and knowledge in health care and medicine requiring, apart from knowledge in health and medical informatics, also knowledge in medicine or of other health sciences to such an extent, which can only be imparted within the scope of a medical or health science education. In such an approach to health and medical informatics education knowledge and skills of medicine and of other health sciences predominate. The recommendations, given in section 4.2 and 4.3 for health and medical informatics specialists are recommendations for health care-based approaches to health and medical informatics. The recommendations in sections 4.4 and 5.2 are oriented towards an informatics-based approach. With respect to educational progression, especially for a bachelor, master, and doctoral degree, the general distinctions in depth and breadth should be considered as mentioned in section 5.

4.2. Recommendations for Health and Medical Informatics Courses as Part of Medical, Nursing, Health Care Management, Dentistry, Pharmacy, and Public Health Programs Courses/Course Tracks for IT Users In order to achieve the levels of knowledge and skills in health and medical informatics as recommended in section 3 for IT users, the total student workload for educational components in health and medical informatics should comprise at least 2 ECTS credits1 (see [3]). 1 In the European Credit Transfer System (ECTS, [3]) a full academic year’s student workload is 60 credits. Four ECTS credits can correspond, e.g., to approx. 40 hours of lectures, exercises and practical training at universities. A course, charged with four ECTS credits, may e.g. consist of a 3 hours/week lecture given in one semester with 14 weeks of lecturing.


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Specific examples from the work of the respective health professionals should be used. Emphasis should particularly be given to practical training. The additional recommendations of this section may also apply to the programs of other professions in health care such as medical laboratory technicians, medical librarians, radiology technicians, dieticians, occupational therapists etc. or for the programs allied health/clinical researchers studied. These people also need to know about the potentials and the risks of information processing in health care and be able to efficiently use methods and tools of information processing and information and communication technology. Courses/Course Tracks for Health and Medical Informatics Specialists In order to achieve the levels of knowledge and skills in health and medical informatics, as recommended in section 3 for specialists, the student workload associated with these educational components in health and medical informatics should be at least 60 ECTS credits, i.e. one year of full time studies. This is similar to dedicated master programs in health and medical informatics. In addition to the ‘core’ knowledge and skills obtained in each program, the relative amount of student workload for the three knowledge and skills areas inside the health/medical informatics course track should approximately be as indicated in table 2. For all health care professionals area (2) should focus on health system organisation, area (3) on practical informatics and project management. For nurses it should be possible that specialisation can be included in a post registration nursing curriculum. For health care managers knowledge and practical skills of information systems architectures and information systems management should particularly comprise enterprise functions for administration, controlling, quality management and executive decision making. 4.3. Recommendations for Health and Medical Informatics Courses as Part of Health Record Administration Programs Within the past decade the discipline of health record administration (also denoted as health information management) has often enhanced its scope from document handling to managing health care information. Also the scope of practice has changed considerably. For educating health record administrators, two different levels of education are recommended:

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A first level should cover introductory concepts and principles and assumes an introductory skill level. Students at this level take e.g. a two- or three year prescribed course of study at a college level resulting (e.g. in the U.S.) in an associate’s degree. At a second level a deeper understanding of knowledge and more advanced skills, developing problem solving and critical thinking skills in more depth is assumed. Students at this level take e.g. a three- or four-year prescribed course of study resulting in a bachelor degree. Further studies may follow.

Courses/Course Tracks for IT Users Health record administration students at the mentioned first level can be regarded as IT users. The recommendations on levels of knowledge and skills are the same as for IT users, mentioned in section 4.2. Particular emphasis should be given to information literacy, health terminology, coding systems, the electronic health record, and evaluation methodology. There should be introductory knowledge and skills in the knowledge/skill-domain medicine, health and biosciences, health systems organisation. Courses/Course Tracks for Health and Medical Informatics Specialists Students of health record administration programs, respectively health information management programs, who lead to bachelor and master degrees should have the knowledge and skills of HMI specialists, as mentioned in section 4.2. Again, special emphasis should be given to information literacy, health terminology, coding systems, the electronic health record, and evaluation methodology. 4.4. Recommendations for Health and Medical Informatics Courses as Part of Informatics/Computer Science Programs Courses/Course Tracks for Health and Medical Informatics Specialists In order to achieve the levels of knowledge and skills in health and medical informatics, recommended in section 3 for specialists, the length of studies for educational components in health and medical informatics should be at least 60 ECTS credits, i.e. one year of full time studies. In addition to the ‘core’ knowledge and skills of informatics/computer science, the relative amount of student workload for the three knowledge and skills areas inside the health/medical informatics course track should approximately be as indicated in table 3. The student workload in (3) comprises knowledge and skills in biometry and evaluation methods. Applying methods and tools of informatics in health care institutions and for concrete problems in diagnosis, therapy, nursing and health care management should be emphasised. This helps to learn to know the health care environment as informatics or com-


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puter science student. Health information systems management should include the development and implementation of software and hardware components of health information systems. In medical signal and image processing technical and informatics aspects should particularly be considered.

5. Recommendations for Dedicated Educational Programs in Health and Medical Informatics 5.1. General Remark The aim of all dedicated programs in health and medical informatics is to prepare graduates for careers in health and medical informatics in academic, health care (e.g. hospital) or industrial settings. 5.2. Recommendations for Bachelor Programs in Health and Medical Informatics For programs leading to a bachelor degree in health informatics or medical informatics, curricula should be application-related, serving the purpose of a direct preparation for the future professional activity. In addition they should offer a good foundation for studying in a master program in this field or in related ones. The objective of such a type of education is to impart specialised knowledge in the field of health and medical informatics as well as skills in a practice-oriented application of the acquired knowledge. The intention is to provide a practice-related education to qualify for translating expertise gained in the field of health and medical informatics into practical activity, in conformity with the state of knowledge. As compared with the comprehensive formal methodological foundation of a master program, it is the practice-oriented application that predominates. In order to achieve the levels of knowledge and skills in health and medical informatics as recommended in section 3, and in order to achieve a broad depth and breadth of all educational components, the length of study for educational components in health and medical informatics should be at least three years. This corresponds to a student workload of at least 180 ECTS credits. For an informatics based approach to health and medical informatics, the relative amount of student workload for the three knowledge and skills areas for the bachelor program should be approximately as indicated in table 4. This composition can be varied from very strong technical IT skill acquisition to less IT skill and a stronger health application focus, depending on the desired learning outcomes.

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5.3 Recommendations for Master and Doctoral Programs in Health and Medical Informatics For programs leading to a master or doctoral degree (e.g. Ph.D.), it is the comprehensive formal methodological foundation for health and medical informatics that predominates, at a formal level. The objective is to provide an education of scientific character that includes theory, specialised knowledge and practical skills. Graduates shall, apart from a practice-oriented application of methods and tools from health and medical informatics, be enabled to independently participate in research and in the methodi cal advancement within the field of health and medical informatics. In contrast to bachelor programs, these higher degrees include formal penetration and abstraction as well as the afore-mentioned qualification of graduates independently contributing to the methodical and scientific advancement that predominates. In order to achieve the levels of knowledge and skills in health and medical informatics as recommended in section 3, and in order to achieve the desired broad depth and breadth of the educational components previously defined, the length of study should be at least one year full time for a master degree, corresponding to at least 60 ECTS credits. Ph.D. studies or Ph.D. work should usually last three years. The relative amount of study time for the three knowledge and skills areas for the master program should approximately be as indicated in table 5. It is expected that master students have successfully finished either (a) a bachelor program in health and medical informatics, (b) a bachelor or master program in medicine or another health science, or (c) in computer science. For cases (b) and (c) additional complementary courses in informatics/computer science (for case (b)) or medicine, health and biosciences, health system organisation (for case (c)) should be offered. For programs leading to a doctoral degree, comprehensive own research should be carried out independently by the student in addition to the requirements previously mentioned. Knowledge and skills should also have additional depth or breadth. This should also be considered for the learning outcomes of sections 3 for depth and breadth of educational components when transforming them to educational components in doctoral programs.

6. Recommendations for Continuing Education 6.1. Continuing Education in Health and Medical Informatics To prove sufficient qualification in health/medical informatics both in relation to the academic education or continuing education in health and medical informatics and in relation


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to a successful at least four-year professional activity (operational qualification), a certificate of ‘Health Informatics’ or ‘Medical Informatics’ should be offered. Furthermore, for physicians, who usually have well established forms of continuing education, there should be offered the possibility of receiving, in addition to their medical degree, the supplementary qualification of ‘Medical Informatics’ or ‘Health Informatics’. This additional qualification can be issued by the national medical associations. The same holds for nurses, for whom in many countries also forms of continuing education are very well-established. In order to offer courses in health and medical informatics for continuing education, it is recommended that institutions are established to provide such courses. These institutions might be inside universities or, e.g. as academies of health/medical informatics established by associations in health and medical informatics. 6.2. Life Long Learning Working in the field of health and medical informatics and even using information and communication technology requires life long learning. Therefore opportunities for continuing education should be offered for HMI specialists as well as IT users of the various health professions. The ability of ‘learning to learn’ will become of particular importance.

7. Other Recommendations 7.1. How to Commence with Health and Medical Informatics Education Health and medical informatics affects all health care professionals. To commence education in this field IMIA recommends that education in health and medical informatics for all types of health care professionals, including the different types of specialisation and levels of education is considered. In countries, where no education in health and medical informatics exists, the following steps are recommended. First of all teachers have to be educated (‘teach the teachers’), courseware has to be prepared and institutes for health informatics or medical informatics have to be established within universities, usually inside medical or health sciences faculties. A broad education in the use of information processing and information and communication technology for health care professionals, especially physicians and nurses, should have the first priority. Thus, introductory courses especially for medical and nursing students should be offered first. Other types of education, as mentioned above, should then follow. 7.2. Modes of Education Certain modes of education should be chosen, considering the specific profile and possibilities of the respective universities. Besides lectures it is of importance that practical exercises within health care institutions (e.g. in hospitals) are offered. Besides ‘traditional’ lectures and exercises within universities, and given the explosive growth of the Internet and World Wide Web, different models of flexible, distance and supported open learning should be actively pursued. Problem-oriented learning might particularly support the relevance of health and medical informatics as it requires integration of information and a cross-disciplinary understanding.

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7.3. Qualified Teachers Courses and programs in health and medical informatics must be of good quality. Teachers of courses in health and medical informatics must have adequate and specific qualifications in this field. It must be possible to obtain such qualifications for lecturing in health and medical informatics, usually from universities. 7.4. Recognised Qualifications Education of students in health and medical informatics, which goes beyond introductory courses in the use of information and communication technology, only makes sense if positions for these graduates exist or are created. The qualifications of such health and medical informatics graduates must be recognised and there should be positions as specialists in health and medical informatics.

8. IMIA Support for Programs and Courses in Health and Medical Informatics 8.1. IMIA Certification To support education of high quality in the field of health and medical informatics, IMIA offers help by providing expert advice to persons and institutions in this field, as far as the resources of IMIA allow. This might especially be needed when commencing with educational activities and when national institutions are not yet established to do this. Health and medical informatics courses inside programs and in specialised programs in this field can upon request add to the description of their course track or program the phrase ‘endorsed by the International Medical Informatics Association’ and can use the IMIA logo in this context. This is conditional to the IMIA recommendations being fulfilled and once the quality of the program, including organisational integration and resources, has been assessed by IMIA appointed experts. Single courses can not be considered, only course tracks or programs. The fulfilment of the recommendations and the assessment of the quality of the program will be examined by a committee usually consisting of 4 IMIA WG1 members or other persons, experienced in HMI education, and will be approved by the IMIA president and the chairperson of IMIA WG1. The members of this committee will be nominated jointly by the IMIA president and by the chairperson of IMIA WG1. After approval, a written certificate, signed by the IMIA president, the chairperson of IMIA Working Group 1 on Health and Medical Informatics Education, and by the committee members, will be given to the respective organisation. Requests should be submitted to the chairperson of IMIA Working Group 1. 8.2. International Programs, International Exchange of Students and Teachers IMIA encourages and recommends international activities in educating health and medical informatics specialists. IMIA also recommends the international exchange of students and of teachers in this field. It encourages the establishment of international programs to support this and to exchange courseware. Programs should be built up in a modular way, and international credit transfer systems such as the ECTS ([3]) should be used in the respective national programs to support these international perspectives.


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9. Information Exchange on Programs and Courses in Health and Medical Informatics Supported by IMIA 9.1. IMIA WG1 Database on Programs and Courses in Health and Medical Informatics IMIA’s Working Group 1 on Health and Medical Informatics Education (IMIA WG1) has established a WWW site to provide up-to-date information about its work ([10]). The main feature of the site is a database providing information on health and medical informatics programs and courses world-wide ([7]). To be able to have a database of high quality and value IMIA encourages all teachers and institutions to submit information about courses and programs on HMI education offered and to set pointers to their own WWW sites. 9.2. IMIA WG1 Mailing List In addition, IMIA WG1 operates a mailing list to facilitate communication between all persons interested in health and medical informatics education world-wide. For subscription, a message has to be sent to ‘[email protected]‘. The body of the message should read ‘SUBSCRIBE IMIAWG1‘. Messages to the IMIA WG1 list have to be sent to ‘[email protected]‘. 9.3. Developing and Sharing Courseware IMIA encourages the development and sharing of courseware of high quality for courses in health and medical informatics. This will help to further establish courses in this field. Examples for such initiatives are the IT Eductra project of the European Union ([11]) or the WWW sites of the Handbook of Medical Informatics ([16]). IMIA encourages the use of its IMIA WG1 WWW server and list server for the dissemination of information about such courseware.

10. Concluding Remarks These recommendations provide a beginning framework for individual curriculum development. Individual countries may wish to develop more detailed or better defined curricula guidelines to suit their specific needs and educational system. This could include specific minimum level competencies required for each level and knowledge/skill domain. Such national efforts are expected to inform future reviews of these guidelines. The IMIA WG1 may in the near future develop teaching credentialing criteria to serve as a guide for teachers wishing to participate in health and medical informatics education.

Acknowledgements These recommendations are the result of numerous meetings, mainly of IMIA WG1, and have been discussed and modified by many groups of IMIA and its national associations. They were endorsed by the IMIA General Assembly at November 11th, 1999 in Washington. Significant contributions to the recommendations came from John Arokiasamy (Malaysia), Marion Ball (USA), Denise Barnett (United Kingdom), Margaret Bearman (Australia), Jan van Bemmel (The Netherlands), Judith Douglas (USA), Paul Fisher (Canada), Robert

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Garrie (USA), Lael Gatewood (USA), William Goossen (The Netherlands), Andrew Grant (Canada, HEALNET), Joseph Hales (USA), Arie Hasman (The Netherlands), Reinhold Haux (Germany), Evelyn Hovenga (Australia), Merida Johns (USA), Petra Knaup (Germany), Franz Josef Leven (Germany), Nancy Lorenzi (USA), Peter Murray (United Kingdom), Roderick Neame (United Kingdom), Denis Protti (Canada), Michael Power (South Africa), Janise Richards (USA), Ernst Schuster (Austria), Wendy Swinkels (Australia), Jim Yang (Norway), Lynn Zelmer (Australia), Jana Zvárová· (Czech Republic). The recommendations have been edited by Reinhold Haux (chairman of IMIA WG1), Andrew Grant, Arie Hasman, Evelyn Hovenga and Petra Knaup (secretary of IMIA WG1).

References [1] [2]

[3] [4] [5] [6]

[7]

[8]

[9] [10] [11] [12]

[13] [14]

[15] [16]

Council of Europe Committee of Ministers (1995): Recommendations No. R (90) 21 of the Committee of Ministers to Member States on Training Strategies for Health Information Systems. In: [5], 3-6. Enabling People Programme & English National Board for Nursing, Midwifery and Health Visiting (1997): Information for Caring: integrating informatics into learning programmes for nurses, midwives and health visitors. Birmingham: Institute of Health and Care Development. European Credit Transfer System: http://europa.eu.int/comm/education/socrates/ects.html. HASMAN A, ALBERT A (1997): Education and Training in Health Informatics: Guidelines for European Curricula. Int J Med Informatics 45, 91-110. HASMAN A, ALBERT A, WAINWRIGHT P, KLAR R, SOSA M (eds) (1995): Education and Training in Health Informatics in Europe. State of the Art - Guidelines -Applications. Amsterdam: IOS Press. HAUX R, DUDECK J, GAUS W, LEVEN F J, KUNATH H, MICHAELIS J, PRETSCHNER D P, THURMAYR R, WOLTERS E (1992): Recommendations of the German Association of Medical Informatics, Biometry and Epidemiology on Education in Medical Informatics. Meth Inform Med 31, 6070. HAUX R, FRANK J, KNAUP P (1997): The IMIA WG1 database on health and medical informatics programs and courses: a call for participation. Meth Inform Med 36, 233-4. Reprint in: VAN BEMMEL, J.H., MCCRAY, A.T. (eds). IMIA Yearbook of Medical Informatics 1998, 528-9. Stuttgart: Schattauer. HAUX R, SWINKELS W, BALL MJ, KNAUP P, LUN KC (eds) (1998): Health and medical informatics education: transformation of health care through innovative use of information technology for the 21st century. Int J Med Informatics, 50, 1-300. International Medical Informatics Association (IMIA). WWW server: http://www.imia.org. International Medical Informatics Association (IMIA), Working Group 1 (WG1) on Health and Medical Informatics Education. WWW server: http://www.imia.org/wg1. IT EDUCTRA: http://www.fundesco.es/it-eductra. NACNEP, National Advisory Council on Nurse Education and Practice (1997): A national informatics agenda for nursing education and practice. Report to the Secretary of the Department of Health & Human Services. Washington DC: US Department of Health and Human Services, Division of Nursing. Physicians for the Twenty-First Century (The GPEP Report). Association of the American Medical Colleges, Washington, 1984. VAN BEMMEL JH, FESTEN C (eds) (1987): Medical Informatics: Renewal in Medicine (In Dutch with English Summary). Amsterdam: Committee from Medicine of the Royal Netherlands Academy of Arts and Sciences. VAN BEMMEL JH, MCCRAY AT (eds): IMIA Yearbook of Medical Informatics. Stuttgart: Schattauer. Annual appearance. VAN BEMMEL JH, MUSEN MA (eds) (1997): Handbook of Medical Informatics. Heidelberg: Springer. WWW sites: http://www.mieur.nl/mihandbook, http://www.mihandbook.stanford.edu.

Address of Correspondence: International Medical Informatics Association (IMIA) Working Group 1: Health and Medical Informatics Education Internet: http://www.imia.org/wg1 Chairman: Prof. Dr. Reinhold Haux


Secretary: Dr. Petra Knaup University of Heidelberg Institute for Medical Biometry and Informatics Department of Medical Informatics Im Neuenheimer Feld 400 D-69120 Heidelberg Germany http://www.med.uni-heidelberg.de/mi Phone: ++49/6221/56-7483 Fax: ++49/6221/56-4997 E-Mail: {Reinhold_Haux, Petra_Knaup}@med.uni-heidelberg.de Current Chairman: Prof. Dr. John Mantas University of Athens Faculty of Nursing Laboratory of Health Informatics Papadiamantopoulou 123, 115 27 Athens Greece http://www.nurs.uoa.gr Phone: +30 210 746 1460 Fax: +30 210 746 1461 E-Mail: [email protected]

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Authors Professor Evelyn J.S Hovenga, RN PhD FRCNA, FCHSE, MACS, Program Director Health Informatics School of Information Systems, Faculty of Informatics and Communication, Central Queensland University, Rockhampton, AUSTRALIA [email protected] Professor John Mantas, BSc(Hons), MSc, PhD Program Director of Health Informatics Postgraduate Course Director of Health Informatics Laboratory, Faculty of Nursing, University of Athens, 123, Papadiamantopoulou Street, GR-11527, Athens GREECE [email protected] Jean Roberts Consultant, Macclesfield, Cheshire UK [email protected] Jeannette Murphy, Senior Lecturer, CHIME University College London UK [email protected] Professor Arie Hasman Department. of Medical Informatics University of Maastricht, P.O. Box 616, NL-6200 MD Maastricht, THE NETHERLANDS [email protected]

Professor Dr. Reinhold Haux Rector of the University for Health Sciences, Medical Informatics and Technology (UMIT) Innsbruck, AUSTRIA [email protected] Professor Virginia K. Saba, EdD, Honorary PhD, RN, FAAN, FACMI, LL 2332 South Queens Street Arlington, VA 22202 USA [email protected] Professor Bijan B Gillani Coordinator of Educational Technology Leadership Graduate Program Department of Teacher Education, California State University, Hayward USA [email protected] Sylvia Alexander Manager, UK national Learning and Teaching Support Network (LTSN) Subject Centre for Information and Computer Sciences, University of Ulster, N. Ireland, UK [email protected] Dr Kathy Egea Senior Lecturer Faculty of Informatics and Communication, Central Queensland University, Rockhampton, AUSTRALIA [email protected] Professor Umberto Giani

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Authors

Dept of Preventive Medical Sciences, Faculty of Medicine, University of Naples, ITALY [email protected] Professor Kaija Saranto, PhD, RN Professor in Social and Health Informatics Department of Health Policy and Management, Faculty of Social Sciences University of Kuopio FINLAND [email protected]

GERMANY [email protected] Lisa Bricknell Faculty of Informatics and Communication, Central Queensland University, Rockhampton Qld MC 4702, AUSTRALIA Christina O’Guinn Adjunct Professor NASA Ames Educational Technology Team, Lead NASA Ames Research Center, USA

Dr. Christian Nohr M.Sc., PhD, Associate Professor Department of Development and Planning, Aalborg University, DENMARK [email protected]

Professor George Kernohan School of Nursing University of Ulster Shore Road, Jordanstown, Co. Antrim, N. Ireland. BT37 0QB UK

Dr. Diane J. Skiba, PhD, FAAN, FACMI Associate Professor School of Nursing University of Colorado Health Sciences Center Denver, CO, USA

Dr Paul McCullagh Senior Lecturer School of Computing and Mathematics University of Ulster Shore Road, Jordanstown, Co. Antrim, N. Ireland. BT37 0QB UK

Dr. Carol Bickford, PHD, RN, BC Senior Policy Fellow Department of Nursing Practice and Policy American Nurses Association Washington, DC, USA

AC Lynn Zelmer Faculty of Informatics and Communication Central Queensland University Rockhampton, AUSTRALIA

Dr. Glyn Hayes Council for Health Informatics Professions British Computer Society HQ, 1 Sanford Street, Swindon, Wiltshire, SN1 1HJ, UK Dr. R. Engelbrecht MEDIS Institut GSF Forschungszentrum Ingolstaedter Landstrasse 1 D-85764 Oberschleissheim

Johanna Lammintakanen Department of Health Policy and Management, University of Kuopio, P.O. Box 1627, FIN-70211 Kuopio, FINLAND Kristiina Häyrinen Department of Health Policy and Management, University of Kuopio, P.O. Box 1627, FIN-70211 Kuopio, FINLAND

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Glossary Term Access

Explanation The possibility to retrieve medical information stored in a database or remote application. Access should be limited by security authentication mechanisms. [from CEN/TC 251]

Accreditation

A self-regulatory process by which governmental, nongovernmental, voluntary associations or other statutory bodies grant formal recognition to educational programs or institutions that meet stated criteria of educational quality. Educational programs or institutions are measured against certain standards by a review of written information, selfstudies, site visits to the educational program, and thoughtful consideration of the findings by a review committee. Whereas programs or institutions are accredited, individual physicians are licensed or certified.

American Medical Association (AMA)

According to its mission statement, this professional association represents the voice of the American medical profession and constitutes the partnership of physicians and their professional associations dedicated to promoting the art and science of medicine and the betterment of public health. The AMA serves physicians and their patients by establishing and promoting ethical, educational, and clinical standards for the medical profession and by advocating the highest principle of all: the integrity of the physician/patient relationship.

Architecture

A framework from which applications, databases and workstations can be developed in a coherent manner, and in which every part fit together without containing a mass of design details. Normally used to describe how a piece of hardware or software is constructed and which protocols and interfaces are required for communications. Network architecture specifies the functions and data transmission needed to convey information across a network. [from CEN/TC 251]

Archive System

Archiving is the process of long-term storage and organisation of data and documents. An archive is an off-line storage of patient data or other information, in a way that ensures the possibility to restore them on-line when needed. [from CEN/TC 251]

Glossary

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Term Explanation Artificial Intelligence (AI) Artificial Intelligence (AI) is the discipline concerned with the technology, the background, and the theory of building computer systems that perform functions that would be said to require intelligence if performed by humans or animals (or functions that might otherwise be described as intelligent). AI is an interdisciplinary area with inputs from computer science, psychology, neuroscience, cybernetics, linguistics and philosophy. AI is concerned with such things as natural language understanding, machine learning, computer vision, machine reasoning, expert systems. There are two main paradigms of AI - the symbolic paradigm where information is explicitly represented in a symbolic form (this corresponds to the knowledge based approach (see knowledge based system (KBS)) - and the sub-symbolic paradigm (corresponding to the neural networks approach). [from CEN/TC 251] Assessment

A system of evaluation of professional accomplishments using defined criteria and usually including an attempt at measurement either by grading on a rough scale or by assigning numerical value. The purpose of assessment in an educational context is to make a judgment about the level of skills or knowledge, to measure improvement over time, to evaluate strengths and weaknesses, to rank students for selection or exclusion, or to motivate. Assessment should be as objective and reproducible as possible. A reliable test should produce the same or similar scores on two or more occasions or if given by two or more assessors. The validity of a test is determined by the extent to which it measures whatever it sets out to measure. One can distinguish three types of assessment: Formative assessment is testing that is part of the developmental or ongoing teaching/learning process. It should include delivery of feedback to the student. Summative assessment is testing which often occurs at the end of a term or course, used primarily to provide information about how much the student has learned and how well the course was taught. Criterion-referenced assessment refers to testing against an absolute standard such as an individual's performance against a benchmark.

Association for Medical Education in Europe (AMEE)

A worldwide association concerned with education in the medical and health care profession – teachers, curriculum developers, deans, administrators, researchers and students. AMEE works with the continuum of education and its quality, the facilitation of high quality research in medical education and serves as a source of advice on matters relating

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Glossary

Term

Explanation to medical education. AMEE assists with the development of skills required by medical teachers and facilitates the exchange of information on medical education. AMEE is concerned with the development of medical education to meet current and future needs, particularly in the European context. The AMEE Office is located at the Centre for Medical Education, University of Dundee, Scotland.

A nonprofit association consisting of the 125 accredited Association of American Medical Colleges (AAMC) United States medical schools, the 16 accredited Canadian medical schools, more than 400 major teaching hospitals and health systems, some 90 academic and professional societies representing 75,000 faculty members, and the nation's medical students and residents. The purpose of the AAMC is to improve health through the advancement of academic medicine, and in pursuing this purpose, the AAMC works "to strengthen the quality of medical education and training, to enhance the search for biomedical knowledge, to advance research in health services, and to integrate education into the provisions of effective health care." The AAMC is responsible for the Medical College Admission Test (MCAT) required of each applicant to medical school in the U.S. and Canada. Best Evidence Medical Education (BEME) Processing

Methods and approaches used by teachers of medical education based on the best available evidence as opposed to opinion-based education. BEME should take into account these factors: how reliable the evidence is as well as its utility, extent, strength, validity and relevance. It calls for critical appraisal of available literature and existing databases and identifying any existing gaps.

Care Planning Systems

These systems include assessment (see Nursing Assessment), diagnosis (see Nursing Diagnosis or Diagnostic Procedure), intervention (see Nursing Intervention), and outcome components of care.

CEN/TC 251

Technical Committee 251 (TC 251) of the European Standardisation Committee (CEN), which is concerned with the establishment of European Medical Informatics standards. The work programme TC 251 is established by seven working groups (WG). For some of the priority work items a Project Teams (PT) have been set up. TITLE : Medical Informatics SCOPE : Organisation, coordination and monitoring of the development of standards, including testing standards, in Health Care Informatics as well as the promulgation of these standards.

Glossary

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Term Centralised Medical Information System

Explanation Health Information System architecture is which processing and information storage resources are centralised at one location and requests for information or usage of the resources are directed to the central resource. [from CEN/TC 251]

Classification

Classification is the systematic placement of things or concepts into categories, which share some common attribute, quality or property. A classification structure is a listing of terms that depicts hierarchical structures. [from CEN/TC 251]

Client-Server Agent Model This is a model of a distributed application process in which various activities are carried out by different entities. The client is that entity which requests a service. The server is that entity which provides the service. An agent is that process which acts on behalf of the client or server. [from CEN/TC 251] Clinical Competence

The mastery of relevant knowledge and the acquisition of a range of relevant skills at a satisfactory level including interpersonal, clinical and technical components at a certain point of education, such as at graduation. In the case of clinical training, which is primarily based on an apprenticeship model, teachers define what the student is expected to do and then test their ability to do it. However, in actuality, most clinical actions are concerned with problems for which there are no clear answers and no single solution. In such situations, an experienced doctor searches his or her mind and sifts through a wide range of options and in some cases the solution will be something he or she has never arrived at before. Therefore, competence itself is only of value as a prerequisite for performance in a real clinical setting and does not always correlate highly with performance in practice.

Clinical Information System

Information system that manages clinical data to support patient care and Clinical Decision making. [from CEN/TC 251]

Clinical laboratory information system

Information System that manages clinical laboratory data to support laboratory management, laboratory data collection and processing, patient care and medical decision-making. Note: It may be part of a hospital information system or it may be independent. [from CEN/TC 251]

Communication

The process by which information and feelings are shared by people through an exchange of verbal and non-verbal messages. In the context of medical education, its primary

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Glossary

Term

Explanation function is to establish understanding between patient and doctor. In an atmosphere of effective communication, patients improve faster, cope better with post-operative pain, require less psychotropic drugs, and experience numerous other health benefits.

Communication Network

Configurations of hardware, software and transmission facilities for transmission and routing of data carrying signals between electronic devices. The term encompasses the telecommunications network and Local Area Network (LAN) and Wide Area Network (WAN) for computer systems. Modern telecommunications offers digital transmission, Integrated Services Digital Network (ISDN) (which allows transmission of voice, data, video, facsimile and other digital information through the network) and packet switching systems (PSS). [from CEN/TC 251]

Communication Skills

Proficiency in the interchange of information. These are essential skills for clinical practitioners because of the large and varied number of people they must communicate with every day. The idea that doctors automatically learn communication through experience or that doctors are inherently either good or bad communicators is being largely abandoned. It is now widely believed that such skills can be taught to both students and doctors by a variety of professionals including doctors and specialists in communication skills as an important part of undergraduate as well as postgraduate and continuing medical education.

Community-Based Education (CBE), Community-Based Learning (CBL), or Community-Based Teaching (CBT)

A form of instruction where trainees learn professional competencies in a community setting focusing on population groups and also individuals and their everyday problems. The amount of time students spend in the community and organizational settings may vary. Instruction may take place at a general practice, family planning clinic, community health centre or a rural hospital. During their training in the community, students learn about social and economic aspects of illness, about health services in the community and methods of health promotion, about working in teams, and about frequency and types of problems encountered outside a hospital setting.

Competence

Possession of a satisfactory level of relevant knowledge and acquisition of a range of relevant skills that include interpersonal and technical components at a certain point in the educational process. Such knowledge and skills are necessary to perform the tasks that reflect the scope of professional practices. Competence may differ from "performance", which denotes actions taken in a real life

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Explanation situation. Competence is therefore not the same as "knowing" on the contrary, it may well be about recognizing one's own limits. The more experienced the professional being tested, the more difficult it is to create a tool to assess their actual understandings and the complex skills of the tasks they undertake. A holistic integration of understandings, abilities and professional judgments i.e. a "generic" model, is one where competence is not necessarily directly observable, but rather can be inferred from performance.

Continuing Medical Education (CME)

A continuous process of acquiring new knowledge and skills throughout one's professional life. As undergraduate and postgraduate education is insufficient to ensure lifelong physicians' competencies, it is essential to maintain the competencies of physicians, to remedy gaps in skills, and to enable professionals to respond to the challenges of rapidly growing knowledge and technologies, changing health needs and the social, political and economic factors of the practice of medicine. Continuing medical education depends highly upon learner motivation and self-directed learning skills.

Curriculum

An educational plan that spells out which goals and objectives should be achieved, which topics should be covered and which methods are to be used for learning, teaching and evaluation.

Decentralised Medical Information System

A health information system architecture in which processing, storage and control is distributed around the system. Such a system would consist of processing units assembled in a network. [from CEN/TC 251]

Departmental System

System that support a specific departmental functional activity within a health care environment, but which could also work as a stand alone unit. [from CEN/TC 251]

Dietary Information System

A Dietary Information System is a kind of Health Information System that contains information on the subject of diet and nutrition, such as information about the dietary needs of people suffering from various conditions, details of contents of various foods, and information about links between diet and certain diseases. [from CEN/TC 251]

Discipline-Based Approach Teaching of the individual classical medical disciplines such as anatomy, biochemistry, pathology, surgery or community medicine as separate educational building blocks. It is expected that this approach lays the foundation for contact with patients which tends to occur later, after completion of the basic science course. In this approach, it is left to the student to put together the knowledge gained in each

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Term

Explanation discipline to form an overall picture of medicine.

Drug Information System A computer based information system that maintains drug related information, such as information concerning appropriate dosages, side effects, and it may access a Drug Interaction Database. A drug information system may provide by way of a directed consultation, specific advice on the usage of various drugs. [from CEN/TC 251] E-Health

A term that refers to all forms of electronic health services provided over the Internet. It includes all educational, information and commercial services and products offered by professionals, non-professionals, businesses and consumers. Based on the unique capabilities of Internet, E-Health is enabling the delivery of clinical services that previously have been domain of telemedicine and telehealth. E-health differs from telemedicine and telehealth in that it is not "professional-centric" and is motivated by the financial gain, whereas telemedicine and telehealth are not. As it is Internetbased, E-health is making the provision of health care more efficient.

Educational or Instructional Objectives

Statements that describe what learners should be able to master. A major aim is the acquisition of facts, concepts and principles. Developing instructional objectives involves learning the fundamentals and vocabulary of each discipline and developing a logical progression of concepts in each discipline. Resources and materials are more effectively deployed when instructional objectives are explicit. It is important to assure that objectives are measurable and that they delineate a specific level of competence. One can and should distinguish between knowledge, skill and attitude objectives.

Elective Program

An educational program where students are given the opportunity to select subjects or projects of their own choice, not covered by obligatory medical courses. This enables students to pursue individual aspirations, provides students with increased responsibility to further their own learning, and facilitates career choice by providing an opportunity to explore various areas of interest.

Evaluation

A process that attempts to systematically and objectively determine the relevance, effectiveness, and impact of activities in light of their objectives. Evaluation can be related to structure, process, or outcome. One can distinguish these various types: Formative individual evaluation provides feedback to an

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Term

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Explanation individual (usually a learner) in order to improve that individual's performance. This type of evaluation identifies areas for improvement and provides specific suggestions for improvement serving as an educational tool. Summative individual evaluation measures whether specific objectives were accomplished by an individual in order to place a value on the performance of that individual. It may certify competency or lack of competency in performance in a particular area. Formative program evaluation provides information in order to improve a program's performance. It usually takes the form of surveys of learners to obtain feedback about and suggestions for improving a curriculum. Quantitative information such as ratings of various aspects of the curriculum can help identify areas that need revision. Qualitative information, such as responses to open-ended questions about program strengths and weaknesses, as well as suggestions for change, provide feedback in areas that may not have been anticipated and provide ideas for improvement. Information can also be obtained from faculty or other observers, such as nurses and patients. Summative program evaluation measures the success of a curriculum in achieving learner objectives for all targeted learners, its success in achieving its process objectives, and/or its success in engaging, motivating, and pleasing its learners and faculty. In addition to quantitative data, summative program evaluation may include qualitative information about unintended barriers or unanticipated effects encountered in program implementation. Formative evaluations generally require the least amount of rigor, whereas summative individual and summative program evaluation for external use (e.g., certification of competence) requires the greatest amount of rigor. When a high degree of methodological rigor is required, the measurement instrument must be appropriate in terms of content, reliability, validity, and practicality.

Expert System

An expert system is a computer program that uses expert knowledge to attain high levels of performance in a problem area or A program that symbolically encodes concepts derived from experts in a field and uses that knowledge to provide the kind of problem analysis and advice that the expert might provide. An expert system is a kind of knowledge-based system (KBS). An expert system can be defined as having the following characteristics: 1. There is a clear separation of knowledge from the control in the system, 2. The system typically possesses large amounts of knowledge (usually based on human expertise), which is

254

Glossary

Term

Explanation applied in a fairly narrow domain, enabling it to achieve a high level of performance in this domain. (The knowledge in the system is represented using some knowledge representation formalism). 3. The system can provide an explanation of its reasoning. Expert systems in health care contain knowledge derived from experts in the field of health care. [from CEN/TC 251]

Faculty Development

Because faculty members may be experts in their subject but may not have received special training in educating others, faculty development programs exist to enable these teachers to acquire the necessary professional knowledge, skills, attitudes and tools. It is an essential component for obtaining high reliability and validity of applied assessment on a dayto-day basis. It also enhances ongoing formative evaluation so that students are given feedback to help them improve continuously. Faculty development activities can be organized as series of special workshops, readings, or individualized feedback sessions. Since teaching is considered a very important aspect of a physician's work, such educational programs are often viewed as a form of Continuing Medical Education.

Field

The smallest named unit of data in a system. Fields are grouped together to form records. [from CEN/TC 251]

Flexner Report, The

The report researched, written and published by Abraham Flexner (1866-1959) in 1910 for the Carnegie Foundation and entitled "Medical Education in the United States and Canada" is known today as the Flexner Report. It triggered much-needed reforms in the standards, organization, and curriculum of North American medical schools. At the time of the Flexner Report, many medical schools were proprietary schools operated more for profit than for education. Flexner proposed that medical schools operate instead in the German tradition of combining strong biomedical sciences with hands-on clinical training. The report caused many medical schools to close down. It remains one of the most important publications on medical education in the 20th century.

Global Minimum Essential Specification of the competencies related to knowledge, skills, professional attitudes and ethical values, which (Core) Requirements students should possess at graduation, regardless of where they are trained. In medical education, this is represented as a three-tiered structure with international, national, and local layers, which reflects the competencies specific to given settings and cultures where the physician will practice in addition to universal competencies required by physicians

255

Glossary

Term

Explanation throughout the world.

Graduate Medical Education (GME)

In the United States, this term typically refers to residency training and fellowships; the education physicians receive after finishing medical school. In many other countries it is called specialty training or postgraduate education.

Graduate Training or Internship

The phase of acquiring widening clinical experience through the practice of basic clinical skills and judgment. This is normally used to designate the period of hospital clerkship. The periods of undergraduate education and graduate training together comprise the doctor's basic medical education.

Health Information System A Health Information System is an information system (i.e. a system of computer equipment, programs, procedures and personnel designed, constructed, operated, and maintained to collect, record, process, retrieve and display information) specific to the health care domain. A Health Information System can be considered as: 1. An integrated (to a greater or lesser degree) collection of a number of different Information Systems in use in a health care context, 2. A generic label for different types of Information Systems used in Health Care. Health Maintenance Services

Any health care service or program that helps maintain an individual's good health. This includes all preventive medical practices such as immunizations and periodic examinations, as well as health education and special self-help programs.

Healthcare Administrative Information about a subject that is requested or required by a healthcare party to enable, finance or manage the provision Information of healthcare services to that subject. [from CEN/TC 251] Healthcare Service

Service provided with the intention of directly or indirectly improving the health of the people, populations or animals to whom it is provided. [from CEN/TC 251]

Hospital Information System (HIS)

Integrated, computer-assisted system designed to store, manipulate and retrieve information concerned with the administrative and clinical aspects of providing services within the hospital. [from CEN/TC 251]

ICNP

In 1993 the International Council of Nurses (ICN) introduced the International Classification of Nursing Practice (ICNP). The major objective was to establish a common language for nursing practice to improve communication among nurses and between nurses and other health care providers. It consists of three alphabetized lists of existing labels or nomenclatures for (1) nursing diagnoses/problems (see

256

Glossary

Term

Explanation nursing diagnosis), (2) nursing interventions, and (3) outcomes.

Informatics

Informatics is the discipline concerned with the study of information and its manipulation via computer-based tools. [from CEN/TC 251]

Information

Organised data or knowledge that provide a basis for decision-making. [from CEN/TC 251]

Information Science

Information Science refers to computer software (Computer programs). It encompasses how the data or tasks are processed, problems are solved, and products are produced. It refers to the algorithms, which are sets of well-defined, simple, and logical instructions or procedures that are followed to solve a problem or direct the execution of a task. (Saba and McCormick, 1995).

Information System

A complex of logically interrelated processes to support the health care process, e.g. laboratory system [from CEN/TC 251]

Institute for International A non-profit medical Institute established in 1999 by a grant Medical Education (IIME) from the China Medical Board of New York, which began its own operations in 1914 as a division of The Rockefeller Foundation. The IIME has been entrusted with the development of 'Global Minimum Essential (Core) Requirements' which include knowledge, clinical skills, professional ethical values and fundamental competencies to the practice of health care worldwide. These essential requirements represent only a portion of the educational experience, since each country and even each medical school has unique needs that the educational curriculum should address. Three committees composed of medical experts from around the globe supervise the work of IIME: the Core Committee, the Steering Committee and the Advisory Committee. The Institute is located just outside of New York City in suburban White Plains, New York. Knowledge

Knowledge can be considered as the distillation of information that has been collected, classified, organised, integrated, abstracted and value added. Knowledge is at a level of abstraction higher than the data, and information on which it is based and can be used to deduce new information and new knowledge. When considering knowledge it is usually in the context of human expertise used in solving problems. [from CEN/TC 251]

Glossary

Term Knowledge Based System (KBS)

257

Explanation 1. A computer based system in which there is a symbolic representation of the knowledge (knowledge representation) and, secondly, a separation of the knowledge from the inferencing mechanism. A knowledge-based system has a typical architecture, consisting of i. a knowledge base (where the knowledge is stored), ii. an inferencing engine, iii. a working memory where the initial data and intermediate results are stored. 2. The term Knowledge Based System (KBS) refers to the study and the theory of such systems. [from CEN/TC 251]

Learner-Centred Education

A method of teaching in which the students' needs have priority. Learners are responsible for identifying knowledge gaps, actively participating in filling them, and keeping track of their learning gains. Teachers are expected to facilitate this process instead of supplying "spoon-fed" information. This approach increases the students' motivation to learn and prepares them for self-learning and continuous education. Learner-centred education is the opposite of teacher-centred education.

Lecture

An instruction or verbal discourse by a speaker before a large group of students. This teaching method has historically been quite prominent in education because it is an economic way to communicate information to large groups. However, increasing knowledge about the group's difficulties in maintaining concentration and absorbing extensive information while in a passive listening mode has brought the value of lectures under criticism. Audiovisual presentations, demonstration of patients and intermittent discussions can help activate learners.

Liaison Committee on Medical Education LCME

A group organized under the sponsorship of the American Medical Association (AMA) and American Association of Medical Colleges (AAMC) to accredit educational programs leading to the MD degree in the US and Canada.

Licensure

The process by which different governmental or nongovernmental agencies, such as specialty boards or other bodies, grant permission to practice a profession to persons meeting predetermined qualifications to engage in a given occupation or use a particular title. In the case of physicians, licensure ensures that they have appropriate education and training and that they abide by recognized standards of professional conduct while serving their patients. This is typically done at a national or local level. In the United States

258

Glossary

Term

Explanation licensure is a process by which physicians receive permission to practice medicine. Candidates for licensure first must complete the rigorous United States Medical Licensing Examination (USMLE), designed to assess a physician's ability to apply knowledge, concepts, and principles that are important in health and disease and that constitute the basis of safe and effective patient care. All applicants must submit proof of medical education and training and provide details about their work history. Results of the USMLE are reported to state medical boards for use in granting the initial license to practice medicine. Each medical licensing authority requires, as part of its licensing processes, successful completion of an examination or other certification demonstrating qualification for licensure.

Local Area Network (LAN) A system of connecting computers and computer equipment together, with physical links which do not use the telecommunications network, within a circumscribed location (usually connected within several hundred metres), so that the computers connected together can: i. share facilities, such as hard disks, data, printers and other peripherals; and ii. transmit data between each other. [from CEN/TC 251] Medical Education

The process of teaching, learning and training of students with an ongoing integration of knowledge, experience, skills, qualities, responsibility and values which qualify an individual to practice medicine. It is divided into undergraduate, postgraduate and continuing medical education, but increasingly there is a focus on the "lifelong" nature of medical education. Undergraduate education or basic medical education refers to the period beginning when a student enters medical school and ends with the final examination for basic medical qualification. This period of education comprises a preclinical and a clinical period. It can result in granting a license to practice, which may be provisional and subject to conditions as to supervision; or permitting the start of postgraduate education. In the United States, however, undergraduate education refers to pre-medical college education, which results in a Bachelor's degree and is the training most students receive before entering medical school. Postgraduate education, graduate medical education or specialty training is used to designate the more or less continuous period of post-basic training which, when it occurs, normally directly follows undergraduate training and is designed to lead to competence in a chosen branch of medical practice.

Glossary

259

Term Medical Educator

Explanation A professional who focuses on the educational process necessary to transform students into physicians. Some medical educators are physicians, but an increasing number have backgrounds in education, behavioural or other health sciences.

Medical informatics

Scientific discipline that concerns itself with the cognitive, information processing and communication tasks of health care practice, education and research, including the information science and technology to support these tasks. [from CEN/TC 251]

Medical record

Systematic record of the history of the health of a patient kept by a physician or other health care practitioner. Note: Different kinds of patient record may be considered according to: i. scope: Inpatient record Outpatient record Health care record ii. structure: problem-oriented record time-oriented record task-oriented record encounter oriented patient record iii. purpose: Nursing record Radiological record Pharmacy record iv. media: Paper patient record Electronic patient record Multimedia patient record (Multimedia record) Patient record on microfilm [from CEN/TC 251]

Medical School

A higher education or university level institution offering a prescribed course of medicine. The following are examples of the names that such institutions may bear and which vary from one country to another or even within countries: Medical College; College of Surgeons; Medical Institute; Institute of Medicine and Pharmacy; Institute of Medicine and Surgery; Faculty of Medicine; Faculty of Medical Sciences; Faculty of Medicine and Surgery; Academy of Medicine or Medical Academy; University Center for Health Sciences; Medical University; Faculty of Medicine and Pharmacy.

Medical Subjects Heading Medical Subjects Heading (MeSH) is a thesaurus of concepts and terms used for the indexing of biomedical literature. (MeSH) MeSH consists of a set of heading arranged in a multi-level hierarchy. At the top of the hierarchy are sections such as Anatomy, Disease, Chemicals. As one proceeds down the hierarchy terms become more specific. There are over 15000 main headings in the primary structure of MeSH. (The Chemical Supplement to MeSH contains about 50000 chemical terms). MEDLARS

The National Library of Medicine, Medical Literature and Retrieval System, which includes specialised databases in health administration, toxicology, cancer, medical ethics and

260

Glossary

Term

Explanation population studies. [from National Institutes of Health, 1989]

MEDLINE

MEDLINE is an on-line bibliographic database of medical information. MEDLINE now indexes about 350,000 new articles each year from those published in the biomedical literature. MEDLINE covers 25 years and includes citations to more than 6 million articles from about 3500 journals. [from National Institutes of Health, 1989]

Minimum Essential Requirements

This specifies the knowledge, skills and attitudes related to the sciences basic to medicine, clinical practice, professional behaviour and ethical values. The graduate of undergraduate medical education should possess these to ensure that he or she is prepared to begin further graduate medical education (specialty training) or to start practicing medicine under supervision.

Nomenclature

System of terms which is elaborated according to preestablished naming rules [ISO 1087]

Nursing Diagnosis

A Nursing Diagnosis is a clinical judgement about individual, family, or community responses to actual or potential health/life processes. Nursing diagnosis provide the basis for selection of nursing interventions to achieve outcomes for which the nurse is accountable. (9th NANDA Conference 1992)

Nursing Documentation Systems

The methods employed in collecting and recording Nursing Data. The documentation of patient care include the following categories: Care planning systems, Direct patient care systems, Discharge care planning systems and Case management systems (Saba & McCormick)

Nursing Informatics

Nursing Informatics is the multidisciplinary scientific endeavour of analysing, formalising and modelling how nurses collect and manage data, process data into information and knowledge, make knowledge - based decisions and inferences for patient care, and use this empirical and experiential knowledge in order to broaden the scope and enhance the quality of their professional practice. The scientific methods central to nursing informatics are focused on: (1) using a discourse about motives for computerised systems, (2) analysing, formalising and modelling nursing information processing and nursing knowledge for all components of nursing practice: clinical practice, management, education and research, (3) investigating determinants, conditions, elements, models and processes in order to design, and implement as well as test the effectiveness and efficiency of computerised information,

Glossary

Term

261

Explanation (tele) communication network systems for nursing practice, and (4) studying the effects of these systems on nursing practice. (William Goossen, 1996)

Nursing information system

Part of health care information system that deals with nursing aspects, particular the maintenance of the nursing record. [from CEN/TC 251]

Nursing Minimum Data Set (NMDS)

The Nursing Minimum Data Set is the minimum data elements that should be included in any paper-based or electronic patient record. The purposes of NMDS (Prophet, 1994) are to (1) describe the nursing care of patients/clients and their families in a variety of settings (2) establish comparability of nursing data (3) demonstrate or project trends regarding nursing care provided and allocation of nursing resources to the patients/clients according to their health problems or nursing diagnosis (4) stimulate nursing research through linkages of detailed data existing in NISs (Nursing Information System) and in other health care information systems and (5) provide data about nursing care to influence health policy and decision making. [from CEN/TC 251]

Nursing Practice

A Social Policy Statement, using the nursing process as a framework.(American Nurses Association,1980). Nursing practice models focus primarily on patient care and the nursing care planning process (see Nursing process). (Saba and McCormick, 1995)

Nursing procedure

Systematic activity directed at, or performed on an individual patient with the object of providing nursing care or treatment. [from CEN/TC 251]

Nursing Process

(A) Assessment (see Nursing Assessment): (a) Defining characteristics (b) Nursing Examination: physiological, behavioural, functional (c) Vital signs, height and weight, and other flow sheets (B) Diagnosis (see Nursing Diagnosis): (a) Cluster defining characteristics (C) Outcome identification: (a) Linkage to diagnoses (D) Planning (see Nursing Planning): (a) Linkage between diagnoses, outcomes, and interventions (b) New nursing diagnosis (E) Implementation phase: 1. Nursing interventions responsive to plans of care (a) Nursing order entry and transmission (b) Risk management 2. Nursing actions responsive to nurse's or physician's orders and/or risk management to satisfy a diagnosis (a) Medication administration, intravenous medications and blood (b) Vital signs and graphic flow sheets (c) Intake and output (d) Diet 3. Nursing actions responsive to procedures and unit tests and/or risk management 4.

262

Glossary

Term

Explanation Patient's actions 5. New actions (F) Evaluation phase 1. Patient's response and actual outcomes resulting from nursing actions in relation to the diagnoses 2. Patient's response and expected outcomes resulting from physicians’ orders 3. Patient's response and expected outcomes resulting from procedures and tests 4. Patient's response and expected outcomes resulting from patient's expectations 5. Patient's response and expected outcomes resulting from care delivered by other allied healthcare professionals (ANA, 1991)

Objective

In medical education, it is what the learner will be able to know or do after taking part in educational activities. Objectives should result from assessment of the needs of the patient or population.

Outcome

All possible demonstrable results that stem from casual factors or activities. In medical education, outcome refers to a new skill, knowledge or stimulus to improve the quality of patient care. Setting outcomes can be very useful for developing a framework of various results expected from various educational activities. Outcomes may be related to the educational process (process outcomes), to the product of undergraduate medical education (learning outcomes), or to the professional role of the physician (performance outcomes).

Outcome-Based Education This approach emphasizes educational outcomes rather than the educational process and focuses on the product of medical education such as what kind of doctors will be produced, and with what professional knowledge, skills, abilities, values and attitudes. Educational outcomes must be clearly specified as they determine the curriculum content, the teaching methods, the courses offered, the assessment process and the educational environment. The scope and definition of competence and the levels of its attainment is defined in terms of student development within the natural progression in medical school. Consequently, the assessment system will ensure that the expected variation of levels of attainment is defined and assessed. Patient record

Systematic record of the history of the health of a patient (patient history), kept by a physician or other health care practitioner. Note: Different kinds of patient record may be considered according to: i. scope: Inpatient record Outpatient record Health care record ii. structure: problem-oriented record time-oriented record task-oriented record encounteroriented patient record iii. purpose: Nursing record Radiological record Pharmacy record iv. media: Paper patient

Glossary

Term

263

Explanation record Electronic patient record Multimedia record Patient record on microfilm [from CEN/TC 251]

Pan-American Federation A non-governmental, academic and educational organization of Associations of Medicals that gathers information on medical schools in the Western Hemisphere from Canada to Argentina. Founded in 1962 in Schools (PAFAMS) Chile, PAFAMS is striving through collaboration toward the improvement and development of innovative medical education. The constituency is integrated by 12 national Associations of Medical Schools, and comprises over 354 Medical schools. The mission is: "The promotion and advancement of medical education and the biomedical sciences in the Americas and the Caribbean" Patient Management Problem (PMP)

A written method that attempts to assess clinical problemsolving abilities. To improve its validity, recent improvements include an attempt to focus testing on the key features within a clinical case, which represents the diagnostic or problem-solving challenge. The main advantage of this innovation is that many more 'clinical cases' can be administered to candidates in a given period of time than with conventional PMP. Computer-Based Patient Management Problem (e-PMP) is a related method that has been used for some years, which more recently has been enriched with the ability to link computers to various audiovisual inputs such as videodiscs and optical holograms produced by lasers extending realism of the simulations and conceivably providing enhanced educational opportunities. The cost of developing, establishing and maintaining the required facility may constitute a significant constraining factor for broader use.

Personal Development Plan (PDP)

A list of educational needs, development goals and actions and processes, compiled by learners and used in systematic management and periodic reviews of learning. It is an integral part of reflective practice and self-directed learning for professionals. It can be equally valuable in teacherdirected medical training for maintaining learner-centred approaches and shared objectives. PDP can be used to manage learning needs systematically, to set development and performance improvement goals, organize learning activities and review outcomes. Some educational organizations accept completed plans for accredited professional development and health managers link them with appraisals.

Picture archiving and communication system (PACS)

System that can store, distribute, retrieve and display images. (See also IMACS). [from CEN/TC 251]

264

Glossary

Term Population Health

Explanation Organized efforts focused on the health of defined populations in order to promote and maintain or restore health, to reduce the amount of disease, premature death and disease-produced discomfort and disability. Programs, services and institutions here emphasize the prevention of disease and the health needs of the population as a whole. Among a broad scope of disciplines, various knowledge and skills are utilized such as bio-statistics, epidemiology, planning, organization, management, financing and evaluation of health programs, environmental health, application of social and behavioral factors in health and disease, health promotion, health education and nutrition.

Portfolio-Based Learning or Portfolios

A collection of evidence that learning has taken place, usually set within agreed objectives or a negotiated set of learning activities. Some portfolios are developed in order to demonstrate the progression of learning, while others are assessed against specific targets of achievement. In essence, portfolios contain material collected by the learner over a period of time. They are the learner's practical and intellectual property and the learner takes responsibility for the portfolio's creation and maintenance. Because the portfolio is based upon the real experience of the learner, it helps to demonstrate the connection between theory and practice, accommodating evidence of learning from different sources, and enabling assessment within a framework of clear criteria and learning objectives. The use of portfolios encourages autonomous and reflective learning, which is an integral part of professional education and development. Candidates are expected to produce evidence and process such evidence with relation to a pre-determined standard. Since the portfolio approach includes both content and a reflective component, one must first determine which components are to be assessed. Portfolios provide a process for both formative and summative assessment, based on either personally derived or externally set learning objectives or a model for lifelong learning and continuing professional development

Preventive Medicine

A specialized field of medical practice composed of distinct disciplines that focus on the health of defined populations in order to promote and maintain health and well-being and prevent disease, disability and premature death. It aims at the application of preventive measures within all areas of clinical medicine. In addition to the knowledge of basic and clinical sciences and the skills common to all physicians, practitioners of preventive medicine possess knowledge of and competence in other disciplines. Among a broad scope of such disciplines are: bio-statistics, epidemiology, planning,

Glossary

Term

265

Explanation organization, management, financing, and evaluation of health programs, environmental health, application of social and behavioural factors in health and disease, health promotion, health education and nutrition.

Primary Health Care

The World Health Organization defines primary health care as the principal vehicle for the delivery of health care at the most local level of a country's health system. It is essential health care made accessible at a cost the country and community can afford with methods that are practical, scientifically sound and socially acceptable. Everyone in the community should have access to it, and everyone should be involved in it. Beside an appropriate treatment of common diseases and injuries, provision of essential drugs, maternal and child health, and prevention and control locally endemic diseases and immunization, it should also include at least education of the community on prevalent health problems and methods of preventing them, promotion of proper nutrition, safe water and sanitation.

Problem-Based Learning (PBL)

In this approach, students learn in small groups supported by a tutor. They initially explore a predetermined problem. The problem contains triggers designed to evoke objectives or concepts that are used to set the agenda for individual or group investigation and learning after the initial session. Subsequent group meetings permit students to monitor their achievements and to set further learning goals as required. The tutor's role is to offer support for learning and to help reach the expected outcomes. PBL enables students to develop the ability to translate knowledge into practice at an early stage, encourages individual participation in learning and also allows the development of teamwork skills. Students in PBL courses have been found to place more emphasis on "meaning" (understanding) than "reproduction" (memorization). Students must engage in a significant amount of self-directed learning; lectures are kept to a minimum. PBL originated at McMaster University in Canada, and then at Maastricht University, and is now widely adopted in medical schools in many countries. Each school makes its own adjustments to the basic model. It does require a heavy investment in resources (library books, IT, tutorial rooms) as well as requiring education and training for tutors.

Reflective Learning Process

An important model of learning that is based on the principle of gaining from the learner's own experience; this is significantly different from the traditional model of undergraduate medical education. It has very clear links with the model of self-directed learning based on a portfolio which gives evidence of activity, reflection and the outcomes of

266

Glossary

Term

Explanation learning. Students use their knowledge, skills and attitudes to solve problems in the workplace. However, many problems are ambiguous and create surprises. Recognition of these surprises causes the student to review problems and create alternative hypotheses, which is termed "reflection in action". This leads to a search for more information, seeking help from colleagues or experts, reading texts or searching on-line to solve the problem. In order to turn the new information into new learning, a further step is required, which takes place after the problem has been solved: Reflecting on action' involves looking back critically over the initial 'surprise' and the resolution of the problem. The process of reviewing and evaluating information leads to learning and this in turn adds to expertise. The process of learning itself tends to generate new questions and motivates the professional to undertake further inquiry, which results in the learning process being determined more by the learner than by the person who designed the activity. This process of reflection provides a stimulus for learning and helps learners to derive maximum benefit from their own experiences.

Reliability

The reliability of a software system is a measure of how well it provides the services expected of it by its users. [from CEN/TC 251]

Resident or Resident Physician

An individual at any level in a Graduate Medical Education program, including subspecialty programs. Other terms used to refer to these individuals include interns, house officers, house staff, trainees, or fellows. The term "intern" is often used to denote physicians in their first year of training. The term "fellow" is frequently used to denote physicians in subspecialty programs (versus residents in specialty programs) or in Graduate Medical Education programs that are beyond the eligibility requirements for first board certification in the discipline.

Security

The controls of threats made to the integrity of a system.

Security Administration

An authority (a person or group of people) responsible for implementing the security policy for a security domain. [from CEN/TC 251] A form of education that involves the individual learner's initiative to identify and act on his or her learning needs (with or without assistance), taking increased responsibility for his or her own learning.

Self-Directed Learning

Standard

1. A standard is an accepted or approved example or technique against which other things are judged or measured, or which sets out a set of criteria that serves as a guideline for

Glossary

Term

267

Explanation how something should be done. 2. A standard is a document established by consensus and approved by a recognised body, that provides for common and repeated use rules, guidelines or characteristics for activity/ies or their results, aimed at the achievement of the optimum degree of order in a given context. Standards can become established by a recognised body (a standards body), the process of their formation usually takes place through a process of consultation and consensus approval. Often a pre-standard is established, which is proposed as a pre-cursor to the formally approved standard. In Europe pre-standards have been put on a formal basis (see European Pre-Standard (ENV)). [from CEN/TC 251]

Standard Generalised Markup Language (SGML)

The SMGL is a language for logical document structure and is an international standard for publishing [from ISO 8879] which facilitates the exchange of electronic document information. SGML is based on the Generalised Markup Language developed at IBM. SGML is based on the generic markup of the structural elements of a document without regard to the presentation. SMGL is based on the principles of the generic encoding of documents and marks up a document's logical structure and not its physical presentation. [from CEN/TC 251]

Standard in Education

A model design or formulation related to various aspects of medical education and presented in a manner that enables the assessment of graduates' performance in compliance with generally accepted professional requirements. They are set up by consent of experts or by decision of educational authority. Three types of interrelated educational standards can be envisaged: Content standards or curriculum standards describe skills, knowledge, attitudes and values; what teachers are supposed to "teach" and students are expected to learn. Thus the content standards define what is to be taught and learned. Content standards can be also defined as "essential (core) requirements" that the medical curriculum should meet to equip physicians with the knowledge, skills and attitudes necessary at the time of graduation. Performance or assessment standards define degrees of attainment of content standards and level of competencies in compliance with the professional requirements. Performance standards describe how well content has been learned. Process or opportunity-to-learn standards define availability of staff and other resources necessary for the medical school so that students will be able to meet content and performance

268

Glossary

Term

Explanation standards. A standard can be also classified four ways: An absolute standard refers to the knowledge and skills a student must possess in order to pass a given course. An absolute standard stays the same over multiple administrations relative to the content specifications of the test. The failure rate may vary due to changes in the group's ability, from one administration to the other. A relative standard can be set at the mean performances of the candidates, or by defining the units of standard deviation from the mean. A relative standard may vary from year to year due to shifts in the ability of the group and may result in a fixed annual percentage of failing students, if the scores maintain a normal distribution across administrations. A norm-referenced standard is a standard based on the representative group of the candidates' population. Credentialing organizations may use norm-referenced orientation, in which the standard is based on the performance of an external large representative sample (norm group) equivalent to the candidates taking the test. The normreferenced standard will be somewhat unstable and will shift according to the performance of the norm group, as large as it may be. Shift of the standard over time is a concern. A criterion-referenced standard is a fixed standard that may undergo periodic re-evaluation in view of shifts or trends in candidates' performance over time. The criterion reference orientation links the standard to the content of the level of competence.

Standardisation

Subject-Based Teaching

Activity of establishing, with regard to actual or potential problems, provisions for common and repeated use, aimed at the achievement of the optimum degree of order in a given context. [from CEN/TC 251] A method of teaching in which each subject area of curriculum is addressed separately. In the past, this model had been very prominent in basic science education. Now, however, it is gradually being replaced with a problem-based learning (PBL) where knowledge and skills unfold as elements in cases that illustrate real life situations.

SNOMED is a 50000-concept thesaurus used for indexing Systematised Nomenclature of Medicine parts of patient record [from Wingert, 1986]. In the course of their practice, physicians create descriptions of patients that (SNOMED) become part of the patient record. SNOMED is a language for the coding and retrieval of information in patient records.

Glossary

269

Term Teacher-Centred Education

Explanation An educational system in which the teacher dictates what is being taught and how it is to be learned. The teacher is the central or key figure and activities such as the formal lecture and the formal laboratory are emphasized. Individual students have little control over what they learn, the order in which they learn and the methods they must use. In this approach, learning is rather more passive than active. It is the opposite of the learner-centred approach.

Telemedicine

Investigation, monitoring and management of patients, which allow ready access to expert advice and patient information, irrespective of the distance or location of the patient or expertise or relevant information.

Terminology

The collection of terms used in a particular discipline (sometimes the meanings of the terms are included). A thesaurus provides a way of linking similar items (nearsynonyms) together, to help the user find the precise term required.

Thesaurus

Unified Medical Language The Unified Medical Language System (UMLS) system is a large project sponsored by the United States National Library System (UMLS) of Medicine (NLM) to produce a unified thesaurus and cross reference linking various medical nomenclatures including the Medical Subjects Headings (MeSH), ICD-9-CM Procedure Code Classification, Systematised Nomenclature of Medicine (SNOMED) and the terminologies of DXPlain and Quick Medical Reference (QMR). One of the main outputs of the UMLS project is the Meta-1 Metathesaurus. The Unified Medical Language System (UMLS) has three components: an Information Sources Directory, a Metathesaurus and a Semantic Network. The Information Sources Directory contains information about publicly available biomedical information resources. For each source the Directory contains the sources scope, vocabulary, syntax, rules and access conditions. The Metathesaurus contains concepts from a variety of biomedical vocabularies. Each concept has a canonical representation that includes a semantic type. Mappings between different vocabularies are handled by this canonical representation. The Semantic Net represents relationships among the semantic types. Unified Nursing Language Since 1988, nurses in the United States have been working toward the development of uniform classification schemes to System (UNLS) incorporate into nursing documentation systems and a unified nursing language system (UNLS) to improve communication about nursing. Forces driving these movements include the need to track outcomes of care, case management, policies regarding the quality of care, and the utilization of resources.

270

Glossary

Term

Validity

Explanation The ANA has taken positions on recognising classification schemes that have been added to the Unified Medical Language System (UMLS) to provide a UNLS. (Saba and McCormick, 1995) A term that reflects a solid foundation or justification for bringing the intended results. In the case of assessment, validity means the degree to which a measurement instrument truly measures what it is intended to measure. The establishment of validity is the first priority in developing any form of assessment. Without it, all other attributes are of little consequence. The assessment instrument should accurately represent the skills or characteristics it is designed to measure. Validity may be characterized in these four ways - content, concurrent, predictive or criterion-related validity: Content validity is the one of greatest concern to teachers as the test must contain a representative sampling of the subject matter the student is expected to have learned. This sampling must be representative and should cross several categories of competence, a range of patient problems and a list of technical skills. Valid clinical examination should assess the components of clinical competence, including the ability to obtain from the patient a detailed and relevant history; carry out a physical examination of the patient; identify the patient's problems from the information obtained and reach a differential diagnosis; identify the appropriate investigations; interpret the results of the investigations; recommend and undertake appropriate management including patient education. Concurrent validity considers the degree to which a measurement instrument produces the same results as another accepted or proven instrument which measures the same parameters. Predictive validity examines the degree to which a measure accurately predicts expected outcomes; for instance, a measure of attitudes toward preventive care should correlate significantly with preventive care behaviors. Criterion-related validity includes concurrent validity as well as predictive validity.

Variable

A quantity, attribute, phenomenon or event that may assume any one of a set of values: Independent variable refers to a characteristic being observed or measured that is thought to influence an event or manifestation (the dependent variable) within the defined

Glossary

Term

271

Explanation area of relationships under study. In medical education, it is a factor that could explain or predict the curriculum's outcomes such as the curriculum itself, previous or concurrent training, environmental factors. Dependent variable is a manifestation or outcome whose variation we seek to explain or account for the influence of independent variables. It can be a program outcome, such as knowledge or skill attainment, real-life performance, and clinical outcomes. It is prudent to focus on a few dependent variables that are most relevant to the main evaluation questions and similarly, to focus on the independent variables that are most likely to be related to the curriculum's outcomes.

Vocabulary

1. a set of terms used for a particular purpose. 2. a list of terms with the definition of those terms [in this sense vocabulary is synonymous with glossary].

Wide Area Network (WAN)

A kind of computer network linked by telecommunication links. The network is over a wider area than with Local Area Networks (LAN), which are not connected by telecommunications links.

World Federation for Medical Education (WFME)

A non-governmental organization with ties to WHO and UNESCO, the WFME is concerned with global education and training of medical doctors and umbrella organization for six regional associations for medical education. The WFME’s general objective is to strive for the highest scientific and ethical standards in medical education and to take initiatives with respect to new methods, tools and management of medical education. The central office has been located at the University of Copenhagen, Denmark since 1996, in collaboration with Lund University in Sweden.

References: J. Mantas, A. Hasman: ‘Textbook in Health Informatics’ URL: http://www.iime.org/glossary.htm: ‘Glossary of Medical Education Terms’


273

Subject Index academic standards 18–20,26 academic workload 135,136 accreditation 18–27 adult learning 131,135,139 Biomedical Informatics 117–119,126 borderless education 25 Certification 75,82–84 Cognition 144 collaboration 3,154,155,158 communication 131–133,135,138, 140–142,167–170,173,176,178, 180,181,214,215,217,221,222 competencies 56,58–62 competency 90 Constructivism 143,147,148 credit transfers 18,20,23–26 cultural awareness 167,179 Curricula 63,64,66,69–73 curriculum structure 63,72 distance education 213,214, 216–218,220–222 distance learning 141,142,182,185, 190,194,198,199,201, 202,213,214,217,222 Dynamic Knowledge Networks (DKN) 182,190 Dynamic Virtual Learning Networks (DVLN) 182,190 Educational delivery 167,179 educational framework 55,56,61 educational model 182–184,186,187, 189,194,195,198,199 educational programme 14 educational target groups 8

eHealth 114–117,120,121,123–127 E-learning 143,144,146–150 flexible learning 140,194,199,202 global learning environments 152,160 Informatics Competencies 75–80,85, 88,89 infrastructure 213,214,222 learning experiences 152,158,160, 163,164 learning outcomes 56,61,66 learning styles 132–138,191,198,201 lifelong learning 152,153,155, 159–161,163,165 medical informatics 63–74 Nursing 75–89 Nursing Informatics 75–83,85–89 Partnerships 3,5 Pedagogics 214–218 Piaget's theory 146,147 Portfolio 75,85–89 qualification 90,93 qualifications framework 60–62 recognition 90,91,93,94 recognition of prior learning 20–24 registration 90–93 stakeholders 36–39,43–50 student assessment 174,175,180,212 student exchange 30 student support 178,180 technical support 168,176,178,180 trans-national education 19 Virtual University 3–7 web-based education 203–206,208, 210–212


275

Author Index Alexander, S. Bickford, C. Bricknell, L. Egea, K. Engelbrecht, R. Giani, U. Gillani, B. Hasman, A. Haux, R. Hayes, G. Häyrinen, K. Hovenga, E.J.S. Ingenerf, J.

152 75 131 167 95 182 143 63 63 90 203 3, 18, 55, 131 95

Kernohan, G. Lammintakanen, J. Mantas, J. McCullagh, P. Murphy, J. Nohr, C. O’Guinn, C. Reiner, J. Roberts, J. Saba, V.K. Saranto, K. Skiba, D.J. Zelmer, A.C.L.

152 203 8, 114 152 36 213 143 95 28, 90 75 203 75 167


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