Realizing the promise: delivering pulmonary continuing medical education over the Internet

Enabling Access to Medical and Health Education in Rwanda Using Mobile Technology: Needs Assessment for the Development of Mobile Medical Educator Apps

BACKGROUND

Lack of access to health and medical education resources for doctors in the developing world is a serious global health problem. In Rwanda, with a population of 11 million, there is only one medical school, hence a shortage in well-trained medical staff. The growth of interactive health technologies has played a role in the improvement of health care in developed countries and has offered alternative ways to offer continuous medical education while improving patient's care. However, low and middle-income countries (LMIC) like Rwanda have struggled to implement medical education technologies adapted to local settings in medical practice and continuing education. Developing a user-centered mobile computing approach for medical and health education programs has potential to bring continuous medical education to doctors in rural and urban areas of Rwanda and influence patient care outcomes.

OBJECTIVE

The aim of this study is to determine user requirements, currently available resources, and perspectives for potential medical education technologies in Rwanda.

METHODS

Information baseline and needs assessments data collection were conducted in all 44 district hospitals (DHs) throughout Rwanda. The research team collected qualitative data through interviews with 16 general practitioners working across Rwanda and 97 self-administered online questionnaires for rural areas. Data were collected and analyzed to address two key questions: (1) what are the currently available tools for the use of mobile-based technology for medical education in Rwanda, and (2) what are user's requirements for the creation of a mobile medical education technology in Rwanda?

RESULTS

General practitioners from different hospitals highlighted that none of the available technologies avail local resources such as the Ministry of Health (MOH) clinical treatment guidelines. Considering the number of patients that doctors see in Rwanda, an average of 32 patients per day, there is need for a locally adapted mobile education app that utilizes specific Rwandan medical education resources. Based on our results, we propose a mobile medical education app that could provide many benefits such as rapid decision making with lower error rates, increasing the quality of data management and accessibility, and improving practice efficiency and knowledge. In areas where Internet access is limited, the proposed mobile medical education app would need to run on a mobile device without Internet access.

CONCLUSIONS

A user-centered design approach was adopted, starting with a needs assessment with representative end users, which provided recommendations for the development of a mobile medical education app specific to Rwanda. Specific app features were identified through the needs assessment and it was evident that there will be future benefits to ongoing incorporation of user-centered design methods to better inform the software development and improve its usability. Results of the user-centered design reported here can inform other medical education technology developments in LMIC to ensure that technologies developed are usable by all stakeholders.

Development and implementation of a web-based continuing professional development (CPD) programme on medical genetics

We developed, implemented and evaluated a web-based continuing professional development (CPD) programme on medical genetics. Development of the CPD programme followed the ADDIE model, i.e. Analysis, Design, Develop, Implement and Evaluation. An invitation to participate in a needs analysis survey was sent to all doctors on the email list of the Sri Lanka Medical Association. A total of 129 completed surveys was received (57% of the 228 who accessed the online survey). The average age of respondents was 42 years (range 27-81). The male: female ratio was approximately 2 : 1. Almost all respondents (96%) selected web-based CPD programmes, or web-based and conventional lectures, as their preferred method of learning. The programme was piloted on a group of 10 doctors. The average pre-knowledge score was 40.3 and the post-knowledge score was 62.1 marks out of 100 (P = 0.002). We conclude that a web-based CPD programme on medical genetics is feasible in Sri Lanka.

Effects of online palliative care training on knowledge, attitude and satisfaction of primary care physicians

Background

The Spanish Palliative Care Strategy recommends an intermediate level of training for primary care physicians in order to provide them with knowledge and skills. Most of the training involves face-to-face courses but increasing pressures on physicians have resulted in fewer opportunities for provision of and attendance to this type of training. The effectiveness of on-line continuing medical education in terms of its impact on clinical practice has been scarcely studied. Its effect in relation to palliative care for primary care physicians is currently unknown, in terms of improvement in patient's quality of life and main caregiver's satisfaction. There is uncertainty too in terms of any potential benefits of asynchronous communication and interaction among on-line education participants, as well as of the effect of the learning process.

The authors have developed an on-line educational model for palliative care which has been applied to primary care physicians in order to measure its effectiveness regarding knowledge, attitude towards palliative care, and physician's satisfaction in comparison with a control group.

The effectiveness evaluation at 18 months and the impact on the quality of life of patients managed by the physicians, and the main caregiver's satisfaction will be addressed in a different paper.

Methods

Randomized controlled educational trial to compared, on a first stage, the knowledge and attitude of primary care physicians regarding palliative care for advanced cancer patients, as well as satisfaction in those who followed an on-line palliative care training program with tutorship, using a Moodle Platform vs. traditional education.

Results

169 physicians were included, 85 in the intervention group and 84 in the control group, of which five were excluded. Finally 82 participants per group were analyzed. There were significant differences in favor of the intervention group, in terms of knowledge (mean 4.6; CI 95%: 2.8 to 6.5 (p = 0.0001), scale range 0-33), confidence in symptom management (p = 0.02) and confidence in terms of communication (p = 0.038). Useful aspects were pointed out, as well as others to be improved in future applications. The satisfaction of the intervention group was high.

Conclusions

The results of this study show that there was a significant increase of knowledge of 14%-20% and a significant increase in the perception of confidence in symptom management and communication in the intervention group in comparison with the control group that received traditional methods of education in palliative care or no educational activity at all. The overall satisfaction with the intervention was good-very good for most participants.

This on-line educational model seems a useful tool for palliative care training in primary care physicians who have a high opinion about the integration of palliative care within primary care. The results of this study support the suggestion that learning effectiveness should be currently investigated comparing different Internet interventions, instead of Internet vs. no intervention.

Trial Registration

German Clinical Trials Register DRKS00000694

Internet-based medical education: a realist review of what works, for whom and in what circumstances

BACKGROUND

Educational courses for doctors and medical students are increasingly offered via the Internet. Despite much research, course developers remain unsure about what (if anything) to offer online and how. Prospective learners lack evidence-based guidance on how to choose between the options on offer. We aimed to produce theory driven criteria to guide the development and evaluation of Internet-based medical courses.

METHODS

Realist review - a qualitative systematic review method whose goal is to identify and explain the interaction between context, mechanism and outcome. We searched 15 electronic databases and references of included articles, seeking to identify theoretical models of how the Internet might support learning from empirical studies which (a) used the Internet to support learning, (b) involved doctors or medical students; and (c) reported a formal evaluation. All study designs and outcomes were considered. Using immersion and interpretation, we tested theories by considering how well they explained the different outcomes achieved in different educational contexts.

RESULTS

249 papers met our inclusion criteria. We identified two main theories of the course-in-context that explained variation in learners' satisfaction and outcomes: Davis's Technology Acceptance Model and Laurillard's model of interactive dialogue. Learners were more likely to accept a course if it offered a perceived advantage over available non-Internet alternatives, was easy to use technically, and compatible with their values and norms. 'Interactivity' led to effective learning only if learners were able to enter into a dialogue - with a tutor, fellow students or virtual tutorials - and gain formative feedback.

CONCLUSIONS

Different modes of course delivery suit different learners in different contexts. When designing or choosing an Internet-based course, attention must be given to the fit between its technical attributes and learners' needs and priorities; and to ways of providing meaningful interaction. We offer a preliminary set of questions to aid course developers and learners consider these issues.

Internet and continuing medical education

Keeping abreast of medical advances is an important, ongoing responsibility for medical professionals, one that categorises physicians as lifelong students. In the USA, continuing medical education (CME) is the bridge that connects basic research and the practicing physician, who must fulfill credit requirements for licensure and board certification. Developments in multimedia technology and the Internet have made online CME courses possible, making the process of obtaining CME credits more efficient and convenient for physicians. Although first-generation courses have been criticised for the lack of interactivity, new developments in multimedia technologies and broadband connectivity promise a new online learning experience, where distant participants can communicate using voice or video channels. In addition, future online CME generations may incorporate virtual reality modules that will enable physicians to learn and practice procedural techniques, as well as gain knowledge. Continued application of sophisticated technologies and continued content-development promises to add new dimensions to traditional learning and may identify online CME courses as a major medical education paradigm.

A qualitative study of physicians' experiences with online learning in a masters degree program: benefits, challenges, and proposed solutions

BACKGROUND

In response to challenges to faculty development (e.g. time away from clinical, teaching, and other responsibilities; lack of mentors; and limited resources) online learning has become an important venue to provide education for physicians in curriculum development, instruction, assessment, evaluation, educational leadership, and education scholarship. Online learning however has its own unique challenges. Little is known about clinician-educators' experiences while participating in online programs and few studies have focused on their approaches to facilitate online learning.

AIM

To explore the experiences of physicians pursuing a degree in higher education with online learning, including motivations for choosing this format, barriers encountered, and ideas for facilitating learning in the online environment.

METHOD

All students (n = 71) enrolled in online courses in the University of Illinois at Chicago Masters of Health Profession Education Program were surveyed in the spring of 2006. Responses were analysed using a qualitative approach.

RESULTS

Of the 48 students who completed the survey (response rate 68%) 45 (94%) were physicians. The online format is convenient, flexible, and may be beneficial for learning. Students' responses raise issues inherent to online learning that must be addressed to optimize student-centered learning. These issues relate to: clarity of communication; difficulties in negotiating team work and in building relationships; technical demands; learning style preferences, and time commitment. Students provided recommendations for strategies to address these issues such as how to communicate clearly, facilitate teamwork, and optimize time management. Member checking supported the analysis.

CONCLUSIONS

Online education programs meet the needs of physicians but have associated challenges. Further research is needed to explore the potential value of student suggested ways to optimize the online learning experience.

Web-based education for postpartum depression: conceptual development and impact

Postpartum depression (PPD) is a major public health problem that occurs in one of every seven women in the first 3 months after birth. Left untreated, PPD can persist for months to years and lead to adverse consequences for both mother and child. Primary care providers have the most medical contact with postpartum women and are well positioned to screen for and identify PPD. However, PPD recognition and treatment is generally not included in physician training, and few continuing education programs on PPD are available. Developed with support from NIMH SBIR contract (# HHSN278200554096C), the Web site MedEdPPD was designed to provide professionals with the tools to successfully engage, screen, diagnose, treat, and refer women with PPD. Resources on the site include CME/CE modules; interactive case studies; classic papers and current literature; provider tools; a comprehensive slide library; events calendar; and resources. MedEdPPD also contains materials for women with PPD, their friends and family members. As of March 2008, the site had over 17,000 visitors who represented both consumers and a broad distribution of health care professional disciplines. The nine CME/CE learning modules on MedEdPPD have been particularly heavily utilized by nurses. The number of repeat and new visitors has increased steadily since the site's launch. User feedback has been consistently positive. Based upon theories of adult education, MedEdPPD offers diverse strategies to facilitate learning. The site promotes education and training in PPD treatment that is flexible, cost-effective, and meets the needs of health care professionals.

A web-based Alcohol Clinical Training (ACT) curriculum: is in-person faculty development necessary to affect teaching?

BACKGROUND

Physicians receive little education about unhealthy alcohol use and as a result patients often do not receive efficacious interventions. The objective of this study is to evaluate whether a free web-based alcohol curriculum would be used by physician educators and whether in-person faculty development would increase its use, confidence in teaching and teaching itself.

METHODS

Subjects were physician educators who applied to attend a workshop on the use of a web-based curriculum about alcohol screening and brief intervention and cross-cultural efficacy. All physicians were provided the curriculum web address. Intervention subjects attended a 3-hour workshop including demonstration of the website, modeling of teaching, and development of a plan for using the curriculum. All subjects completed a survey prior to and 3 months after the workshop.

RESULTS

Of 20 intervention and 13 control subjects, 19 (95%) and 10 (77%), respectively, completed follow-up. Compared to controls, intervention subjects had greater increases in confidence in teaching alcohol screening, and in the frequency of two teaching practices - teaching about screening and eliciting patient health beliefs. Teaching confidence and teaching practices improved significantly in 9 of 10 comparisons for intervention, and in 0 comparisons for control subjects. At follow-up 79% of intervention but only 50% of control subjects reported using any part of the curriculum (p = 0.20).

CONCLUSION

In-person training for physician educators on the use of a web-based alcohol curriculum can increase teaching confidence and practices. Although the web is frequently used for dissemination, in-person training may be preferable to effect widespread teaching of clinical skills like alcohol screening and brief intervention.

Systematic review of educational interventions in palliative care for primary care physicians

BACKGROUND

A literature review of educational interventions in palliative care (PC) for primary care physicians (PCP) was performed, to evaluate its impact in changing professional practice.

METHODS

Studies undertaking any educational intervention in PC by PCP, published between 1966 and February 2005, identified through Medline, EMBASE, Cochrane Database of Systematic Reviews and Clinical Trials, Educational Resources Information Centre, Research and Development Resource Base in Continuing Medical Education, Spanish Medical Index, using a combined text word and MESH heading search strategy.

RESULTS

Eighteen articles were included with 1653 physicians. Educative methods were: role model training, small group discussions, and distribution of guidelines. Quality of the studies was low. Opioids prescription improved in two studies. Discrepancies were shown between the perception of PCP in symptom management, determined through questionnaires, and the data concerning opioids prescription. Knowledge improved in all studies. Some benefit of multifaceted approach was stated. Carers were satisfied, in general, with the PCP care, but dissatisfied with patients' pain control.

CONCLUSION

PC education for PCP is poorly studied. Adequate research designs are necessary in future studies with objective outcomes and patient opinion.

To the Point: reviews in medical education online computer assisted instruction materials

Computer technology is rapidly changing the way educators can interact with their students. This article reviews the research regarding the integration of online computer-assisted instructional materials into medical education.

A review of evaluation outcomes of web-based continuing medical education

INTRODUCTION

The Internet and worldwide web have expanded opportunities for the provision of a flexible, convenient and interactive form of continuing medical education (CME). Larger numbers of doctors are accessing and using the Internet to locate and seek medical information. It has been suggested that a significant proportion of this usage is directly related to questions that arise from patient care. A variety of Internet technologies are being used to provide both asynchronous and synchronous forms of web-based CME. Various models for designing and facilitating web-based CME learning have also been reported. The purpose of this study was to examine the nature and characteristics of the web-based CME evaluative outcomes reported in the peer-reviewed literature.

METHODS

A search of Medline was undertaken and the level of evaluative outcomes reported was categorised using Kirkpatrick's model for levels of summative evaluation.

RESULTS

The results of this analysis revealed that the majority of evaluative research on web-based CME is based on participant satisfaction data. There was limited research demonstrating performance change in clinical practices and there were no studies reported in the literature that demonstrated that web-based CME was effective in influencing patient or health outcomes.

DISCUSSION

The findings suggest an important need to examine in greater detail the nature and characteristics of those web-based learning technologies, environments and systems which are most effective in enhancing practice change and ultimately impacting patient and health outcomes. This is particularly important as the Internet grows in popularity as a medium for knowledge transfer.

Evaluation of the quality and contents of diabetes mellitus patient education on Internet

Patient education is widely regarded as an essential component of chronic disease care and effective health promotion. Internet is extremely useful medium in this respect. Web-based information is seldom the subject of systematic investigation for its accuracy and appropriateness for patients. Objective of this study was to evaluate of web-based diabetes patient education material for well-accepted evaluation criteria and core education concepts. Out of 214 web-sites retrieved from meta search engine, 53 sites themselves provide patient information and so considered for evaluation. Data obtained was analyzed by cluster analysis and classified into four categories with respect to quality. Considerable variability in quality of diabetes patient education web-sites was found with respect to core educational concepts and HSWG criteria. Inclusion of evidence-based medicine concepts, role of family support, enhancement in customized content and easier feedback mechanism in the web-sites can be a significant development in the direction of patient-centered diabetes care.

Discourse analysis of computer-mediated conferencing in World Wide Web-based continuing medical education

INTRODUCTION

Computer-mediated conferencing (CMC) is a computer messaging system that allows users to engage in asynchronous text-based communications that are independent of time and place. It has been suggested that CMC is an effective modality for facilitating constructivist learning environments that enable adult learners to engage in a continuous, collaborative process of building and reshaping knowledge and understanding. The goals of this exploratory study were to assess the nature of the interactions and collaborative learning characteristics exhibited in World Wide Web-based continuing medical education courseware programs that used CMC and to examine physicians' satisfaction with on-line CMC discussion as a planned learning activity of Web-based CME.

METHOD

The Transcript Analysis Tool (TAT) was used to analyze the nature of the discourse that took place in four different Web-based CME courseware programs. Course evaluation surveys and interviews were also conducted with participants to evaluate their satisfaction with on-line CMC discussion.

RESULTS

The results suggest that the nature of participation in the programs consisted primarily of independent messages with a minimal amount of learner-to-learner interaction. Elements of critical reflection, interaction, and debate between participants appeared to be missing from these discussions. As such, these discussions were not characteristic of the principles of constructivist learning environments.

DISCUSSION

Interactive participation will not occur just because CMC is being used. The design of Web-based CME learning activities, participant characteristics, and facilitation are key factors that influence the effective use of CMC.

The TEAM methodology for the evaluation of information systems in biomedicine

The TEAM evaluation methodology for information systems in biomedicine (Total Evaluation and Acceptance Methodology) is a unifying methodology for any computer-based information system based on a three dimensional framework; these dimensions being Role, Time and Structure. The theory is derived from how the information system relates to the general system where it should operate, the properties of information flow within a general system and the relation between a system and its models. As a system can in theory be modelled from many perspectives, a perspective to be modelled is built up by formulating criteria relevant to that perspective which can be evaluated by quantitative and qualitative assessment methods. Key characteristics of the methodology include the insistence on a global rather than partial approach to the evaluation of information systems, also the dynamic nature of an information system which is continually in modification as it more successfully deals with the inherent complexity of the environment in which it is operating. The role dimension identifies four main categories, designer, specialist user, end user and stakeholder from which several sub-categories may be identified. The time dimension has four main phases towards relative stability of the information system. The structural dimension distinguishes strategic, tactical or organisational and operational levels that often are confused together with risk of dilution in current approaches. It is believed that this framework and methodology can provide a basis for future standardisation of evaluation methodologies.

Maximizing the use of a Web-based teaching skills curriculum for community-based volunteer faculty

BACKGROUND

The University of Kansas School of Medicine in Wichita created an Internet-based faculty development curriculum for community-based faculty. Because relatively few physicians use Internet-based continuing medical education (CME), the most cost-effective methods of encouraging use need to be identified.

METHOD

Five interventions intended to increase use of the curriculum were assessed. The number of times the CME curriculum Webpages were accessed was correlated with the interventions.

RESULTS

Demonstrating the Website to faculty at a semiannual meeting elicited the most Website "hits." Electronic mail and flyers also appeared to be effective in stimulating interest in the Website. Only four community-based faculty applied for CME credit for completing the curricular modules.

FINDINGS

Multiple modalities should be used in advertising and stimulating interest in an Internet-based faculty development curriculum. Demonstrating the Website to faculty at a meeting appeared to achieve the greatest return. Offering CME credit was not helpful in stimulating interest.

Using the Internet in the management of asthma

The ultimate goals of managing asthma are to eliminate death, prevent or promptly treat exacerbations, and maximize the quality of life and health status of patients. Current strategies include appropriate education, trigger control, and timely access to effective pharmacotherapy and follow-up. Internet-based technologies have emerged as potentially powerful tools to enable meaningful communication and proactive partnership in care for various medical conditions. The main types of Internet-based applications for asthma management include remote monitoring and feedback between health professionals and their patients; online education and marketing for either patients or professionals; networking and collaborative research; and administrative oversight through policy making, planning, and decision support. With increased understanding of integrated disease management and the technostructural as well as psychodynamic issues related to Internet use, further refinement and evolution of the Internet and related technologies may drastically improve the way we monitor, educate, treat, and establish policies for this global problem while attending to individual or local community needs. This review presents a conceptual overview of the current challenges and use of the Internet for improving asthma management through timely and tailored education and appropriate access to health care expertise.

Evaluation of internet-based clinical decision support systems

BACKGROUND

Scientifically based clinical guidelines have become increasingly used to educate physicians and improve quality of care. While individual guidelines are potentially useful, repeated studies have shown that guidelines are ineffective in changing physician behavior. The Internet has evolved as a potentially useful tool for guideline education, dissemination, and implementation because of its open standards and its ability to provide concise, relevant clinical information at the location and time of need.

OBJECTIVE

Our objective was to develop and test decision support systems (DSS) based on clinical guidelines which could be delivered over the Internet for two disease models: asthma and tuberculosis (TB) preventive therapy.

METHODS

Using open standards of HTML and CGI, we developed an acute asthma severity assessment DSS and a preventative tuberculosis treatment DSS based on content from national guidelines that are recognized as standards of care. Both DSS's are published on the Internet and operate through a decision algorithm developed from the parent guidelines with clinical information provided by the user at the point of clinical care. We tested the effectiveness of each DSS in influencing physician decisions using clinical scenario testing.

RESULTS

We first validated the asthma algorithm by comparing asthma experts' decisions with the decisions reached by nonpulmonary nurses using the computerized DSS. Using the DSS, nurses scored the same as experts (89% vs. 88%; p = NS). Using the same scenario test instrument, we next compared internal medicine residents using the DSS with residents using a printed version of the National Asthma Education Program-2 guidelines. Residents using the computerized DSS scored significantly better than residents using the paper-based guidelines (92% vs. 84%; p <0.002). We similarly compared residents using the computerized TB DSS to residents using a printed reference card; the residents using the computerized DSS scored significantly better (95.8% vs. 56.6% correct; p<0.001).

CONCLUSIONS

Previous work has shown that guidelines disseminated through traditional educational interventions have minimal impact on physician behavior. Although computerized DSS have been effective in altering physician behavior, many of these systems are not widely available. We have developed two clinical DSS's based on national guidelines and published them on the Internet. Both systems improved physician compliance with national guidelines when tested in clinical scenarios. By providing information that is coupled to relevant activity, we expect that these widely available DSS's will serve as effective educational tools to positively impact physician behavior.