weaving the ‘e's together

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Medical Teacher, Vol. 28, No. 7, 2006, pp. 587–590 COMMENTARY Weaving the ‘e’s together RACHEL ELLAWAY The University of Edinburgh, Scotland, UK ABSTRACT This paper reviews the ways that the many threads and systems involved in computer-mediated and -supported healthcare education can be woven together by using educational interoperability standards and specifications. By taking a non- technical perspective the author considers the ways that these technologies impact on teaching and learning and how the educational landscape is changing in healthcare education as a whole. Introduction One of the major obsessions of contemporary education has been the pursuit of ‘e-learning’ (or one of its many synonymic forms). Arguably an aspect of the ‘information revolution’ that has swept the world in the past few decades, e-learning has been used to cover all sorts of technology use in educational environments, from training to assessment, from individual activities to whole online community interactions and from accessing content to consuming online services. A core question that is often overlooked is who this ‘e-learning’ is actually for. The term ‘e-learning’ suggests that the focus is on the learner but this is often not the case. For instance, there is clearly a tension between ‘e-teaching’ and ‘e-learning’ (Ellaway, 2004b) as the design and provision of the online learning environment is far more about preemptive choices and decisions by teachers and the institution than it is about those of students, either individually or collectively. While e-learning does indeed happen, in the sense that we often make prodigious and innovative use of technology in support of learning, this involves both public and personal choices, much of it therefore being invisible to the institutions learners are working in. In this respect what the institution, teacher and learner do and experience reflect the problems of the ‘hidden curriculum’ (Snyder, 1971)—see Figure 1. So, is e-learning for students or teachers, about engaging with a process or culture, belonging to an institution or profession, or is it just about supporting our own interests? Current thinking indicates that learners are best supported by enabling them to support themselves by providing structured yet flexible learning environments (Entwistle et al., 2002; Laurillard, 2002). However, while the technologies they use and the opportunities they afford continue to change and develop at a bewildering rate, there seems relatively little added value to be had by trying to teach them how to be e-learners (Prensky, 2001). The e-teacher on the other hand often needs more support in rethinking his/her approaches to teaching while protecting his/her role as both subject expert and academic gatekeeper (Brown & Duguid, 1995). Irrespective of how we view or model the use and impact of working online on teaching and learning, a key lesson is the need to treat individuals holistically rather than compart- mentalizing their identities and activities. This is reflected in the combinations of social, technical and domain-specific activities found in many of the more successful contemporary online learning environments (Dewhurst & Ellaway, 2005). How, then, can the disparate ‘e’s of contemporary healthcare education be woven together to better support and improve the experience and outcome for all concerned? Although there are many pedagogical approaches and techniques that might be applied (Salmon, 2000, 2002), it is often in other areas that the greatest benefits may be found. Somewhat akin to the human genome project, there has been a major international collaborative focus in recent years on the development and implementation of information standards and specifications for e-learning systems. This has been driven by both the impermanence of learning technologies and the need for systems interoperability, both requiring a better return for investment (Ellaway et al., 2004). The rest of this paper will review the issues and opportunities this provides and how they are changing the design and delivery of healthcare education. Standards and specifications The central ethos of e-learning standards and specifications is based on allowing different educational systems and software to talk to one another, sharing information and resources by using common formats and protocols. The difference between ‘standards’ and ‘specifications’ is that while developing specifications is a formative process moving towards ever better data models and can be developed by any organization, standards are summative sets of rules for modeling data, and need to be accredited by a standards organization such as ISO 1 or ANSI 2 . Typically standards are developed from specifications. Groups such as IMS Global 3 , ADL 4 and IEEE 5 have been involved in the development of educational data standards and specifications for a number of years, including models for describing learners, educational content, learning activities and assessment. A particularly noteworthy current development is that of the e-Framework 6 , a collaboration Correspondence: Dr Rachel Ellaway, The University of Edinburgh, Learning Technology Section, Hugh Robson Building, 15 George Square, Edinburgh, EH8 9XD, UK. Tel: þ44 131 651 1749; email: [email protected] ISSN 0142–159X print/ISSN 1466–187X online/06/070587–4 ß 2006 Informa UK Ltd. 587 DOI: 10.1080/01421590600909070 Med Teach Downloaded from informahealthcare.com by National Silicosis Library on 10/27/14 For personal use only.

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Page 1: Weaving the ‘e's together

Medical Teacher, Vol. 28, No. 7, 2006, pp. 587–590

COMMENTARY

Weaving the ‘e’s together

RACHEL ELLAWAYThe University of Edinburgh, Scotland, UK

ABSTRACT This paper reviews the ways that the many threads

and systems involved in computer-mediated and -supported

healthcare education can be woven together by using educational

interoperability standards and specifications. By taking a non-

technical perspective the author considers the ways that these

technologies impact on teaching and learning and how the

educational landscape is changing in healthcare education as a

whole.

Introduction

One of the major obsessions of contemporary education has

been the pursuit of ‘e-learning’ (or one of its many synonymic

forms). Arguably an aspect of the ‘information revolution’

that has swept the world in the past few decades, e-learning

has been used to cover all sorts of technology use in

educational environments, from training to assessment,

from individual activities to whole online community

interactions and from accessing content to consuming

online services.

A core question that is often overlooked is who this

‘e-learning’ is actually for. The term ‘e-learning’ suggests that

the focus is on the learner but this is often not the case. For

instance, there is clearly a tension between ‘e-teaching’ and

‘e-learning’ (Ellaway, 2004b) as the design and provision of

the online learning environment is far more about preemptive

choices and decisions by teachers and the institution than it is

about those of students, either individually or collectively.

While e-learning does indeed happen, in the sense that we

often make prodigious and innovative use of technology in

support of learning, this involves both public and personal

choices, much of it therefore being invisible to the institutions

learners are working in. In this respect what the institution,

teacher and learner do and experience reflect the problems

of the ‘hidden curriculum’ (Snyder, 1971)—see Figure 1.

So, is e-learning for students or teachers, about engaging

with a process or culture, belonging to an institution or

profession, or is it just about supporting our own interests?

Current thinking indicates that learners are best supported by

enabling them to support themselves by providing structured

yet flexible learning environments (Entwistle et al., 2002;

Laurillard, 2002). However, while the technologies they use

and the opportunities they afford continue to change and

develop at a bewildering rate, there seems relatively little

added value to be had by trying to teach them how to be

e-learners (Prensky, 2001). The e-teacher on the other hand

often needs more support in rethinking his/her approaches to

teaching while protecting his/her role as both subject expert

and academic gatekeeper (Brown & Duguid, 1995).

Irrespective of how we view or model the use and impact

of working online on teaching and learning, a key lesson is

the need to treat individuals holistically rather than compart-

mentalizing their identities and activities. This is reflected in

the combinations of social, technical and domain-specific

activities found in many of the more successful contemporary

online learning environments (Dewhurst & Ellaway, 2005).

How, then, can the disparate ‘e’s of contemporary

healthcare education be woven together to better support

and improve the experience and outcome for all concerned?

Although there are many pedagogical approaches and

techniques that might be applied (Salmon, 2000, 2002), it

is often in other areas that the greatest benefits may be found.

Somewhat akin to the human genome project, there has been

a major international collaborative focus in recent years on

the development and implementation of information

standards and specifications for e-learning systems.

This has been driven by both the impermanence of learning

technologies and the need for systems interoperability, both

requiring a better return for investment (Ellaway et al., 2004).

The rest of this paper will review the issues and opportunities

this provides and how they are changing the design and

delivery of healthcare education.

Standards and specifications

The central ethos of e-learning standards and specifications is

based on allowing different educational systems and software

to talk to one another, sharing information and resources by

using common formats and protocols. The difference

between ‘standards’ and ‘specifications’ is that while

developing specifications is a formative process moving

towards ever better data models and can be developed by

any organization, standards are summative sets of rules for

modeling data, and need to be accredited by a standards

organization such as ISO1 or ANSI2. Typically standards are

developed from specifications.

Groups such as IMS Global3, ADL4 and IEEE5 have been

involved in the development of educational data standards

and specifications for a number of years, including models for

describing learners, educational content, learning activities

and assessment. A particularly noteworthy current

development is that of the e-Framework6, a collaboration

Correspondence: Dr Rachel Ellaway, The University of Edinburgh, Learning

Technology Section, Hugh Robson Building, 15 George Square, Edinburgh,

EH89XD, UK. Tel: þ44131 651 1749; email: [email protected]

ISSN 0142–159X print/ISSN 1466–187X online/06/070587–4 � 2006 Informa UK Ltd. 587DOI: 10.1080/01421590600909070

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between a number of international bodies to draw up

a comprehensive model for how all the individual services

within an educational organization (and thereby the

standards and specifications that underlie them) fit together.

The development of common data models for education

has faced many problems, and these continue to emerge as

the broad front of this shared project moves forward.

Not least among these are the heady political wrangling

between participants over their differing understanding and

motivations as regards the purpose and result of these

processes. Nonetheless, the development of e-learning

standards and specifications has in just a few years expanded

to encompass many if not most aspects of educational

activity, moving from relatively static models such as

metadata and question and test to more subjective and

process-oriented models such as learning design and virtual

patients. Even highly subjective areas such as educational

narrative have recently moved into the scope of standards and

specifications developers (Ellaway, 2004a).

All of this activity should be seen within the wider context

of what is being called ‘Web 2.0’7, the move to service-

oriented architectures (SOAs) where systems can provide and/

or consume services and information remotely. In education

this is reflected in the increasing use of news feeds, podcasts

and reusable learning objects (RLOs), all of which depend on

common interoperability specifications and standards to work.

Why bother?

Standards and specifications development and implementa-

tion can be highly complex, partial and downright hard . . . so

why bother? Interoperability has been described as ‘a mutual

condition of two or more systems that subscribe to the same

protocols, formats and methods of sharing and exchanging

data and services’ (Ellaway, 2006). So, if you are not working

with more than the one system do you really need to

implement e-learning standards and specifications? Currently

if you do not need to get your systems to talk to each other or

the cost clearly outweighs the benefits of doing so then there

can be little incentive to do so. However, even if they are not

fully implemented, the use of standards and specifications

provides well-considered and widely implemented data

models and as such they provide a rich basis for design and

reflection in local contexts. In this way it can be argued that

standards and specifications can be seen as providing

ecological models that embody an exhortation to ‘act locally,

think globally’ (Schumacher, 1974).

As was discussed earlier, standards and specifications reify

particular models of reality and praxis and as such are

sometimes fetishized by those who work with them and

demonized by those who do not, thereby becoming very

political. Despite this, effective and productive standards and

specifications development processes are most often marked

by a sense of common purpose and a suspension of the usual

contest of professional egos and exercising of organizational

rivalries found in other collaborative activities. In this respect

the MedBiquitous8 group is particularly noteworthy, both

for its success in developing a number of healthcare-

education-focused standards and its ability to provide a

common ‘trusted working context’ for the many participants

in the standards and specifications development processes it

runs.

Despite this, standards and specifications can also provide

an excellent forum for negotiating common purpose. In their

absence we run the very real risk of reinventing (often

substandard) wheels and excluding ourselves from the wider

learning technology discourse. The failure to pay attention to

standards and specifications led to the $150-million Mars

Climate Orbiter satellite being lost in 1999 following the

mismatch of imperial and metric units of measure.

However, unlike high-performance aerospace engineering,

practical implementation of e-learning standards and specifi-

cations can be both fuzzy and partial (Alexander et al., 2003).

Pursuing a pragmatic path allows implementers to consider

the political trade-offs between autonomy and conformance

with a standard, the economic trade-offs between cost and

conformance and the individual trade-offs between craft and

personal expression and conformance. Standards and speci-

fications can in this way better support local autonomy and

flexibility by requiring vendors of monolithic e-learning

systems to use the same public metrics as everyone else.

Standards and specifications in healthcare education

The development of standards and specifications and their

implementation is currently the brave new frontier in

educational technology and as such it has often proved to

be ahead of formal research-orientated informatics. One area

where the two are coming together is in healthcare education

where medical informatics systems (such as HIS9, PACS10

and EHRs11) and associated data standards and vocabularies

(HL7/RIM12, MeSH/SNOMED13 etc.) are coming up

against educational systems development. Two examples of

this are the development of a public standard for virtual

patients (Ellaway et al., 2006a) and educational extensions for

MeSH (Haig et al., 2004). Other notable healthcare-educa-

tion oriented developments employing standards and

specifications include IVIMEDS14, IVINURS15, HEAL16

and MedEdPortal17, all of which demonstrate the key role of

standards and specifications in underpinning any form of

technology-mediated collaborative venture.

On a broader front, although there has been some

progress connecting the informatics of practice and

Figure 1. Different aspects of the ‘e’ domain only partially

overlap, reflecting similar patterns to ‘hidden curricula’.

Source: After Snyder (1971).

R. Ellaway

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informatics of education it remains the biggest challenge and

the greatest opportunity to enhance and reshape the way

healthcare education can relate to actual practice. As an

example, in healthcare education patients are an often

overlooked yet essential constituency. Standards and

specifications could, for instance, allow patient information,

student learning and clinical support systems to be integrated

to the benefit of all. Expert patient programmes18 could be

integrated with courseware and treatment algorithms,

allowing patients to work with both clinicians and students

to manage their conditions with each constituency working

within its existing environments. Although this raises many

issues, not least that of consent, these are also beginning to be

addressed in a more standardized and structured way

(Ellaway et al., 2006b).

Discussion

The development of standards and specifications for health-

care education can be both philosophically and practically

challenging, requiring skills in abstraction, pattern identifica-

tion and codification of domains of knowledge and practice

as well as the more technical skills of implementing the

resulting models. The breadth of skills required to work in

this area has meant that new professions are now engaged

with healthcare education (such as educational informati-

cians) and established practitioners are finding they too need

to acquire more formal informatics skills, all of which have

implications for staff development, resourcing and the

professional identities of all those involved.

One of the most exciting aspects of the work being done in

this area is the way participants are prepared to revise and

rethink their practice and the way they see it being modeled

as part of a larger set of activities. In this respect standards

and specifications also behave like models in the research

sense, reified hypotheses on the nature and praxis of

education and its associated activities and services.

Standards and specifications can therefore also provide

mirrors to practice, thereby enabling ‘double loop learning’

(Argyris & Schon, 1978) where the very nature of practice

changes as a result of new ways of modeling and under-

standing educational entities and processes.

With groups like MedBiquitous now providing open fora

for developing freely available healthcare education standards

and specifications their rate of development and

implementation is increasing. It is likely that in a few short

years their use as a common underpinning foundation for

healthcare education systems will become the norm and, as a

result, new ways of linking and configuring the teaching and

learning environment will become ever easier. Whether this

marks an evolution or revolution in healthcare education only

time will tell.

Whatever position you might take on this matter,

remember that there is often no ‘someone else’ who will do

this for you—‘they’ are ‘us’; it is medical educationists as well

as technologists who are undertaking this work. Involvement

in the standards and specifications development process

allows you to influence it and ensure it reflects your needs

and philosophy.

Healthcare education can benefit by engaging with the

standards and specifications being developed to describe

and structure it. However, we still need better coordination

and connections between education, practice and patients,

better understanding of the underlying patterns of interoper-

ability, better understanding of the impact and effect of this

interoperability on educational and clinical practice, and,

above all, action, not just reflection!

Notes

[1] ISO (International Standards Organization) (http://

www.iso.org).

[2] ANSI (American National Standards Institute) (http://

www.ansi.org).

[3] IMS Global Learning Consortium has developed

a number of widely adopted specifications including

content packaging, learner information profile,

e-portfolio and question & test (http://

www.imsglobal.org).

[4] ADL (Advanced Distributed Learning) is most notable

for its development of SCORM (http://

www.adlnet.org).

[5] IEEE (Institute of Electrical and Electronics Engineers,

Inc.) is particularly notable for having published the

Learning Object Metadata standard (LOM) (http://

www.ieee.org).

[6] The e-Framework is a major international project to

codify and unite ways of integrating the many aspects of

educational systems interoperability (http://www.

e-framework.org).

[7] For more on Web 2.0 see the following website (http://

en.wikipedia.org/wiki/Web_2).

[8] MedBiquitous’s mission is ‘To advance healthcare

education through technology standards that promote

professional competence, collaboration, and better

patient care’ (http://www.medbiq.org).

[9] Hospital Information System (http://en.wikipedia.org/

wiki/Hospital_information_system).

[10] Picture Archiving and Communication Systems

(http://en.wikipedia.org/wiki/Picture_archiving_and_

communication_system).

[11] Electronic Health Records (http://en.wikipedia.org/

wiki/HER).

[12] ‘HL7 is an international community of healthcare

subject matter experts and information scientists

collaborating to create standards for the exchange,

management and integration of electronic healthcare

information’. RIM is the reference implementation

model of HL7 (see http://www.hl7.org).

[13] MeSH (Medical Sub Headings) is a controlled medical

vocabulary developed by the National Library of

Medicine in the US and originally intended for

cataloguing books and other literature (http://

www.nlm.nih.gov/mesh/meshhome.html). SNOMED

is another US-based medical nomenclature system

(http://www.snomed.org).

[14] IVIMEDS—a subscription-based international

collaboration to provide e-learning materials and

Weaving the ‘e’s together

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support for medical education (http://

www.ivimeds.org).

[15] IVINURS—based on the IVIMEDS approach,

a subscription-based international collaboration to

provide e-learning materials and support for nursing

education (http://www.ivinurs.org).

[16] The Health Education Assets Library is a free

repository of healthcare education resources (see

http://www.healcentral.org).

[17] MedEdPortal is a repository/catalogue of educa-

tional resources from the American Association of

Medical Colleges (AAMC) (http://www.aamc.org/

mededportal).

[18] See for example the following website (http://

www.expertpatients.nhs.uk).

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