Implementing an E-Learning Strategy

Valerie Smothers, Peter Greene, MD
MedBiquitous Consortium

This article proposes a series of strategies for implementing self-directed e-learning solutions in a professional medical society or other organization focused on medical and health professions education. The proposed strategies have been developed by and proposed for professional organizations that share a common desire to leverage Internet technologies to improve health professions education.

Key strategies include:

Embracing a learning-objects approach to e-learning content creation that will facilitate interoperability, reuse, integration, and delivery of targeted online resources when and where they are needed.
Adopting industry-wide standards for e-learning in general (SCORM) and for healthcare e-learning in particular (MedBiquitous).
Deploying a Learning Content Management Systems (LCMS)/ Learning Management System (LMS) for managing and administering modular, standards-based learning objects and courses.
Creating and delivering high-quality educational materials, leveraging materials from partner organizations when appropriate.
Creating a competency portfolio that allows learners to track and report (to certifying boards and other entities) their ongoing educational, competency, and certification-related activities.

Successfully implementing these strategies will require widespread support and participation within the organization as well as collaboration with other medical and healthcare education organizations. There will also need to be a well-designed, standardized, and reliable technology infrastructure supporting a consistent and widely-accessible approach to e-learning.

What is E-Learning?

Definitions of e-learning abound. In this article, e-learning is defined as the use of Internet technologies to create or deliver a learning experience to one or more learners. For our purposes, e-learning includes online courses, learning objects, blended learning (which combines online resources with face-to-face interactions), performance support, knowledge management, self-assessment, communities of practice (online educational communities), and other online resources that encourage learners to assess, improve, or change their knowledge or clinical performance.

Various companies offer what at times is a bewildering array of products and services to support e-learning. In order to sort out these offerings, a useful categorization of the elements of e–learning is proposed:

E-Learning content includes the text and multimedia materials that are provided to learners.
E-Learning technology describes the information technology (IT) infrastructure used to support learning, including Learning Management Systems (LMSs), Learning Content Management Systems (LCMSs), and Virtual Learning Environments (VLEs).

Many companies provide assistance with the content development, implementation, and design of the e-learning technology and infrastructure within an organization.

A wide variety of choices are available. Organizations may choose to develop all of their own content or they might license content created by third parties. Learning technology systems can be run internally by an organization or they can be hosted externally using the Application Service Provider (ASP) model. Software licensing models may require per-user (seat license) fees or a flat rate for unlimited usage. With careful planning, this wide range of options makes it possible to implement a plan that meets the needs of learners and educators.

What are the Characteristics of Good E-Learning?

The Internet is still a relatively new medium for use in healthcare learning. As with the transition to any new media, there have been some growing pains as content developers take content from other media and deploy it for access over the Internet. The one-hour presentation that was engaging and interesting at a live meeting becomes less effective deployed on the Internet as e–learning. The following are some of the key characteristics of effective e–learning.

Visual – The Web is a largely visual medium and e-learning should use relevant images, video, audio, and other media, rather than simply text, when appropriate to provide information to learners.
Concise – Written information that is part of e-learning should be concise and to the point. Use formatting elements like bulleted lists and bolded text that will draw learners' attention to the most important information on a screen. In addition, content developers should be aware that e-learners often have short attention spans. Design content in 5 to 15 minute “chunks.”
Interactive – An advantage of e-learning is that learners can interact with the courseware through quizzes and multimedia activities that let them practice skills, demonstrate knowledge, discover relationships and new information, and reinforce learning. Make sure that learners engage in some form of interaction at least every 2 to 5 minutes (clicking next doesn't count). If possible, provide ways for learners to interact with one another as well.
Engaging – Appeal to the learner's professional experience and their emotions. Use case-based learning and scenarios that get the learner to analyze and synthesize information and put it within a frame of reference. Ask the learner to make decisions or judgments relevant to the case-based learning and scenarios.
Relevant – E-learning should address a learner's current needs or learning gaps. In addition, developers must maintain the accuracy of the content. Revisit e–learning content on a regular basis to ensure that it is still relevant and accurate for your audience.
Feasible – Make sure that the technologies you choose for enabling e-learning are feasible for your learners. If your audience is using 56K modems, be mindful of that limitation in choosing media and tools for creating your e-learning experience.
Empowering – Provide access to additional resources for more information so that the self-directed learner can explore content relevant to their interests and learn more.

What Technologies are Available to Support E-learning?

A Scottish Enterprise Report on e-learning¹ describes three general categories of e–learning technology systems:

Learning Management Systems (LMS) support administrative tasks such as registration, scheduling, and learner tracking.
Learning Content Management Systems (LCMS) allow developers to store, manage and provide access to pieces of content used in e-learning.
Virtual Learning Environments (VLE) provide a platform for supporting online courses typical of a university environment, including syllabi, resources, chat, discussion, document storage, integration with student information systems.

Because medical and healthcare professionals need flexible and convenient ongoing education, this article focuses on implementing self-paced, self-directed e-learning solutions supported by an LMS/LCMS. Instructor-led solutions, such as a VLE, may be highly appropriate for universities and other types of organizations depending on their learners and goals, but they are not addressed here.

A Learning Objects Approach

An important evolution has occurred in e-learning in which the focus has shifted from the online course, which might take 20 minutes to an hour or more to complete, to the learning object, which might take a few minutes to complete. These learning objects are discrete units of digital instruction typically focused on a single learning objective. By packaging information in these smaller pieces of instruction and then aggregating them in large repositories, which can be searched and mined, these learning objects become versatile and reusable building blocks that can provide content for both formal and informal learning. When combined, the learning objects can form a longer online course. As distinct objects easily discovered and integrated into the clinical environment, they can serve as the basis of a performance support/knowledge management system that provides education and information to learners when and where they need it. Learning objects can also be used within a community of practice as part of a blended learning approach that extends access to pertinent learning material beyond a single scientific meeting.

What is SCORM?

The United States Department of Defense (DoD) and White House Office of Science and Technology Policy (OSTP) launched the Advanced Distributed Learning (ADL) initiative in November of 1997 in order to meet the expanding education and training needs of government, academia, and industry (http://www.adlnet.org). The mission of ADL is “to provide access to the highest quality education and training, tailored to individual needs, delivered cost-effectively, anytime and anywhere.” ²

In order to accomplish these goals, the ADL developed the Shareable Content Object Reference Model (SCORM) to foster the creation of learning objects within a common learning technology framework. SCORM creates a coherent framework based on a collection of pre-existing specifications and standards developed by a number of different industry and standards groups.

The SCORM model provides the following e-learning standards:

Learning Object Metadata defines how to describe discrete modules of online instruction
Content Packaging defines how to aggregate and package content so that it can be moved between different systems.
Run-Time Environment standards describes how to deliver content to a learner and track their progress through a course
Simple Sequencing standard provides a way to define a learner's path through a course, offering “if-then” options for delivering, for example, customized content based on pre–assessment outcomes.
Navigation provides a consistent way of describing navigational elements that the learner uses to navigate the course content.

The SCORM is a suite of standards that represents the cumulative experience of almost 15 years of computer-based training by the airline, DoD, and technology industries, and is now being broadly accepted and implemented by a wide range of organizations. Most consultants and industry analysts recommend SCORM as the de facto standard for e-learning content. ³ Many content authoring and LMS software tools support the SCORM specification.

There are a number of benefits to deploying SCORM compliant e-learning solutions.

SCORM Content is…	Definition	Example
Accessible	Easily discovered and located.	Searching a repository for pediatric asthma brings up all relevant results.
Reusable	Independent of learning context. Can be used for multiple situations.	A learning object on initiation of cardiopulmonary bypass can be included be included in multiple courses.
Interoperable	Can function in multiple hardware/software environments.	Learning objects created by the VA or the CDC could run in an LMS hosted by the American College of Surgeons.
Durable	Will continue to function as systems are upgraded.	This year's course on critical care procedures will still run on the LMS you buy in 5 years.

What is MedBiquitous?

MedBiquitous (http://www.medbiq.org) is a non-profit organization that develops open technology standards for medical education. Its 43 organizational members include an international group of professional medical associations (representing more than 400,000 physicians), universities, commercial, and governmental organizations, including many of the leaders in healthcare. The mission of MedBiquitous is to advance medical education through technology standards that promote professional competence, collaboration, and better patient care.

MedBiquitous members are working together to create a technology blueprint for professional medical education. Based on XML and Web services standards, this blueprint will weave together the many activities, organizations, and resources that support the ongoing education and performance of clinicians, creating more integrated access to educational resources, scientific journals, and competency-related activities. MedBiquitous is accredited by the American National Standards Institute (ANSI) as the developer of technology standards for medical education.

One of the most important early projects for MedBiquitous has been the development of a healthcare version of SCORM. MedBiquitous has signed a Memorandum of Understanding with the Advanced Distributed Learning group to co-develop a MEDBIQ-SCORM that meets the needs of healthcare educators. The MedBiquitous Medical learning object metadata (Medical LOM) draft standard provides a consistent way of describing medical learning objects. This customization of the LOM standard used by SCORM involves adding elements that are critical to medical education, including credit information, off-label use disclosure, conflict of interest disclosure, and level of medical evidence. Medical LOM also customizes the vocabularies for some of the generic metadata elements, including classification and educational context.

How Will MEDBIQ-SCORM be Useful?

Continuing Medical Education (CME) reforms and changes to how physicians maintain their certification necessitate enhanced communication and collaboration in professional medicine. MEDBIQ-SCORM is an essential part of a standards framework to enable this communication and collaboration. MEDBIQ-SCORM could allow organizations to track clinical education and training, integrate educational resources with systems at the point of care, deploy online courses in different environments, and link education to core competencies and curricula.

With the increasing development of e-learning in healthcare, and growing adoption of the SCORM standard, the MedBiquitous version of SCORM will become an important resource for healthcare educators. MEDBIQ-SCORM is important for a wide range of healthcare education scenarios involving audiences of both clinicians and patients. MEDBIQ-SCORM is particularly important for organizations that need to do the following:

Provide learning for the self-paced, individual learner
Track learner progress and completion of materials
Manage large amounts of learning content
Reuse content in different contexts
Share learning content across an enterprise
Share learning content with different organizations
Support a learning objects approach to education and performance support
Move content from one system to another

What is an E-portfolio?

An e-portfolio is a secure Web resource for saving, organizing, tracking, and selectively reporting professional education and competency accomplishments. Many disciplines have used portfolios as a way to organize and present work in order to summarize activities and enable critique and evaluation. As work has become more widely available in digital formats, the portfolio notion has been extended more broadly, particularly in the higher education community where a variety of projects are underway to define e-portfolios that document learner accomplishments across many institutions. ⁴

Clinician learners will benefit from a consistent and comprehensive way to track their ongoing competency-related accomplishments. Organizations should partner to maintain a “Competence Portfolio,” which will allow organizations and learners to report continuing education and certification activities and allow learners to transmit that data to accreditation bodies when needed. Projects are already underway to enable tracking of education and certification activities. MedBiquitous is working with the American Academy of Pediatrics and the American Board of Pediatrics to create an XML-based activity report standard that can allow items from a pediatric portfolio of learning and competency activities to be counted toward ongoing maintenance of certification (MOC).

A portfolio resource for a clinical specialty would provide a centralized administration system for gathering and tracking accomplishments and activities. Many different organizations could provide educational content and competency activities that could be recorded in these e–portfolios, which would become career-long resources for clinician learners. Certification and credentialing organizations could design their own electronic systems to receive data from learner portfolios.

How Can We Get Started?

Successfully implementing e-learning for healthcare education requires careful planning and consideration. Organizations should complete the following planning steps to ensure that the solution meets their needs:

Define the role of e-learning in the organization's overall education strategy (how will it fit with and support other types of learning).
Define specific target audiences and identify learning gaps or needs that might be addressed by e-learning.
Define an intellectual property strategy that enables contributed learning resources to be reused in multiple contexts and shared with outside organizations, if desired. This involves negotiating electronic reuse agreements with external content partners.
Identify a feasible business model for supporting ongoing development and delivery expenses. Collaborating with other organizations and reusing content will often be essential to reduce development expenses and deliver high-quality offerings.
Consider a multi-phase approach in which early pilot projects help to develop organizational capabilities and processes that can scale to larger subsequent endeavors.
Define precise requirements for a supporting technology infrastructure for each phase of implementation.
Identify personnel to carry the project forward. Project teams usually consist of individuals with the following skill sets: project management, instructional design, graphic design, programming, and subject matter expertise. If these skill sets are not currently available in the organization and hiring new staff or educating current staff is not feasible, consider using contractors to provide these services.
Plan for a learning curve in order to become accomplished in developing high-quality e-learning content.

There are a number of tactics that can facilitate efficient development of high-quality e-learning content. E-learning templates can provide a standard layout, look and feel, navigation, and method of tracking learners in MEDBIQ-SCORM conformant manner. In addition, templates can make it easier for non-technical subject matter experts to contribute content. For example, many organizations are developing templates using Macromedia Flash technology. These templates can separate content from the final presentation format, making it easier for non-technical contributors to edit content. Developing e-learning resources with the help of templates can allow project teams to begin learning best practices without taking excessive financial risk.

Another tactic for facilitating high-quality content development is implementation of an LMS/LCMS product. Such systems are appropriate when many participants are developing e–learning content and there is a desire to embrace a learning-object approach. The LCMS typically has a friendly authoring interfaces that facilitates content creation, and stores objects in a repository that can be shared across many developers and projects. The LMS manages the registration and delivery of multiple courses in a standards-based fashion, and often allows learners to track and send reports about their accomplishments. Licensing of these kinds of software systems make sense for larger organizations that need to efficiently manage online learning for large numbers of learners.

For Further Reading

For more information about a standards-based approach to e-learning, visit the MELD Best Approaches and Courses sections.

References

Martin G, Jennings A. Learning Technology Evaluation Report, 2002.
URL: http://www.scottish-enterprise.com/publications/elearning_technology_evaluation_report.pdf
[Last accessed 14 October 2008].
Advanced Distributed Learning. SCORM 2004 Overview (version 2, 2004).
URL: http://www.adlnet.gov/scorm/20043ED/
[Last accessed 14 October 2008].
Gartner Research Note. SCORM Standard Unites E-Learning Software and Content, April 2003.
Electronic Portfolio Consortium. Electronic Portfolio Whitepaper, 2003.
URL: http://www.eportconsortium.org/Uploads/whitepaperV1_0.pdf
[Last accessed 14 October 2008].