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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: rachel.ellaway@ed.ac.uk
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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