Internet Platforms For Lifelong Learning

Otolaryngol Clin N Am 40 (2007) 1275–1293

Internet Platforms for Lifelong Learning: A Continuum of Opportunity Susan E. Sedory Holzer, MAa,*, Phillip Kokemueller, MS, CAEb a

Strategy and Governance, American Academy of OtolaryngologydHead and Neck Surgery Foundation, 1 Prince Street, Alexandria, VA 22314, USA b Education, American Academy of OtolaryngologydHead and Neck Surgery Foundation, 1 Prince Street, Alexandria, VA 22314, USA

Knowledge is of two kinds. We know a subject ourselves, or we know where we can find information on it. dSamuel Johnson (1709–1784)

Statistics on the growth of the Internet and its revolutionary impact on how the world accesses information, without the barriers of location or time, are captivating but largely superfluous. With more than 1 billion users, the opportunities for finding new knowledge need only be described as both vast and inexhaustible. Samuel Johnson, circa 1755, and his publication, A Dictionary of the English Language, could not have possibly found in a lifetime what the average user can find in a day on the Internet [1]. Access to knowledge has spawned a world of online learning. What is not to love about on-demand access to expert knowledge, fed by a nearly constant infusion of new or updated information and enhanced through multimedia, interactive tools, or virtual discussions? Report after report document the ways in which the World Wide Web is stimulating a new passion for lifelong learning in academia, professional environments, the workplace, and at home [2,3]. Not only has the number of students studying online increased at a higher rate than the rate of growth in higher education overall, access to online education is a strategic imperative for organizations ranging from Fortune 500 companies to developing nations. Whether one faults the user or the usability, a decade ago it was not uncommon for physicians to be characterized as Internet technophobes [4]. Both authors are employees of the American Academy of OtolaryngologydHead and Neck Surgery Foundation, whose educational products are described in parts of this article. * Corresponding author. E-mail address: [email protected] (S.E. Sedory Holzer). 0030-6665/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.otc.2007.07.007

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Gradually, over the past 5 years, surveys have demonstrated that nearly all physicians have access to the Internet and know how to use it to obtain medical information. The most recent release of an annual survey conducted by Manhattan Research, entitled Taking the Pulse: U.S. Physicians and Emerging Information Technologies, found that 99% of doctors are now using the Internet on a daily basis [5]. These researchers consider that the tipping point and suggest that physicians are prepared to make major shifts in using the Internet to impact health care. The path to effective online continuing medical education has been a steady but slow one. In their study on Web-based instruction, Casebeer and colleagues [6] reported 209 continuing medical education sites in 2001, a doubling of sites from just a year before. Yet, despite offering 18,263 hours of continuing medical education credit, 28% of these sites contained only text; only 17% were interactive and 7% were guideline-based. And although the availability and quality of sites may have increased since then (at press time, sites such as CMEList.com [7] were tracking 300 online CME sites, offering about 16,000 activities and more than 26,000 hours of AMA Category I CME credits), concerns persist about inconsistent use of content that is evidence-based and methods grounded in adult learning theories. Rather than spending time characterizing online medical education sites as suboptimal tools for improving physician performance or patient outcomes, the intention of this article is to take a fresh look at the wide spectrum of opportunities for online medical education for physicians. We first explore a continuum of ‘‘e-learning’’ models and then look at the range of platforms used to support these systems. We also try to look forward to the options likely to change e-learning in the near future.

A continuum of e-learning models Fig. 1 illustrates a continuum of e-learning models in use today. The basis for the continuum is interactivity of the content as well as the learner. This is in keeping with what is often referred to as the ‘‘new science of learning’’ [8]. The premise is that as learners become more directly involved with the learning content and materials, they make active choices about the path they need to take and the ‘‘building blocks’’ of their studies. By controlling their learning, they monitor their mastery of skills and transfer learning into practice. Additionally, interactive content typically requires that such knowledge seeking does not occur passively, but instead through more compelling, interactive formats that offer a virtual extension of a teacher-centric model of learning [9]. Internet access to digitized content At the most basic level, physicians spend a great deal of time researching and learning from digitized content on the Internet, just like the rest of its 1 billion users. In the 10 years since Senators Tom Harkin and Arlen Specter

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Fig. 1. Illustrates a continuum of e-learning models in use today. The basis for the continuum is interactivity of the content as well as the learner.

announced free Web-based access to MEDLINE through PubMed and Internet Grateful Med in June 1997, complete with a demonstration by Vice President Al Gore, there now exists a nearly complete digital archive of the volumes of medical knowledge found in more than 5000 biomedical journals [10,11]. Other commercial aggregators, such as Ovid (www.ovid. com), offer premium access to a growing list of journals, books, and 200 databases [12]. Through sophisticated and unsophisticated search engines, physicians and their patients are offered access to the equivalent of a 24/7 virtual library of medical education resources, well beyond traditional peer-reviewed journals, found on academic, government, nonprofit, and commercial Web sites. One example of a typical online textbook is ACS Surgery: Principles and Practice. First published in 1989 as a loose-leaf reference, the entire contents of this textbook are available in an online format [13]. Access to this content is on a pay-per-chapter basis or through an annual or monthly subscription; for a modest surcharge, users have access to tests through which they can obtain up to 60 CME credits. Although it is described as ‘‘practical, fast, and richly illustrated,’’ this online textbook is simply a digitized version of the same text-rich product that normally resides on office or library shelves. Another example of digital content sometimes erroneously called an online course is the CME available from the commercial Web site CMEWeb [14]. Whereas some courses are described as containing multimedia features, a typical course on CMEWeb requires the learner to read several different articles and complete a post-test for claiming CME credit. As a tool for continuing medical education, access to digitized content on the Internet is an important but limited offering. While specialized search

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engines are powerful tools for addressing specific clinical questions, their current formats are not straightforward enough to be undertaken during the clinical encounter. The burden remains on the learners to critically assess the validity of the content, extract meaning, and teach themselves when and how to apply what they have learned. CME tests measure if they have gotten it right. Box 1 summarizes the advantages and limitations of online content for physicians. Shared library of multimedia and video-based learning objects One step up from digitized text is a much more fun side of e-learning. Thanks to significant increases in bandwidth and digital storage, today most Internet users can watch and interact with objects online in ways they never imagined. Whether it is live streaming lectures or a central online shared library for slides and digital images, the Internet is a natural source for stimulating different cognitive processes to enhance learning. These objects are largely used to create more sophisticated interactive learning courses rather than as stand-alone learning interventions. Yet there is educational opportunity to be found in searching and browsing a shared library of multimedia and video-based training. One hot topic in medical education is the creation of shared digital resource collections, such as media libraries and learning object repositories. A noteworthy example is the Health Education Assets Library (HEAL)

Box 1. Advantages and limitations of online content for physicians Model: Internet access to digitized content Description: Access to medical education resources via the Internet Advantages  24/7, transportable accessibility to a virtual library  Convenience of digitized versions of online textbooks and other reference materials Limitations  Clinician must leave the clinical encounter to seek information  Still requires the learner to extract meaning and teach themselves when and how to apply it Examples  MEDLINE and PubMed  ACS Surgery: Principles and Practice  CMEWeb

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[15]. HEAL is a digital library providing free access to a centralized national repository of high-quality digital teaching resources in the health sciences. Resources are submitted by individual authors and peer reviewed before publication in HEAL. HEAL has also partnered with other digital libraries to include their content as affiliate collections that can be searched and browsed through HEAL. In a similar way, medical schools in Canada are collaborating to develop and share noncommercial digital media files through The Common Currency Project [16]. This project aims to bring together one-time, limited funding projects, such as the DalMedix media library, McGill’s Health Library, and the Alberta and British Columbia-based BELLE project, to build up these media collection mechanisms ‘‘beyond the pilot stage’’ of test content. The AAO-HNSF has begun to develop and use an image library for various initiatives, including the National Resident Online Study Guide (NROSG) [17]. As shown in Fig. 2, images are accessible through a custom-built image viewer tool, allowing users to search for cataloged images using metadata and text searches, read and store slide notes and annotations, and zoom in and out on the images and image sectors. If a picture is worth a thousand words, then videos at 60i (interlaced; frames per second) should be worth 60,000 words per second. High-resolution digital images stored at 200  200 and viewed with pan and zoom tools on today’s monitors offer a universe of words and information to explore. Opportunities are no longer limited by technical issues of capturing, storing, and sharing digital media learning objects online. Instead, institutions and communities are tackling logistical, financial, and copyright issues of maintaining a high-quality, comprehensive, and consistent collection into which contributors are comfortable exchanging widespread distribution for the hope of future enhancements to medical education and for commercial sale. Box 2 summarizes advantages and limitations of multimedia and video-based learning. Point-of-care e-learning As an educational tool, point-of-care systems provide real-time learning in a manner designed to be informative and not intrusive in the clinical pathway. The key is in the quality of the content and the usability of the interface. Today’s point-of-care offerings tend to use real-time automated tools that are integrated into existing clinical information systems to provide contemporaneous education for the physician. The educational product is essentially highly customized knowledge linking a clinical diagnosis with the appropriate guidelines, order rules, or point-of-care recommendations. According to Manhattan Research, approximately 25% of physicians are accessing the Internet during patient consultations; typically, these physicians are in group practices with an electronic health record system and spend more than 10 hours online per week [5].

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Fig. 2. Shows an image accessible through the AAO-HNSF image viewer tool. (Courtesy of the American Academy of Otolaryngology-Head and Neck Surgery Foundation, Alexandria, VA; with permission.)

One example currently released in beta version is the American College of Physicians’ (ACP’s) Best Dx/Best Rx [18]. Best Dx/Best Rx captures the patient care recommendations from ACP Medicine and offers them in a format for use on a computer or a handheld wireless device. The clinician browses condition modules to access ‘‘bullet-style lists of key clinical features, differential diagnosis and best tests, best therapeutic regimens and recommended references for further research.’’ Another example are the InfoPOEMs (Patient-Oriented Evidence that Matters) from InfoRetriever, which are designed to bring clinicians daily evidence-based learning [19]. For subscribers, one or two POEMs are delivered via email everyday, each structured to provide a 5-minute, high-level yet evidence-based answer to a specific clinical question. For example, one POEM might ask ‘‘Is modafinil safe and effective for night-shift sleep disorder?’’ In addition to offering a bottom-line answer with an evidence-level rating (‘‘Modafinil provides modest benefit for patients suffering from disordered

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Box 2. Advantages and limitations of multimedia and video-based learning Model: Shared library of multimedia and video-based learning objects Description: Central online shared library for digital images and videos for direct learning or reuse in other learning programs Advantages  Multiple media sources stimulate different cognitive processes to enhance the learning  24/7, transportable accessibility Limitations  Clinician must leave the clinical encounter to seek learning  Still requires the learner to extract meaning and teach themselves when and how to apply it  Challenged by intellectual property and copyright issues Examples  Health Education Assets Library (HEAL)  The Common Currency Project  AAO-HNSF Image Library

sleep due to shift work. This must be balanced against the very high cost of this drug. [Level of Evidence ¼ 1b]’’), the POEM provides a link to the source article and a structured, 300- to 400-word synopsis of the article. Because all of these daily POEMS are readily available on the vast InfoRetriever Web site, seeking highly focused clinical answers can occur at the point-of-care. As mobile devices and electronic health record (EHR) usage increases, this format for education will overcome the current content limitations. Several current CME offerings associated with point-of-care systems offer 0.5 credits by tracking the physician’s activitydwhat content or activity was accessed, the status of progress within the activity, and the resulting actions as they pertain to the clinical encounter. It is not yet clear just how much depth of knowledge can be provided during an encounter. Box 3 summarizes the advantages and limitations of point-of-care e-learning. Online courses When most people hear the term ‘‘e-learning,’’ an online course is typically what they think about. In fact, a recent survey of nonprofit organizations found that of the 54% of respondents with active e-learning programs, 71% used on-demand, self-paced e-learning as a component of their

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Box 3. Advantages and limitations of point-of-care e-learning Model: Point-of-care e-learning Description: Contemporaneous education from real-time automated tools integrated into existing clinical information systems, linking diagnosis-specific information to knowledge resources such as guidelines, order rules, and point-of-care recommendations Advantages  Clinician gains learning during the clinical encounter in a manner that is informative and not intrusive in the clinical pathway  Increasingly offered through personal digital assistants and other mobile devices Limitations  Systems are limited by content  Limited depth of knowledge can be provided during an encounter Examples  Best Dx/Best Rx: Point of Care Recommendations from ACP Medicine  InfoPOEMs and InfoRetriever

program, followed by custom-built courses based on their organization’s content (52%) and blended classroom-based e-learning (46%) [20]. For purposes of our discussion, we define an online course as any variety of learning formats specifically designed for online delivery and learning. A course can vary greatly in content format and delivery method. One characteristic, though, that sets online courses apart from digitized content is the application of a teacher-centric model. That is to say, long before the course ‘‘goes live online,’’ an instructional designer and a subject matter expert will have spent hours designing a course that will aid the learner to extract meaning from the materials to be presented. There are three basic content structure models for online courses: presentation, interaction, or collaboration [21]. In a presentation model course, information is presented one-way to the learner via text, graphics and sound and is akin to a demonstration, simulation, story or movie. People who watch TV to learn will be most comfortable with this medium. The interactive model goes beyond a one-way presentation and requires users to interact directly with the program. This may be as simple as clicking buttons to navigate through the course content or more involved such as answering test questions, running simulated experiments, or connecting objects and

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concepts. A more collaborative approach would be to encourage the social aspect of learning through online communities to share discourse or collaborate on projects. Online courses also fall into one of three delivery models: synchronous, asynchronous, or blended [21]. Synchronous courses hinge on real-time, ritualistic communication methods (eg, Web-based video conferences) to bring together multiple participants from various geographical locations in a realtime, virtual classroom. Asynchronous delivery follows the ‘‘anytime, anywhere’’ approach that lets the learner set their own pace. Blending a hybrid of the two models will encourage the social side of learning, reduce the burden of costly technology and live instruction, and maintain the adult learner’s demand for self-paced study, repetition, and a personalized learning plan. Commercial start-ups such as Medscape were the first to market online courses to physicians. Medscape, part of the WebMD Health Professional Network, started with the goal of helping physicians and health care professionals ‘‘stay current on medical and scientific research and findings, patient care and the latest treatments.’’ They provide online CME in a variety of what they consider to be interactive formats, including News CME/CE, Clinical Cases, Clinical Reviews, Conference Coverage, and Slide/Lecture Presentations. Of these, only the clinical cases go beyond having the learner read an article online and achieve a minimum score on a ‘‘post-test’’ to earn AMA Category I credit. In 2007, the American Academy of OtolaryngologydHead and Neck Surgery Foundation launched its new Web-based learning system, AcademyU, to provide a one-stop Web site and transform the way education is delivered to otolaryngologists. Using convenient and efficient new technologies, AcademyU will provide ‘‘anytime, anywhere’’ access to practical, vital, and relevant medical education authored by otolaryngologists for otolaryngologists. In addition to providing access to knowledge documents and policy statements, two unique types of online courses will be available in AcademyU in its first generation. A series of 15-minute video courses have been built from the most popular instruction courses and miniseminars present at the prior year’s Annual Meeting. In a different learning opportunity, contents from the Academy’s successful self-instructional package (SIPac) series are being repurposed into an entirely new interactive learning format. In both cases, Academy members have the unique opportunity to receive the latest instruction from experts in the field while obtaining CME credit from their own desktop. Box 4 summarizes some of the advantages and limitations of online courses. Problem-based e-learning Problem-based learning (PBL) is a cognitive, interactive learning strategy not new to medical education. In fact, PBL is often seen as, if not proven to

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Box 4. Advantages and limitations of online courses Model: Online Courses Description: Any variety of learning formats specifically designed for online delivery and learning Advantages  Applies a teacher-centric model to aid the learner in extracting meaning from the materials  Not just digitized content; technology and creativity are used to enhance the learning experience Limitations  Clinician must leave the clinical encounter to seek information  Early entrants relied on commercial funding Examples  Medscape CME  AcademyU be, an education method that is more effective and more fun than traditional methods [22]. By reviewing problem cases or scenarios as they unfold, students are ‘‘triggered’’ to figure out what they do not know; subsequently, they pursue independent, self directed study before sharing and refining acquired knowledge, often with a peer group or through a test [23]. Thus, like an effective teacher, PBL helps the student to not just solve problems but increase knowledge and understanding. Clinical Otolaryngology Online (COOL), one of the first e-learning initiatives from the AAO-HNSF, uses PBL strategies [24]. In COOL, medical students click through a clinical case study and need to make decisions about solving real-world problems. Students are responsible for seeking more information than is initially presented to them to understand what is occurring or decide what answer to choose. In a similar manner, Harvard CME online offers 30 different ‘‘multimedia-enriched, comprehensive, and interactive’’ courses following a PBL model [25]. One sample case introduces the learner to an agitated 42-yearold woman brought to the emergency room by her roommate, who was concerned not only about the woman’s increasing pain, but also her escalating anxiety about her symptoms, which included fever, flank pain, nausea, vomiting, and palpitations for the previous 24 hours. After reviewing the physical examination and laboratory results, the learner is asked to answer 7 questions about how to manage the patient. Feedback on correct and incorrect answers is provided in real-time. The courses range in cost from $25 to $150 and provide 1 to 6 CME credits, each. Due to its interactive nature and clearly defined learner-centric approach, PBL is seen as a natural fit for e-learning. Yet Internet PBL systems take

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time and work to build. Both of these Internet PBL programs follow a fixed formula for completing the case, which does not quite offer the learner the full benefit of PBL problem-solving. Box 5 summarizes some advantages and limitations of e-learning. Self-assessment and personal development planning (e-portfolios) As mentioned in previous models, learning systems for adults need to engage the learner to track and plot their own course for development. One way the Internet enables this aspect of lifelong learning is through what is often called an ‘‘e-portfolio.’’ An e-portfolio is a secure, Web-based tool in which you can critique, organize, and track professional education and competency milestones [26]. As CME and ongoing maintenance of certification (MOC) efforts evolve, e-portfolio systems will no doubt find use for helping learners transmit required data and competency activity reports to accreditation bodies when needed. The AAO-HNSF’s AcademyU system is built on a platform to specifically support a strong e-portfolio for otolaryngology. Users set up a personal and secure learning portfolio account where they customize their own selfstudy roadmap, test their knowledge through self-assessment tools, and track all of their CME credits, whether taken within the system or from outside activities. With educational content and competency activities stored in these e-portfolios, AcademyU promises to be a career-long resource for Academy members, from which certification and credentialing organizations could receive data. Box 6 summarizes some of the advantages and limitations of self assessments and e-portfolio models.

Box 5. Advantages and limitations of e-learning Model: Problem-based e-learning Description: Mirrors how real-world clinical problems unfold by guiding the learner to solve problems and increase knowledge and understanding Advantages  Interactivity and learner-centric approach make PBL a natural for e-learning  Gives the learning the chance to practice Limitations  Internet PBL systems take time and work to build Examples  AcademyU COOL cases  Harvard CME Online

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Box 6. Advantages and limitations of self assessments and e-portfolio models Model: Self-assessments and e-portfolios Description: A secure web-based tool for a learner to critique, organize, and track professional education and competency milestones Advantages  Highly interactive motivation for learners to make active and informed choices about their learning path  Stores competency and CME data in one convenient location for transmission to regulatory bodies as needed Limitations  Systems do not offer learning per se or measure changes in outcomes Examples  AcademyU

Performance improvement activity tracking As the effectiveness of traditional CME has received scrutiny over the past several years, working groups within organized medicine have explored ways to reform and reposition CME. One of the noteworthy efforts was a Task Force of the Council on Medical Specialty Societies (CMSS) whose ‘‘Conjoint Committee on CME’’ issued a series of recommendations to stimulate system-wide changes for CME [27]. In particular, their report addressed the need for ‘‘Performance and Continuous Improvement’’ as part of the CME process: An evolving CME system should facilitate continuously improved approaches to evaluate CME’s effectiveness. New and existing methodologies should produce documented evidence substantiating physician utilization of acquired knowledge and skill in practice performance measurement and outcomes in patient care. Parallel or complementary systems should be developed to assist CME professionals in the design and delivery of effective CME to achieve these goals [28].

A recent article showcased how three organizations are putting performance-improvement CME into practice, following a three-stage approach [29]. Stage A activities, learning from current practice performance assessment, involve physicians viewing a brief slide presentation, conducting a structured audit of recent patient cases, then completing a questionnaire on attitudes and practice related to the learning program. In stage B, participants completed a more in-depth educational module, complete with

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another slide presentation, scholarly articles, and organizational protocol review; participants also completed an examination and wrote a personal statement about how what they learned would change what they will do in the future. After a period of time elapsed and new patients were treated, physicians completed stage C by completing the structured audit and personal statement processes again. Although most current PI activities are still taking place through traditional channels, access to electronic patient records and 24/7 learning and documentation models will significantly enhance our ability to develop effective PI e-learning programs. Virtual reality and high-fidelity human patient simulation Broadly speaking, virtual reality (VR) is any advanced human–computer interaction designed to let humans interact with computers in computer-generated environments that simulate our physical world [30]. The spectrum of VR applications spans varying levels of realism and user immersion, many of which have been used in nonmedical fields to significantly reduce human error rates. Medicine, and surgical specialty training in particular, now routinely uses VR simulators with overwhelmingly positive subjective and objective outcomes. Additionally, high-fidelity simulatorsdspecifically, ‘‘full-body automated mannequins designed to provide realistic tactile, auditory, and visual stimuli’’dare now being explored at the multidisciplinary level as a way to provide ‘‘flight simulators for doctors [30].’’ As the field of simulation matures, mannequin simulators will no doubt play a supporting role in VR systems as well as dynamic medical or disaster scenarios. A continuum of internet platforms Just as there is a continuum of e-learning models, there are a variety of platforms that make Web-based ‘‘anytime, any place, any pace’’ access to learning content and administration possible. Too often, we describe e-learning by the platform rather than the learning model; yet it is still important to understand the different features offered by the platforms so the technology can support, not control, the learning. Learning content management systems A content management system, referred to as a CMS, is a structured way to store and manage Web content, independent of display format. The ‘‘content’’ in a CMS includes computer files, images, multimedia, audio files, portable electronic documents and any other type of Web content. CMS brought into the mainstream versioning, WYSIWYG (‘‘what you see is what you get’’) authoring, and other tools to open the opportunities to create rich and dynamic Web pages with little programming knowledge.

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A learning content management system, or LCMS, takes content management one step further with needs specifically tailored toward education and adult learning [26]. Content within an LCMS is focused at the learning object. Discrete units of instruction, typically created to answer a single learning objective, are created and stored in a database indexed according to standardized meta-data. When searched and mined, these learning objects can be aggregated into large repositories or reused as building blocks of a longer online course. These discrete units are also ideal kernels of knowledge to support point-of-care or problem-based learning. Learning management systems A learning management system (LMS) is any software package that enables the management and delivery of online content to learners. The focus of the LMS is on the individual learner rather than the educational content. It performs the administrative tasks, but does not have the capability to create course content or store learning objects. A typical LMS lets a learner register for, receive, and be tested on learning activities, all in an online environment. More comprehensive LMSs also include tools to conduct competency management and skills gap analyses, track certifications, and manage resources. One of the most comprehensive lists of open source and commercial LMS software solutions is available on the Web, thanks to Wikipedia’s collaborative volunteers [31]. Standards and open-access frameworks Although LCMS and LMS tools help organizations build, deliver, and manage educational activities, medical e-learning will ultimately succeed when content can be accessed across proprietary websites scattered across a variety of locations and formats, to enable seamless integration with key partners, including professional societies, academic institutions, certifying boards, government agencies, scientific publishers, and pharmaceutical and device companies [32]. Advancing open access and interoperability of systems through standards setting has been the focus of the Advanced Distributed Learning Initiative (ADL). The ADL collaborative created a suite of standards for education called the Shareable Content Object Reference Model (SCORM) [32]. SCORM standards define not only how learning objects are stored and retrieved, but also how content can be moved between systems and how learner progress is tracked. By coding structured data using XML (eXtensible Markup Language) and using Web services to integrate resources and ‘‘feed’’ programs out through a variety of different portals, standardized platforms of the future will be able to support multiple models across the e-learning continuum from a single access point.

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Where are we headed For the past 4 years, the Horizon Project has issued an annual report on the application of emerging technologies on ‘‘teaching, learning, or creative expression within higher education [33].’’ The 2007 report identified and prioritized six trends and six challenges as most likely to have a significant impact on education in the next five years. Two trends and two challenges seem particularly prescient for creating, maintaining, and accessing lifelong medical learning through the Internet: Trend #5: The notions of collective intelligence and mass amateurization are pushing the boundaries of scholarship. Trend #6: Students views of what is and what is not technology are increasingly different from those of faculty. Challenge #4: There is a skills gap between understanding how to use tools for media creation and how to create meaningful content. Challenge #5: The renewed emphasis on collaborative learning is pushing the educational community to develop new forms of interaction and assessment. This final part of the article explores the implications of some of the ‘‘technologies to watch’’ from the 2007 Horizon Report. We hope to stimulate creative thinking for lifelong learning innovation in otolaryngology–head and neck surgery. If these technologies and applications feel strange, refer to Trend #6 above. Ubiquitous computing The concept of ubiquitous computing was shaped in the early 1990s by Mark Weiser, then a chief scientist of Xerox Palo Alto Research Campus, when contemplating how the next wave of computers would be used in actual activities of everyday life. He postulated that the first wave, mainframes shared by several people, led to the second wave of personal computers, with the ‘‘person and machine staring uneasily at each other across the desktop.’’ The next wave would be ‘‘the point at which the technology takes a backseat and the applications have converged into our daily existence.’’ Not at all like science fiction virtual reality, ubiquitous computing would allow the computer to live inside our people-generated world by integrating human qualities with computer science, engineering, and social sciences. For the past decade, we have been living more and more in this third wave of ubiquitous computing. Most specifically, mobile devices supported by cost-effective wireless networks are everywhere; information is accessible anytime and the computations and connections made occur unnoticeably in the background. We merely recognize these ubiquitous machines as our phones, day planners, on-demand TVs, libraries, and juke boxes. We are beginning to see limited evidence on the effectiveness of mobile learning for medical education and training programs in the areas of

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Web-based skill and knowledge assessment, standardized procedural training, worldwide videoconferencing, and global collaboration through multinational databases [34,35]. Take for example the National Institutes of Health Office of High Performance Computing and Communications, who equipped the medical teams at a community hospital with smart phones (mobile phone/personal digital assitant hybrid devices) to provide immediate access to National Library of Medicine evidence-based resources as well as other medical Web sites [36]. The result: a post-study survey showed that the information retrieved was perceived to be useful for patient care and academic activities, showing that evidence-based practice can be a reality. Of course, the impracticality of learning from your current phone is obvious, with its limited screen and keyboard size, download speed, and battery life. However, prototype next-generation mobile phones already anticipate using projection systems, full-size keyboards made of light, and carbon-nanotube technology, making it possible to transfer a movie from your personal computer to your phone in 2 seconds [33,36]. Bob Iannucci, head of the Nokia Research Center in Helsinki, Finland, perhaps characterized the future phone best: ‘‘Just imagine, as a business traveler, being able to open up your phone in a hotel room and have real-time video conferencing with the image projected on the wall and stereo sound. We’re not far.’’ On a different front, ubiquitous computing also promises to radically change the usability of medical technology. Although this article does not explore the world of electronic health records and ubiquitous health care, the authors would be remiss in this section to not refer back at least briefly to the notion that physicians, together with the technologies they use and the patients they treat, are indeed at a tipping point for using the Internet to impact health care. One need only search for ‘‘ubiquitous health care’’ in the knowledge resources stored on the Web site of the Computer Society, whose 100,000 members comprise the largest of the 39 societies of the Institute of Electrical and Electronics Engineers, to be fascinated about the ways that ubiquity is enabling a reality of expedited decision making, improved efficiency, and enriched information exchange [37]. User-created content Web 2.0 is a phrase coined by O’Reilly Media in 2003 to characterize a second generation of Web usage. Although the technology components used are not new, Web 2.0 implies a significant change in how visitors use the Web. Weblogs, wikis, social networking, social bookmarking, podcasts, and RSS feeds (and other forms of many-to-many publishing) are examples of a significant shift toward collaboration and sharing between Web users. There now exists a social phenomenon to generate and distribute Web content openly, decentralized from authority and in a spirit to share and re-use assets previously coveted as intellectual property. Although blogs and wikis are appropriately criticized for inaccuracies and mixing fact

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with opinion, there is little disagreement that, collectively, these amateur scholars have the ability to form the debate on many fronts. All one has to do is conduct a search on Google for ‘‘collective intelligence’’ to see how this universal, timeless phenomenon is speeding up the pace of real research, innovation, and learning. In one example, the University of Southern California recently piloted a campus-wide wiki service, making it easy for faculty and students to not only collectively create and edit knowledge, but also to conduct undergraduate research involving collaboration and coordination across disciplines and institutions [38]. Multimedia content development, in particular, has engaged amateur scholars, hobbyists, and enthusiasts. Whether they have created and submitted podcasts to iTunes or videos to YouTube, the value of these sites as creative outlets is already being transformed into more serious endeavors and learning. According to eMarketer, podcast users are not a homogeneous group and are not exclusively twenty-something tech-savvy consumers [39]. Notably, people between the ages of 35 and 54 make up about half of the podcasting audience, with many of the more popular podcasts being from the educational and business genres. Not all collaboration is about content creation and editing. Folksonomies, which were created by a group of individuals who add and share tags to online items such as images, videos, bookmarks, and text, are emerging as a Web-based distributed classification system. Although the concept of applying meta-data tags to information has been an essential feature of the Web since the beginning, the organic nature of tools like del.icio.us [40], digg [41], and technorati [42] are empowering individual Web users to determine what is important or what appeals to them. Whether folksonomies become a more natural means of searching, sorting, and classifying or merely a fun way to enjoy Web media (see www.liveplasma.com), exploiting the power of meta-data invites others to discover new knowledge and share in a conversation about the content. On a longer-term trajectory, the 2007 Horizon Report recognizes that the same explosion of access and collaboration, which has enhanced the pursuits of academic research and scholarly activity, will challenge that same community’s time-honored traditions of peer review, publication, and tenure. Prepublication releases, dynamic visualization of data through tools like Gapminder, and other new models for nontraditional publication are seen by their proponents as ‘‘serving a different purpose than traditional writing and researchda purpose that improves, rather than runs counter to, other kinds of scholarly works’’ [33]. Ultimately, the greatest challenges ahead for managing user-created content to create accurate and compelling lifelong learning opportunities will not be the development or application of new technologies. Instead, professional education will thrive when e-learning empowers all students to actively construct knowledge and the community works together to decide who is and who should be scholarly.

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