Editor’s Note: This article discusses the rationale for a telehealth web course, using video and web to extend steps to achieve the educational goals, and provides analysis of feedback received from students.

Developing a Web-based Telehealth Course

Ilkka Winblad I, Riitta-Liisa Kortesluoma, Jarmo Reponen

Finland

Abstract

The transfer from a paper-based workflow to an electronic environment in health care has created an increasing need for education in telehealth. Real-time videoconferencing enables education in spite of distance, but it is bound by time and date constrictions that may affect participation. web courses offer teaching any time and anywhere. They necessitate careful consideration and design of topics to be taught, students with the necessary computing skills, receive site with adequate coverage and maturity of technology, and design of interactivity between the students and teachers. Most of our students rated the developed web course better than conventional lectures although some of them mentioned the lower interaction as a drawback. They usually viewed the video recorded lectures of the course for half an hour in each session without break, outside office hours, and at their own convenience.

Keywords: tele-education, web-based course, telehealth, telemedicine, telecommunication, assessment of performance, student self-assessment, e-learning environment, e-learning methods, computing skills.

Introduction

Information exchange and the delivery of health care services are increasingly achieved through telemedicine. In Finland, implementation of telemedicine in health care began in the 1990s. This created a need for formal education and in 1998 the Open University of Oulu started a course in telemedicine for students of health sciences, medical technology, information technology, social work, and for professionals of health care and social welfare (Kortesluoma & Rajaniemi, 1998). The decision was in line with a strategic choice taken in the development of education as the University of Oulu operates in the low populated northern part of Finland distinguished by long distances between populated areas.

In the first year, a course entitled “Introduction to Telemedicine” was offered to 36 students of the Faculty of Medicine. The first realization was almost entirely delivered through conventional contact teaching in Oulu, however, two video-lectures were given by a foreign expert from the UK (Kortesluoma & Rajaniemi 1998). For assessment of their performance, students answered exam questions at home and mailed their responses to the teachers. After correcting and commenting on the answers, teachers mailed them to the Open University, which passed the results to the students.

Attendance at lectures was laborious because the students were from different parts of Finland and separated by distances up to 400 km. To offer better access from remote sites, the following course was delivered by contact teaching and also through real time interactive video conferencing supported by local tutoring and group work. The telecommunication links were 2-3 ISDN lines (each 128 kbits/s) from one and or up to six remote sites.

At this stage, real time videoconferencing with discussions were bound to a certain point of time and date, which constrained the attendance of those who were also working. For the teachers, real-time videoconferencing required the same resources as conventional classroom with technical support for television. Support of distant students required re-assessment of teaching practices and for distance education.

Developing a web-based course

To facilitate course development, the university established in 2005 an e-learning team consisting of experts in medical informatics, clinical medicine and distance learning from the Centre of Excellence for Telehealth, Learning and Research Services and the Department of Information Processing Science.

The team had four questions to answer:

1) Why to develop?    – Analysis of learning needs within the proposed operational environment,

2) What to educate?     – Analysis of the content,

3) Who to educate   – Analysis of potential students and

4) How to educate?     – Analysis of the educational technology and management.

Why to develop? On a strategic level, e-learning has the potential to improve the quality of learning, to facilitate access to learning resources, to address special needs, and to enhance learning in the workplace (European Parliament and the Council, 2003).  On a practical level, the goal is simply to serve the students better by offering them easy access to education regardless of distance and time factors.

What to educate? The widespread use of information and communication technology belongs to strategic choices in the delivery of health services both on an international and national level (WHO, 1998; Craig, 1999). This development has raised an increasing need for education in telemedicine. Although Finland together with the other Scandinavian countries is at the forefront in the use of information technology in the health sector (Hämäläinen et al., 2007), there has been a lack of education in the field of telemedicine.

Opinions on the content of the course “Introduction to Telemedicine” were collected from the teachers and students on earlier courses, and the course was updated in accordance with this data. This led to a new program entitled ‘The Basics of Telehealth’. It now consists of sixteen different modules on telehealth as follows: society, delivery of health services, legislation, human interaction, electronic patient records and data transfer, remote consultations, radiology, surgery, psychiatry, economic assessment, functional assessment, education, technical requirements, data security, and visions for the future. The whole course is worth five ECTS (European Credit Transfer and Accumulation System) credits (about 120 hours of student work). This provides basic, updating, and post-graduate education for physicians, nursing sciences and medical technology.

Who to educate? Being a basic course it was planned to meet the needs of both undergraduate and postgraduate students of health sciences in the university and polytechnics as well as students in higher or continuing education. Marketing research was carried out and many universities and polytechnics with health sciences in their education programs expressed interest in purchasing the course.

How to educate? The target set up was an educational module which would offer: 1) effortless access to the factual content of the course and other educational resources, 2) support interaction between the teachers and students, and 3) facilitate assessment of course activity, evaluation, and course management, regardless of time and distance. The choice was made to tap into a modern mixed learning strategy, the main components being: video streaming files on web sites, asynchronous computer mediated interaction, assessment and evaluation, and course management (Curran et al., 2003). In addition, the module had to be flexible enough to deliver a forum open to all students, and a forum for confidential private communication.

The technical determinants of a web based multimedia educational material necessitate computers, software and broadband connections capable of delivering user friendly and effective materials (Curran et al., 2003; McKimm et al., 2003). Students must have basic computer skills with support and guidance (McKimm et al., 2003; Jennet et al., 2003). In earlier years, there were problems in complying with these prerequisites. This is no longer the case. Currently, every educational institution in Finland has computers and an Internet connection, there are 1.5 million broadband connections in Finland and 84 % of Finns used the Internet in 2006 (http://www.tietoyhteiskuntaohjelma). This implies a high degree of computing skills.

Description of course arrangements

The Basic Telehealth course starts with a short general introduction to the course, followed by video-recordings of the sixteen topics divided into twelve indexed lectures. Nine of the lectures were video-recorded during conventional contact teaching in a lecture hall, and three were recorded in a studio without an audience. In order to facilitate browsing the recordings, each of them was indexed by subheadings giving the duration in minutes. The length of each of the video-recordings was about one hour, and included 3-15 subheadings that varied from 3-30 minutes. The duration of the video-recordings was fifteen hours with the same factual content as 18 hours of conventional contact lectures. All the video-recorded lectures were accompanied by PowerPoint presentations, which were also available for printing beforehand through a separate web address. There were also links to related websites and video clips.

New students were given user names and passwords for the virtual learning environment called Optima, which includes indexed links for learning materials as well as instructions for use. Optima also includes discussion boards, chat rooms, online assessment, tracking students’ use of the web course, and course management. There is also an area where teachers and students introduce themselves to each other with a photograph and short story about her/his background and their expectations for the course.

Students have access to the web site for two months. In the discussion area of Optima, they ask questions and make comments on course-related topics. Discussions are asynchronous to accommodate the family and work responsibilities of students. At the end of the course there is an exam to be answered at home using Optima. In addition, students prepare an essay on one of six topics provided by the teacher. The time provided to complete these tasks is three weeks.

Students return the essay and exam answers in the private area of Optima. The teacher accesses the same area to assess the essays. After returning their answers to exam questions, the students receive optimal answers structured by key words with instructions to assess and score their own work. After receiving the students’ self-assessments, the teacher scores the exams and gives the final grades. Students receive feedback from their performance and may be required to repeat important topics. The course is free for the students in basic or post-graduate education. For those updating their education, the price is 80€ (about 108$). Modules cannot be performed separately.

Evaluating the course

In order to evaluate the course and its methods, the students were asked to respond anonymously on a web questionnaire. Four questions requested their opinions on: 1) the accessibility of the course, 2) the length of the entire web course, 3) the comfortable duration for a single video clip, and time for viewing a video without pause.

Five Likert Scale questions documented the quality of the course (very weak, somewhat weak, can’t say, better, much better). Responses were summarised in a mode that facilitates interpretation. Additionally, there was one open-ended question dealing with the student’s general idea of the course. The qualitative data obtained was analysed by inductive content analysis (Downe-Wamboldt, 1992).

The trustworthiness of the self-assessments of students was also evaluated. This was done by the teacher who rated the answers of the students to the four questions in the exam before checking the scores the students gave to themselves. The scores of the teacher and students were compared using Cronbach’s alpha coefficient of consistency.

Results of the Evaluation

A total of 21 students, six of them women, participated in 2006 in the first web-based course. They were aged from 20 to 49 years, and most of them were Electrical or IT engineers, 2 nurses in updating education, and engineers in medical technology. Sixteen of them lived in the city of Oulu and five elsewhere at a distance of 30-600 km. Anonymous feedback was provided by 12 students.

According to the answers, the median of the optimal length of the duration of the whole course was two months (range 1-4 months). All but one studied the course outside office hours (Mon - Fri 8 am-6 pm). They usually viewed the video-recordings for half an hour without a break (median 30 min, range 5-120 min). When asked to compare this web course to conventional lectures in terms of learning, most of them (8/12) rated the web course as better or much better than conventional lectures. One rated the web course  somewhat weaker and three could not say.

When asked to compare this web course to a conventional course in terms of the interaction between teachers and students, five of them rated the web course as weaker, three as better, and four could not say. In open questions, two students mentioned low interaction as a drawback to the course. One of them wrote: “Interaction depends on yourself just as in a lecture hall, too. You can ask questions through electronic communication and the answer might be even better when given in written form”.

The students gave high marks to the course in general: 4 on the scale of 1 – 5 (median 4, range 3 – 4). They evaluated the technical quality of the lectures video-recorded in the studio without an audience to be better than that of the lectures video-recorded during a conventional lecture in a lecture hall (medians 4 vs. 3). In open questions one of the students pointed out that a lecture video-recorded without an audience is too intensive: “You see only the speaking head and powerpoint slides without any interruption”.

With regard to the exam, each answer to the four questions could be rated from 0 – 6, the sum of total scores being 24. The mean of the total scores given by the students was 16.1 (on a range of 10 – 21), and the mean assessed by the teacher was 17.3 (on a range of 11-21). Four students scored their own performance higher and nine of them lower than the teacher and in four cases the scores were congruent. The consistency of the scores between the students and the teachers was by Cronbach’s alpha 0.584, i.e. quite low.

Discussion

The education of telemedicine in the University of Oulu started as conventional lecture hall education. The need arose to integrate the principles of “medicine at a distance” into the delivery of education. In the second year, the education was available both in conventional form and in real time videoconferencing. This improved access to education, especially for those who participated in further education while they worked, and for those who experienced difficulties finding a suitable time slot for learning. The web course removed the obstacles of time and distance for them. Almost all of the respondents answered that they viewed the videos out of office hours. This reflects the high motivation and mature attitude toward education that is typical of adult learners (Newman & Peile, 2002). Web courses also free up teacher resources and technical support for other tasks.

A web course necessitates more organized management of education than the traditional collection of lectures given by experts in different special fields. In this case, the Centre of Excellence for Telehealth in the University of Oulu (FinnTelemedicum), established in 2003, took over the realization of the course in 2005. It was decided that a person should be appointed to take charge of the program to implement a multidisciplinary course in an integrated manner and to ensure seamless collaboration with other units of the Educational Institute.

The study sample was small, yet the case feedback confirms the need for continual assessment so as to enhance further development. In terms of learning, most of the students rated the web course higher than conventional lectures. This is in line with the results of Lemaire and Green (2003) in which nursing-related health care workers found web-based education better than conventional classroom lectures without multimedia content. However, in that study, the CD-ROM education module, desktop conferencing and in-person lectures with multimedia content had higher overall ratings than web-based education. When comparing educational software modules to conventional lectures, it must be borne in mind that it is not only a matter of a change in the delivery medium, but also a change in the educational method (Johnson et. al. 2003).

Moreover, the aspects of web-based learning appreciated by learners are accessibility, convenience and ease of use (Curran et al., 2003; McKimm et al., 2003). In order to avoid measuring only superficial learning, a possible disadvantage in computer based education (McKimm et al., 2003),  the essay and exam questions were planned so that the students have to use analysis and synthesis of the learning material in their answers. The online assessment of performance is quick and convenient for students from remote sites (McKimm et al., 2003). When students compare their own answers to test answers, they complete their knowledge and have personal feedback on their performance. This method may partially compensate for face-to-face discussions between a learner and a teacher and thereby bring more interactive elements into the web course. The self-assessment saves time for teachers because it is faster to check students’ self-assessments than to produce separate feedback on numerous points of the exam answers. It seems, however, that student self-assessments cannot substitute for those of the teachers.

Many students considered the low interaction between teachers and students as a drawback in the web course. This raises a need to develop new pedagogical tools, because lively interaction supports learning. An effective web course is based on the idea of collaborative learning targeted to construct an understanding of the topic by mutual interaction (Dillenbourg, 2002; Crook, 2000).  It activates effective mechanisms for learning such as asking and stating, arguing and giving feedback, sharing dimensions of expertise and models for thinking, and synergy. Shared expertise means that students enhance their own understanding when they have to explain issues to others. An asynchronous discussion forum in the virtual learning environment is in the planning stages.

It is a general phenomenon anywhere that experienced professionals, not only in health care, but also in different disciplines and lines of business will undertake further education for their professional portfolio (Newman & Peile, 2002; Hutchinson et al., 2002). A cumulative number of students have undertaken the present course, including experts in technology, information technology, management studies and economics. They have produced qualified and up to date essays with multidisciplinary points of view. This is fruitful for education in this rapidly changing environment. Student skills and knowledge also enrich the know-how of the teachers. The best essays will be stored, with the authors’ permission, in an electronic database to supplement recommended literature for the course. This can be further expanded as a way of working known as “web-weaving” (Tremaine & Mackay, 1999), where students and teachers collaboratively produce materials and lists of references during the course study.

Conclusions

The aim of telehealth is not only to be a channel to deliver education and services, but also to provide an alternative to traditional education. A combination of a mature technical environment, computing literacy, modern pedagogic tools and pioneering spirit support education resulting in better health care services for the future.

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About the authors:

Ilkka Winblad MD, PhD, Docent, Medical Counsellor and Director of FinnTelemedicum, the Centre of Excellence for Telehealth in the University of Oulu, Finland. He is also a specialist in general practice. He has published among others about eHealth development.

E-mail: ilkka.winblad@oulu.fi

Riitta-Liisa Kortesluoma is a registered clinical laboratory scientist (CLS) and a licentiate in nursing science. She has a long background in clinical laboratory work and as a nurse educator. She works currently as a project manager in a schooling project funded by European Social Fund and aiming at training information technology engineers as engineers with a university degree in medical technology at the University of Oulu.

E-mail: riitta-liisa.kortesluoma@oulu.fi

Jarmo Reponen MD is a specialist in diagnostic radiology. He has more than 17 years experience in telemedicine and eHealth development and implementation. He has published about electronic patient record (EPR) and picture archiving and communication systems (PACS). He is research manager at FinnTelemedicum, University of Oulu, Finland.

Email: jarmo.reponen@oulu.fi

Correspondence:

Ilkka Winblad
E-mail: ilkka.winblad@oulu.fi
Ph: +358408671400
Address: c/o KTTYL, POB 5000, FIN-90014 University of Oulu