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1 From the Department of Radiology, University of Palermo, Palermo, Italy (G.S., F.C., G.C., R.L.); and the Departments of Pediatrics (D.M.D.) and Radiology (M.P.D.), University of Iowa Hospitals and Clinics, 2617 JCP, 100 Hawkins Dr, Iowa City, IA 52242. Preliminary work on an e-learning environment was presented as an infoRAD exhibit at the 2004 RSNA Annual Meeting. Received April 24, 2006; revision requested July 27 and received September 15; accepted October 18. G.S. owns and operates NeuroRAD; D.M.D. and M.P.D. own and operate PediatricEducation.org; all remaining authors have no financial relationships to disclose. Address correspondence to D.M.D. (e-mail: donna-dalessandro{at}uiowa.edu).
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Abstract |
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© RSNA, 2007
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Introduction |
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The computer software features of an LMS usually encompass student registration, the delivery and tracking of e-learning multimedia courses and content, communications and interactions between students and teachers, and testing. An LMS has traditionally been implemented across an entire enterprise, most classically a university or corporation, and is most commonly associated with the commercial systems from Blackboard (Washington, DC) (http://www.blackboard.com/) and WebCT (Lynnfield, Mass) (http://www.webct.com/). Unfortunately, these commercial enterprise-wide LMSs are expensive to license and require high-end computer servers and a team of computer specialists to function properly. Recently, for several reasons, there has been a growing dissatisfaction in universities with these LMSs (5,6). First, these systems are increasingly perceived as being too expensive to license. Second, in trying to be all things to all users, they are often too feature laden and thus cause confusion for educators and their students. Third, users often feel that the vendors are unresponsive to suggestions for changes and improvements.
Therefore, open-source enterprise-wide LMSs have been developed by several universities, such as the Sakai (University of Michigan, Ann Arbor, Mich) (http://www.sakaiproject.org/) and .LRN (Massachusetts Institute of Technology, Cambridge, Mass) (http://www.dotlrn.org/) projects. The goal of these projects is to make available open-source enterprise-wide LMSs that are assembled from compatible and interchangeable software building blocks contributed by various universities. These open-source enterprise-wide LMSs cost nothing to license, are expansive yet customizable in their capabilities and functions, and are modifiable to allow the implementation of improvements suggested by users. Like the commercial enterprise-wide LMSs described earlier, however, they require high-end computer servers and a team of computer specialists.
Running along a parallel track has been the development by educators of commercial and open-source LMSs that focus, not on the needs of the enterprise, but on those of individual instructors and their courses, thus garnering these LMSs the sobriquet of educator-centric LMSs. These educator-centric LMSs cost little or nothing to license and, like commercial enterprise-wide LMSs, are expansive yet customizable and are modifiable. In addition, they require only low-end computer servers or personal computers and can be administered by a single computer-literate individual. Persons who are not computer literate can effectively rent access to these educator-centric LMSs from a World Wide Web hosting provider, who administrates the LMS at a cost of $15–$50 per month depending on the services required, thereby effectively renting a computer specialist to run the LMS.
In this article, we describe a formative evaluation of the use of two different educator-centric LMSs, one in neuroradiology and one in pediatric radiology, and explore the implications for the future use of LMSs in graduate medical education and continuing medical education in radiology.
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Materials and Methods |
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Moodle is built on the open-source Linux-Apache-MySQL-PHP (LAMP) platform. Its content is organized with use of the MySQL database (MySQL AB, Uppsala, Sweden) (http://www.mysql.com/) and published with the Apache Web server (Apache Software Foundation, Forest Hill, Md) (http://www.apache.org/) with the PHP scripting language engine (The PHP Group, Shaftsberry, Conn) (http://www.php.net/). Moodle initially ran on the Linux operating system (Linus Torvalds, Santa Clara, Calif) (http://www.linux.org/) but now can also be run on the Windows (Microsoft, Redmond, Wash) (http://www.microsoft.com/) and Macintosh (Apple Computer, Cupertino, Calif) (http://www.apple.com/) operating systems. It is a multilingual platform with over 50 languages available.
Moodle is provided freely as open-source software (Open Source Initiative, San Francisco, Calif) (http://www.opensource.org/), which means that individuals and institutions are free to download it, use it, modify it, and even distribute it under the GNU General Public License. Alternatively, individuals can forgo installation and maintain the software by renting access to it from a Moodle Web hosting provider, who will provide access to a Web site running Moodle starting at $99/y (Moodle.com, East Perth, Australia) (http://www.moodle.com/).
Moodle is used to implement NeuroRAD (http://www.neurorad.unipa.it/), a digital library and learning community of online neuroradiology courses, lectures, and educational resources (Fig 1). The goal of NeuroRAD is to build a neuroradiology virtual learning community. NeuroRAD is written for and intended primarily for use by radiology residents, fellows, or attending physicians. Participation in NeuroRAD is open to anyone, and registration is required only to participate in the online courses. The educational content on NeuroRAD is created by two neuroradiologists who review each other’s work for accuracy. At this time, users may not receive formal credit for studying the material.
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PediatricEducation.org and Manila
Manila (UserLand Software, Danville, Calif) (http://manila.userland.com/) is a commercial educator-centric LMS that consists of an object-oriented database to manage the LMS at its core, surrounded by a content management system that includes editorial work flow to support publishing in the LMS. Manila also (a) provides an integrated discussion system and mailing lists to support collaborative work between students and instructors, and (b) supports Really Simple Syndication to facilitate student and instructor notification of new information (content or discussions) being added to the LMS.
Manila runs on the Microsoft Windows and Macintosh operating systems. Institutional licenses are available for $1099/y for corporations and $499/y for academic institutions. Alternatively, individuals can forgo installation and maintain the software by renting access from a Manila Web hosting provider for between $189/y (Weblogger, Bakersfield, Calif) (http://www.weblogger.com/) and $299/y (UserLand Software) (http://www.userland.com/).
Manila is used to implement PediatricEducation.org (http://www.pediatriceducation.org/), a pediatric digital library and learning community that is intended to serve as a source of continuing education in pediatrics (Fig 2). The educational content on PediatricEducation.org is created by a general pediatrician and a pediatric radiologist who review each other’s work for accuracy. As with NeuroRAD, users may not yet receive formal credit for studying the material.
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PediatricEducation.org is written for and intended primarily for use by residents, fellows, or attending physicians practicing pediatrics. Medical students beginning their study of pediatrics or other healthcare providers practicing pediatrics may also find it useful. Within the larger pediatrics learning community is a smaller pediatric radiology learning community.
Participation in PediatricEducation.org is open to anyone, and registration is not required for participation. Individuals who wish to register for the learning community receive regular e-mails informing them of the addition of new content and features to the site.
A quantitative and qualitative formative evaluation was performed from January 1 through December 31, 2005. For the quantitative analysis, two Web server log file statistical analysis programs (Site Meter, Washington, DC [http://www.sitemeter.com/]; Google Analytics, Mountain View, Calif [http://www.google.com/analytics/]) were used, and the results were analyzed for descriptive statistics (eg, frequencies, mean scores, etc). For the qualitative analysis, user-submitted comment forms were analyzed for common themes.
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Results and Experience |
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Web server log file statistical analysis showed that, in 2005, NeuroRAD was used by 9959 visitors, who read 98,495 pages of information. On average, the visitors read nine pages and spent 5 minutes 32 seconds on the site per visit. The five countries from which the most visitors came were Italy (52%), the United States (8%), Brazil (0.25%), Mexico (0.14%), and Switzerland (0.12%). Peak usage of the site occurred between 1200 and 1700 hours Coordinated Universal Time.
Qualitative analysis of 60 user-submitted comment forms submitted in 2005 showed that the visitors represented the spectrum of learners from medical students to residents to healthcare providers (ie, radiology technologists, physicians) to professors in the domains of general radiology, pediatric radiology, thoracic radiology, and neuroradiology as well as neurology and neurosurgery. The visitors used the site as a reference source to help them prepare for lectures, conferences, and informal teaching sessions, and as a self-directed learning tool to help them stay up-to-date and prepare for examinations.
In 2005, 152 individuals formally joined the learning community to participate in the online courses. Eighty-three of these individuals completed the online courses and took the associated online tests. Forty-five questions were asked by 29 individuals in the learning community during the year. The largest number of questions (n = 20) related to the neuroradiology content being presented in NeuroRAD, followed by reprint requests for images (n = 10) and requests for a clinical consultation on a case in which the individual was involved and that was similar to a case seen online (n = 3). The remaining questions (n = 12) were technical in nature and related to the appearance, underlying software architecture, and operation of NeuroRAD.
PediatricEducation.org and Manila
Currently, a new pediatrics case is being added to PediatricEducation.org each week, with over 100 cases now available. Each month, one of the new cases added to PediatricEducation.org is a pediatric radiology case. There are currently over 20 pediatric radiology cases at PediatricEducation.org (http://www.pediatriceducation.org/casesbyspecialty##RadiologyNuclearMedicineRadiationOncology).
Web server log file statistical analysis showed that, in 2005, PediatricEducation.org was used by 91,000 visitors, who read 186,000 pages of information. On average, the visitors read 2.1 pages and spent 1 minute 35 seconds on the site per visit, with approximately 9% of the visitors accessing the site multiple times. The five countries from which the most visitors came were the United States (54%), United Arab Emirates (4%), Saudi Arabia (4%), India (3%), and Canada (3%). The five languages most commonly spoken by visitors were English (69%), Arabic (8%), French (7%), Italian (4%), and Chinese (3%). Peak usage of the site occurred between 1500 and 2200 hours Coordinated Universal Time. The content accessed spanned the spectrum of pediatric age groups, specialties, clinical presentations, and diseases.
Qualitative analysis of 100 user-submitted comment forms submitted in 2005 showed that the visitors represented the spectrum of learners from students to residents and fellows to pediatric healthcare providers (ie, nurses, nurse practitioners, physicians) to professors in the domains of emergency medicine, family medicine, pathology, and pediatrics as well as radiology. The visitors used the site as a reference source to answer clinical questions and to help prepare for lectures, conferences, and informal teaching sessions, and as a self-directed learning tool to help them stay up-to-date and prepare for examinations.
Over 475 individuals have formally joined the learning community and receive regular e-mail bulletins advising them of the addition of new content and features to the site.
In 2005, Manila’s integrated discussion system was not used due to a software bug that made the system vulnerable to being overwhelmed by inappropriate comments from commercial "spammers," or companies that post inappropriate advertising messages in online discussions. Instead, the learning community was implemented using comment forms that visitors could fill out with their questions, with the answers being posted back by the curators of PediatricEducation.org to a Web page (http://www.pediatriceducation.org/learningcollaboratory). Two questions were asked by individuals in the learning community during the year.
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Discussion |
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Acquiring and maintaining competency in radiology is a lifelong task that requires continuous learning. Learning communities that use e-learning, such as NeuroRAD and PediatricEducation .org, are examples of ways in which continuous learning can take place either during the course of or after one’s daily clinical work. Previous studies have shown the usefulness of providing residents with an online thoracic radiology curriculum on an intranet (9) and an online pediatric radiology curriculum on the Internet (10). However, neither of these studies provided the collaboration tools necessary for the creation of a learning community, and the online pediatric radiology curriculum was implemented using a commercial enterprise–wide LMS. Today, there are many software technologies that can be used to implement e-learning and learning communities, and each of these technologies has unique strengths. A conventional educational Web site features authoritative content, sometimes integrated with online testing, and functions similar to a traditional reference textbook in that it is centrally organized and does not encourage collaborative dialogue between the site’s few authors and its users. A Wiki is a type of Web site that allows users to easily edit and change its content, and thus features the collaborative creation of content by multiple (even thousands) of authors, which content may or may not be authoritative due to its decentralized organizational structure. A blog is a type of Web site on which content entries are made by a single author in reverse chronologic order, and features the views of a single individual on any subject, thus functioning as a decentrally organized, online personal journal. Discussion forums are Web sites with a decentralized organizational structure that feature discussions on any given topic in which all users participate as equals in the collaborative exchange of ideas. Educator-centric LMSs can be thought of as a superset of these e-learning software technologies and can blend the best of each technology into a whole that is greater than the sum of its parts. In so doing, they offer a balance between centrally organized educational content (often integrated with online testing) and decentralized collaborative software—most commonly, discussion forums, but more recently Wikis and blogs as well.
NeuroRAD and PediatricEducation.org represent a first step in demonstrating that radiology learning communities can be implemented with educator-centric LMSs relatively easily and at low cost, by radiologists with minimal computer expertise, and can find receptive and appreciative audiences. These lessons learned are generalizable to any radiology subspecialty.
NeuroRAD and PediatricEducation.org are similar in several ways. Their learning communities are open to all. Both are regularly updated with new educational content—NeuroRAD on a quarterly basis and PediatricEducation.org on a weekly basis—which encourages users to return regularly and to develop a brand loyalty for each site. Finally, both sites encourage conversation and collaboration between and among the site’s users and curators. Interestingly, this final point is what most distinguishes NeuroRAD and PediatricEducation.org from conventional educational Web sites, which function more like reference textbooks featuring one-way dialogue between the site’s authors and its users, with whom the authors do not wish to converse or collaborate.
NeuroRAD and PediatricEducation.org also differ in several ways. NeuroRAD concentrates mainly on lecture-based learning, whereas PediatricEducation.org concentrates mainly on case-based learning. The strong points of Moodle (NeuroRAD LMS) are the features that support student registration, delivery and tracking of e-learning multimedia courses and content, and testing, leading to a focus on and success with delivering online courses. On the other hand, the strong points of Manila (PediatricEducation.org LMS) are the features that support communication and interaction between students and teachers, leading to a focus on and success with maintaining a learning community. In particular, PediatricEducation.org, with over 475 registered members and with 9% of all visitors visiting the site regularly, is taking significant strides toward becoming a vibrant learning community. These repeat visitors, who view the weekly case and lesson in pediatrics and then interact with other individuals, are what differentiates the learning community from a conventional educational Web site.
e-learning differs from traditional face-to-face learning in many respects. The biggest difference between a traditional course and an e-learning course lies in when and where students participate. Whereas a regular classroom exists in real physical space, the e-learning classroom is in cyberspace and can be accessed using a computer anywhere in the world. The capability of e-learning to bridge physical space allows the creation of learning communities that can contain members from individual radiology departments, an entire country, or the entire globe. This capability to create internationally populated learning communities, whose users have broad experience in and perspectives on radiology practice, is a powerful feature of e-learning.
The benefits of e-learning over traditional classroom learning include (a) the ability to learn at any time from any location without having to travel or spend time away from work; (b) an individualized and self-paced approach that allows learners to skip information they already know and move on to less familiar issues; (c) the capacity to be easily and quickly updated; and (d) a multimedia approach, which supports individual learning styles and may lead to increased retention and a stronger grasp of the subject material (11).
The biggest limitation of e-learning is that it requires a certain level of digital fluency on the part of both instructors and students (12). However, with the Internet insinuating itself into individuals’ everyday lives, and with the increasing penetration of picture archiving and communication systems into radiology practices, more and more radiologists are acquiring high levels of digital fluency. Most of today’s medical students and radiology residents, who have never known a world without personal computers, the Internet, video games, and cellular telephones, are already digitally fluent.
An additional limitation of e-learning is that online learners may often be seen but not heard; that is, they read the online information but actively participate less often in the online learning communities, as was seen in our two examples. This lack of participation is disappointing but not altogether surprising. Learning communities face a number of technical, social, and behavioral barriers, including insufficient maturity of current e-learning software, low familiarity and literacy with e-learning software among potential users, and a lack of incentives and rewards for user participation and interaction (13). In our case, another reason for this lack of learner participation in the learning communities may be that our online courses were not being offered for formal credit. Ultimately, as medical schools begin to embrace faculty educational efforts as documented in teaching portfolios as part of the promotion and tenure process, faculty may begin to receive credit for creating content and participating in learning communities (14).
Future directions for the two radiology learning communities described in this article include expansion of content, increased publicity to encourage more participation, and summative evaluations of the two e-learning platforms.
Readers who are interested in participating in and experimenting with a radiology subspecialty learning community are encouraged to try either NeuroRAD (http://www.neurorad.unipa.it/) or PediatricEducation.org (http://www.pediatriceducation.org) to familiarize themselves with some of the issues discussed in this article. Alternatively, general radiologists who are interested in a general radiology learning community rather than a subspecialty community may consider trying the Case-In-Point Web site from the American College of Radiology in Reston, Virginia (http://caseinpoint.acr.org/). Academic radiologists who are interested in creating their own radiology learning community for their department or sub-specialty may consider trying myRadMoodle (15) (Harvard Medical School, Boston, Mass) (http://www.myradmoodle.org/), a specially modified version of Moodle that is designed to facilitate the creation of radiology learning communities.
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Future Trends |
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TopAbstractIntroductionMaterials and MethodsResults and ExperienceDiscussionFuture TrendsConclusionsTAKE-HOME POINTSReferences |
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Conclusions |
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TopAbstractIntroductionMaterials and MethodsResults and ExperienceDiscussionFuture TrendsConclusionsTAKE-HOME POINTSReferences |
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Clearly, online radiology learning communities, by reducing the obstacles of time and distance and thereby facilitating learning anytime and anywhere, could have a significant role in providing e-learning globally to radiologists throughout their careers.
National and international professional radiologic societies, with their organization, resources, reputation, and ability to award continuing medical education credit, are the logical organizers of such radiology learning communities. The Internet and e-learning offer these societies a wonderful opportunity to provide this educational leadership internationally.
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TAKE-HOME POINTS |
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TopAbstractIntroductionMaterials and MethodsResults and ExperienceDiscussionFuture TrendsConclusionsTAKE-HOME POINTSReferences |
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Acquiring and maintaining competency in radiology is a lifelong task that requires continuous learning. NeuroRAD and PediatricEducation.org represent a first step in demonstrating that radiology learning communities can be implemented with educator-centric LMSs relatively easily and at low cost, by radiologists with minimal computer expertise, and can find receptive and appreciative audiences. Learning communities face a number of technical, social, and behavioral barriers, including insufficient maturity of current e-learning software, low familiarity and literacy with e-learning software among potential users, and a lack of incentives and rewards for user participation and interaction. Clearly, online radiology learning communities, by reducing the obstacles of time and distance and thereby facilitating learning anytime and anywhere, could have a significant role in providing e-learning globally to radiologists throughout their careers. National and international professional radiologic societies, with their organization, resources, reputation, and ability to award continuing medical education credit, are the logical organizers of such radiology learning communities.
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Acknowledgments |
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Footnotes |
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Abbreviations: ACGME = Accreditation Council for Graduate Medical Education, LMS = learning management system
See also the article by Rowell et al (pp 563–571) and the editorial by Flanders (pp 559–561) in this issue.
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