Abstract

This proposal seeks funding from IHETS to develop a course in Clinical Infectious Diseases using a Web-based teaching/learning environment called Oncourse developed by the WebLab at IUPUI. The content of the proposed course is currently offered as a series of scheduled case discussions and lectures that cover important topics in infectious diseases. These sessions take place in the hospital while students and residents care for patients with infections. Although the proposed course is designed for immediate use by medical students, residents and fellows enrolled in the Clinical Infectious Disease rotation, the project’s eventual goal is to extend the course to practicing physicians as continuing medical education via the Internet. The application could be adapted to allied health professions as well. Thus, the proposed course is aimed at the second award track for workforce development which may be extended specifically to continuing medical education for Indiana physicians in the near future.

Narrative

Rationale: Infectious diseases remain among the most common of medical illnesses. They are also among the most deadly, treatable, preventable and expensive. Last year (1997) in Indiana alone there were more than 6000cases of gonorrhea, roughly 10,000 cases of chlamydia, and 1000 new cases of AIDS. In addition to well known infectious diseases such as tuberculosis, new pathogens emerge every year. The pace at which infections emerge or reemerge makes it difficult for practitioners to stay current, particularly for those seeing patients in the primary care settings. Infectious Disease consultation is often impossible since there are less than 75 Infectious disease physicians in Indiana, approximately 40 of them in Indianapolis.

Our elective in Infectious Diseases aims to teach not only a sound foundation of medical facts and an understanding of the nature of different categories of pathogens, but also where to get new information and how to use it to solve problems including the diagnosis of diseases caused by microorganisms whose identity may not yet be known.

Course Description: Clinical Infectious Diseases is a month long elective course offered to medical students in the fourth (last) year of medical school, and to medical residents (in post-graduate training). Fellows participate repeatedly in the course as a requirement of their specialty training in infectious diseases. Thus the course is comprised of learners with different levels of expertise who make up a consultation team or "service" headed by a faculty member. The consultation service spends the majority of their time seeing actual patients with infections and giving recommendations for their care.

The curriculum has three components: clinical abilities, a knowledge base and problem solving skills. Clinical abilities are developed at the bedside and include refinement of skills in history taking, the physical examination and interpretation of test results relevant to infectious diseases. In addition to extemporaneous bedside teaching and independent study, the second and third components are taught by members of the Infectious Disease faculty twice a week at "curriculum sessions" i.e. hourly lectures or case discussions. The topics for these sessions were determined by a past "needs" survey of Indiana physicians and learner feedback and include: beta-lactam and non-beta lactam antibiotics, central nervous system infections, pneumonia, endocarditis, diabetic foot infections, fever of unknown origin, sexually transmitted diseases and tuberculosis. According to course evaluations, these sessions are very successful; students "like them".

Nevertheless, the course proposed here is a series of computer-assisted instruction (CAI) sessions aimed at replacing the current curriculum session format.

Need:

There are several problems with the current format.

1. Sessions are time consuming for faculty who have simultaneous responsibilities in patient care, laboratory research, community outreach and/or administration.
2. The number of students taught per session is small, from 2 to 6.
3. Housestaff and students often miss curriculum sessions because of unavoidable conflicts, such as clinical admissions or emergency room responsibilities.
4. Sessions occur at a time that frequently interferes with "rounds" (the bedside teaching and decision making time)
5. An individual faculty member must spontaneously assess the level of expertise of individual learners and redirect their teaching in response to those different (often not apparent) levels
6. Every month a secretary needs to schedule faculty who have conflicts that are sometimes unresolvable.
7. Every month a secretary needs to have the printed materials reproduced for each student at a cost of $1200/year.
8. For a learner to access the written content of a curriculum session, he/she must have the material with him/her, an event unlikely to occur at the times it is most needed such as at night during a clinical evaluation of an acute problem.
9. Mastery depends on learner memory.
10. Given the different levels of learners, the diversity of faculty and session content, there is no way of objectively evaluating the content.
11. There is no record kept of learner participation or performance and doing so would take considerable ongoing faculty effort. Grading of learners for the course is subjective and doesn’t include participation in curriculum sessions or demonstrated mastery of curriculum content.
12. Systematic updating of printed materials occurs sporadically if at all.
13. Utilization of the sessions is limited to individuals in medical school or residency taking the infectious disease elective. There is no current mechanism to offer these materials to practicing physicians.

For these reasons we propose to take the existing materials and use them to create an Internet-accessible course called Topics in Infectious Diseases. The advantages of an online course are that

1. Faculty and students may participate when they are available, that is, asynchronously;
2. Learners with different levels of expertise may proceed through the material at their own pace;
3. Learner participation may be monitored and
4. The effectiveness of each unit in teaching material can be assessed by looking at pooled or segmented (by status or time spent) quiz scores
5. Content can be systematically evaluated and updated
6. Problem solving skills be assessed using interactive case presentations
7. Scheduling faculty can be eliminated
8. Xerox costs can be minimized
9. The use of such a course in teaching medical information can be tested and used to develop an effective model for continuing education.

Technology to be used: The course will use a software system called Oncourse that is being developed by educators and engineers at the WebLab group on the Indiana University/Purdue University at Indianapolis (IUPUI) campus, a part of the Indiana University Advanced Information Technology Laboratory. Oncourse is a Web-based teaching/learning environment where a web site for every course offered at the University may be created using an automated method. This semester (Fall of 1998) a campus wide experiment is taking place at IUPUI as instructors from departments as diverse as Music, English, Chemistry, Engineering and Mathematics offer their courses supplemented by Oncourse.

Once a course offering is entered into the University Registrar database, the teaching faculty and students registered for the course will be able to automatically access the course web site from anywhere via the Internet by entering their University Network ID.

To use, edit, or maintain materials in the Oncourse environment, it is not necessary to have experience with HTML (the hypertext markup language used in Internet communication). When instructors log on to the web sites for their classes, they are automatically entered into the authoring environment where they may add, edit and update the content of each course web site. Each course site includes an up-to-date class roster including the names all registered students as well as photos if they choose. The use of multimedia course content and collaborative tools supports teaching and learning. Students and faculty within a course can communicate daily using interactive forums and chat rooms. Coursework may be electronically submitted and the tasks of class management including the assessment and submission of grades to the registrar simplified.

Oncourse derives much of its power because the environment it offers is driven by ‘forms’ that enter highly structured pieces of information into a database while maintaining the option of Web authoring techniques. Its database foundation greatly facilitates the rapid creation of a course that runs relatively error free and has relatively easy maintainability. This latter aspect is particularly attractive because of the fast pace of changes in the field of Infectious Diseases noted in the introduction.

Instructional design plan:

Analysis: The targeted learning audience is medical students in their third or fourth years and medical residents in their first through third years of post graduate medical training. The goals for the course are for learners recognize and treat important infectious disease syndromes, that is, constellations of clinical findings, based on symptoms, physical findings and laboratory and radiologic data. To do this learners need to know the epidemiology, pathophysiology and natural history of each syndrome, its microbiologic causes, the characteristic tests that will most efficiently yield a diagnosis as early as possible in the course of disease, its recommended treatment regimens and its complications. They must acquire and improve skills in physical diagnosis and problem solving, Lastly, they must understand the financial, social and psychological impact of the disease on the patient, their family and their community. The proposed course will provide information about each of these areas of knowledge and skills.

Design: All design will be reviewed with MERP educational consultant, Kevin Nolley.

The proposed program will be a Web-based course using the Oncourse format (See Appendix). Using Oncourse will allow existing teaching materials to be entered into the database with relative ease and will provide a working version of Topics in Infectious Diseases. This working version can then act as the foundation for a program that can be progressively expanded to incorporate new information and enriched with media assets over time. Furthermore, this working version can incorporate user suggestions during development. The ultimate goal is to produce a CAI product that is superior to its face-to-face counterpart in teaching Topics in Infectious Diseases by taking advantage of the unique aspects of interactive computer based educational software.

After logging into Oncourse (See Appendix for screenshots) and viewing course announcements (not shown) the user will see a screen with his/her name on it and seven blue buttons across the middle entitled Syllabus, Schedule, Class, In Touch, Tools, Help and Logout . Clicking each of these buttons will open a separate section of the course.

In the Syllabus, the course is introduced, its overall goals given and critical information regarding the course given. This information will include some explanation of the course as set up on Oncourse. It will also outline expectations and "grading" guidelines.

When the Schedule button is activated, a page with the list of topics will appear. For each topic, a date will be given for its expected completion. The list will duplicate the topics included in the current "face-to-face" version, that is nine topics including central nervous system infections, pneumonia, endocarditis, diabetic foot infections, fever of unknown origin, sexually transmitted diseases, tuberculosis, b-lactam and non- b-lactam antibiotics. Selection of the topic will bring the user to a topic "Home Page". The topic "Home Page" will provide a menu which contains a list of three items derived from written materials available in the face-to-face format. Currently, the written materials for each topic in the face-to -face format include:

1. articulated goals for the topic,
2. a review of the topic written by the faculty member and/or several original papers from the medical literature discussing the topic and
3. questions and cases about the topic testing the learners’ mastery of the information.

First, to produce the initial working version of the course, each of these items will be entered into Oncourse "as is". From a teaching standpoint, there are several desirable alterations that would improve the presentation of information. These changes, such as dividing each topic into lessons (such as those used in Learning about Infective Endocarditis") and enhancing #3’s questions and cases with segments that enable more sophisticated interactive exploration will follow entry of what currently exists for each topic. Careful consideration will be given to incorporating methods of learner guidance.

The major reason for using existing written materials is that reviews written by faculty members exist for only four of these topics. Developing an up-to-date state-of-the-art review takes 40-80 hours of faculty time. Since each medical faculty member is responsible for bringing in their own salary by their work, no time can be allotted for unfunded activities. At a rate of $40/hr, a rough estimate of the Medicare reimbursement rate, each unit would cost $1600-$3200 to write for a total added cost of $8000-16,000 for new reviews alone not including reorganization and updating of existing ones. Such revisions will require funding outside the scope of this application.

Second, graphics, photographic images, videos, audio clips and animations to supplement textual material will be collected. It is anticipated that most of these already exist since faculty members periodically present information from their topic at large conferences such as Grand Rounds or nontime Residents’ Conferences. Each media asset will be linked to a clickable button either in the form of a thumbnail version of the asset or as highlighted text. Media assets will be updated and enriched over time.

Third, copyright-protected original research and review articles will be made available online, again using clickable text, or "hotwords" to execute the link.

Fourth, existing quizzes and case studies will be set online as non-interactive text. In this format quizzes will allow drill and practice reinforcement of learning while cases provide simulations. Built in utilities for grading online activities and course management are being further developed in Oncourse and will be incorporated as they become available.

Lastly, a questionnaire asking the learner to evaluate the program will be designed. It is likely to be similar to one used previously in Learning about Infective Endocarditis which asked the user to rate the program using a five point scale for each of 20 aspects of the application. An open comment section will also be provided.

Other Buttons: The Class buttion will show a class roster complete with pictures of class members. The In Touch button will allow class members to communicate with fellow students and faculty members using forums and chat rooms based on course content and to post relevant materials. The Tools button allows faculty and students to use Library References, Databases and other Resources available through the Internet. The Logout button allow the user to enter another course or exit the one he/she is using.

Development: Once goals, textual materials, quizzes and cases have been collected and reviewd, they will be entered into Oncourse by a part-time technical assistant. The skills required for the technical assistant include facility with both PC and Mac use, html, FTP, basic Web design, media formats viewable on the Internet, and basic Microsoft programs such Word, Excel, and Powerpoint. Textual material will be saved as html files and edited to include buttons for media assets.

Implementation: The course will be offered in September of 1999. First the course will be offered at the times it has been, 4:00 PM on Mondays and Thursdays in the Learning Resource Center Tutorial Room of MERP. An instructor will be present while learners use the program until the first meeting of the peer review committee in December of 1999. On completion of the program, users will be interviewed for their suggestions and comments. These will be used to improve the program for the next group of users.

Course evaluation plan: In addition to the formative evaluation noted under Implementation, feedback will be provided by a peer review committee (See below). In addition, we will compare test scores of learners receiving instruction with the face-to face method and compare them to the learners receiving instruction via the computer assisted method. Learners will be randomized by month to receive 4 of the lectures by one method and 5 by the other. Testing 50 learners in each group would give us approximately 80% power to detect a difference of 30% in test scores between the two groups at a significance level of 5%. This testing will require observations beyond the initial grant period but are essential in determining the value of our course. Future testing may also be possible by analyzing the board scores of medicine residents randomized to CAI vs. face-to-face methods. Again, such evaluations would not be possible within the year planned for course development.

Plans for peer review: A review panel will meet twice yearly to examine the results gathered in the Course Evaluations and recommend strategies to strengthen quality of the course. The panel members have been contacted and have enthusiastically agreed to participate. They include: Deborah Litzelman, M.D. Director of Clinical Teaching for the Department of Medicine; Palmer Mackie Coordinator for the Introduction to Clinical Medicine Course; Kevin Nolley MERP the educational consultant at MERP assigned to the project and Jonathan Barclay, now Director of Program Development of MERP who authored Learning about Infective Endocarditis.. Hassan Danesh an expert in instructional design at MERP is available for advice on design issues and application to continuing medical education.

Institution's capacity and commitment: The Division of Infectious Diseases has agreed to the construction of the electronic course using the existing materials and barring unforeseen circumstances, has agreed in principle to its test use in Clinical Infectious Diseases. They have agreed to 5% salary support .

Project schedule: The first usable electronic version of Topics in Infectious Diseases with an evaluation component should be available by September 1999 for implementation. See appendix for a Timeline. The project will start with an initial meeting to include the course director (Dr. Arno), educational consultant (Mr. Nolley), a technical assistant (to be named) and a media specialist.

Key course development personnel.

Janet N. Arno M.D. The principal investigator is a clinical associate professor with >10 years of clinical and laboratory experience in infectious diseases. Her interest in medical educational software began in 1995 with the replacement of her own curriculum session with a CD-ROM-based CAI entitled, Learning about Infective Endocarditis, developed in association with the Medical Educational Resource Program , MERP. A second CD-ROM based program is almost complete on the selection of antibiotics in pneumonia, whose content was written with Dr. Richard Kohler.

Kevin Nolley is an instructional developer with MERP . He has taught high school and is currently working towards his PhD in adult education. Media Specialists are available through MERP including Norm Legge, computer animator/video director of MERP. Mr. Legge developed all videos, audio clips, animations and edited all photographic images in Learning about Infective Endocarditis. His background includes degrees in telecommunications and psychology with an emphasis on human perception and learning.

Budget Page Narrative:

The majority of expense are derived from salary costs which are matched by institutional funds. The course director salary was calculated at 22% effort with roughly half coming from the institution and half from IHETS.* Under the heading of Supplies and Expenses $1750 is requested for fees arising from MERP media production services and $2000 is requested for a technical assistant. Biostatistic support is estimated to cost $250 in designing evaluation trials. $600 is included for Mr. Nolley’s consulting services.

In the spirit of consortial contribution to the project, Indiana University has waived indirect costs for these projects.

 

Note:

Improving medical education is challenging in the current medical climate. Academic physicians are called upon to fully support their salary and compete with community hospitals whose patients are better financed and less sick by providing high volume patient care. Improving medical education is particularly difficult as instructors have no training in education. Funds are available for this purpose are few. What educational funds are available are dedicated to existing formats. Major funding agencies such as the NIH have no funding mechanism for medical education and the NSF focuses only on K-12 and undergraduate courses. It is hoped that the development of a course that can serve as a model for extending academic physicians expertise statewide and for evaluating the utility of such programs (including cost) will impact not only the division of Infectious Diseases but also other divisions within the department of Medicine as well.

• Dr. Arno receives compensation from two sources as a faculty member of the Department of Medicine: Indiana University and University Medical Diagnostics Associates, Inc. (UMDA). An equal percentage of each salary source is represented in this proposal, as detailed below:

Salary Base FTE Salary Fringe Total IHETS Cost Share

IU	24,929	22%	5487	2184	7632	5748	1884
Arno UMD	13,658	22%	3057	234	3291	0	3291
Total			8541	2382	10923	5748	5175