Distribución espacial de los cambios en general y de los relacionados

7.3.1 Provision of customized multimedia educational modules to the user

VOEU is based upon the most recent technologies and standards for Virtual Learning Environment (VLE) development (143;144) to accommodate these interrelated clinical, educational, and research experiences. The repository for educational packages is referred to as the Multimedia Educational Orthopaedic Modules (MEOM) component of VOEU, built as an XML application based on Information Management System (IMS) Metadata and Content Packaging standards (145).

Using IMS nomenclature, every educational item is treated as a resource whether it is a whole tutorial, a web page, multiple-choice question (MCQ) or an image. Each resource is described by Learning Object Meta-data (LOM) and can be used and reused in different contexts as the educational content developer chooses. In the current version of VOEU the content can be organized in a varied but static wayi.e.it is based upon hierarchical structures of its governing content-packaging Document Type Definition (DTD). In later stages, a transition to schemas was adopted to increase interoperability and compliance. The aim is to develop ‘learner tracking’ allowing dynamic content-building according to the individual’s profile, similar to the earlier Intelligent Tutoring Systems (ITS). The MEOM development concentrates on two areas: building an automated orthopaedic knowledge repository and serving it to the learner in the most educationally effective way.

Every educational resource, accompanied by its metadata, will form an XML instance/document validated against theVOEU metadata.dtd and stored in the repository currently holding over 500 documents. Content providers will be able to add resources automatically through an MS Word™ .doc form as a template with a metadata header. Conversion of HTML to XML is handled by‘in house’ software developed by the IAM group in the University of Southampton. The intention is to provide customised multimedia educational modules to the user.

7.3.2 Library facilities in VOEU

Multimedia Educational Modulesprovide the declarative (factual) base of material for the education of the users. Reference material is structured for individuals based upon their user profile. This includes text still images, video and simulation in some cases. See Figure 7.1.

Figure 7.1 A screen shot of Library facilities in VOEU. Reference material structured for individuals based upon their user profile.This includes text still images, video and simulation

in some cases.

Figure 7.2 Document content is selected and uploaded using ftp from a local disk

The current VOU3 allows for the following:

 Peer reviewedstructured content.

 User uploadingand reviewing of documents using a simpleMicrosoft Word™

template.

 'ICT for healthcare professionals'available on-line and as a hardcopy for users.

 Support for‘Critically Appraised Topics’development of Evidence-Based Medicine.

Proposed functions for development include full multimedia user centred authoring environment. Political effort to establish user groups for the continuing updating and generation of new material is essential to ensure continued use. The system is already IMS and ‘Dublin core’ compliant.

There is a need for a peer-reviewed uploading process as demonstrated by the following screenshots. This is ostensibly mirrored in the review process, as each aspect of the uploading process is peer-reviewed. To assist navigation through the process for the user, there is a stepwise menu guide to the left of the screen. Over 500 documents have been uploaded using this method. The four steps demonstrated are:

1. Document contentis selected and uploaded using ftp from a local disk (Figure 7.2). 2. Document information is checked against the metadata uploaded in the Word™

template to ensure it represents the appropriate 'Dublin Core' information and is selected for the appropriate intended audience, either by the author or later by the reviewer (Figure 7.3). This includes the author’s perceived audience, targeting specific groups of users.

3. The Intended location of the file within the author’s subject hierarchy is selected. This view may later be changed by the superimposition of ontology, such as a structured surgical course model (Figure 7.4).

Figure 7.3 Document information (Dublin core compliant)

Figure 7.4 The intended location of the file within the authors subject hierarchy is selected. This view may later be ontology-driven

7.3.3 Dynamic Review Journal facilities in VOEU

This is an on-line shared working environment for managing trials both for audit and research. This service also provides a framework for collective contribution to data collection and paper writing. This creates a Virtual Observatory for the collection of data from simulation systems and the actual intra-operative data collection - see Figures 7.6 and 7.7. This developed into the Dynamic Review Journal (DRJ). Whilst all tools are relevant, this one is expanded upon in more detail as it forms the key interface for intraoperative data collection. This tool manages the clinical evaluation, adopting a similar presentation style to the Static Review Journals (e.g. Journal of Bone and Joint Surgery).

It is designed to meet the user requirements for a dedicated ‘journal’ of future surgical education systems. This should allow progressive case analysis and seamless integration with archiving. There will be case data mining that is constantly updated supporting search functions for the records. Unfortunately, demonstrating the benefit of differing clinical approaches upon a small population of cases without a considerable variation in outcome is not suitable for statistical analysis. For this reason, scalability was demonstrated using demographic study data of over 2800 cases.

Figure 7.5 The document content is then reviewed to ensure it is viewable, as intended.

This demonstrated that the statistical engine performed adequately. Technical and ergonomic evaluation to detect technical weaknesses in current Image Guided Orthopaedic Surgery (IGOS) systems can build upon this.

To assure quality, the cases that are output by the DRJ must be technically and medically validated. The technical validation is managed by constraints on data

collection. The medical validation is by the peer-review of case results on an annual/progressive basis. This process provides internal peer-review by the authors and selected panel, but relies upon an independent peer-review process before the document is uploaded in order to be accessible to others. A Static Review Journal (SRJ), which both stores and archives preprints and published articles (termed ePrints), is currently available. Results are only credible if they are peer reviewed and are available for scrutiny. The DRJ provides a record for non-repudiation of results. An infrastructure has been developed to support this by logging an individual’s performance in conjunction with the development of multimedia tools to guide the trainee, see Figure 7.1.

Content Validation Adaption to personal specification (e.g. user expertise) Display of vcontent as HTML pages XML Conversion Building the orthopaedic knowledge Word template to gather content, including XML metadata User controlled Stage of process Adaptive Hypermedia process Displaying the orthopaedic knowledge Personal Profile Peer Review

Figure 7.6 Document uploading procedure - HTML communication with XML forms

This will be the next step for simulation data collection via the DRJ. This could be employed intra-operatively for trainee tracking when using navigation systems. It is an important part of the process of transition to evidence-based medicine. The current version supports On-line trial template generation, web form trial data entry, and use of an on-line statistics package, multiple Journal formats and an alerting system. Dynamically reviewed material can be submitted to the library peer-review process to

ensure up-to-date material based upon established clinical trials and on-going trials in the case of case reports and alerts.

The proposed functions for development include: enhanced trial data entry and heuristic support for users unfamiliar with statistics management. Journal submission templates for all leading journals (upon request) will be included, also offering a vertical prototype exploring other document templates e.g. case reports and editorials. A database should be developed that will provide a foundation for future research and audit. Finally it is envisaged that there will need to be forwarding to national and international trials centres for analysis.

Figure 7.7 A screen shot of Library facilities in VOEU. On-line shared working environment for managing trials both for audit and research. Embedded simulation

Embedded novel modalities of simulation (36;65) have been tested for the emulation of surgical procedures for training and experimentation focusing upon image guided surgery - see Figure 7.8 demonstrating version 2.

Figure 7.8 Embedded simulation (for shoulder arthroscopy in the trials) 7.3.4 Surgical Logbook facilities in VOEU

The logbook module offers the ability to log clinical cases (36;65). This is essential for the recording of surgical procedures for training and management of trials, see Figure 7.9. The current version is BOA compliant with the User profile linked so that users have a Personal case base linking to the dynamic review journal for audit and case review that links to their participation in trials. The intention is for the system to be able to accommodate Regional In-Service Training Agreement (RITA) Summary Sheets and to offer automatic uploading of data to other records, such as the BOA logbook JCHST, GMC revalidation etc. All of this will be facilitated by pervasive access from handheld devices.

Figure 7.9 A screen shot of surgical logbook facilities in VOEU. Conventional surgical case record with ‘drop down’ menus of cases and surgical team members to facilitate data entry

The integration of procedural skills monitoring into the user educational record (the surgical logbook) is an integral part of the dynamic record of surgical performance and is currently a topic of debate since trainees are obliged to use a commercial package that has been imposed upon orthopaedics in the UK. There are however certain basic standards that can be adhered to. Data relating to cases according to the basic requirements of Higher Surgical Trainee’s logbook (see Table 7.1, Figure 7.10) should be collected, including the following data recorded29. There are many other subheadings that can be added, but these will be attached to these groups. Cases will be filtered according to the types of Case / Operation (see Figure 7.10), whether the patient is Adult / Paediatric (up to 16 years old) and whether the operation was assisted, performed supervised or performed unsupervised. A summary page based upon the above classification is provided allowing for expansion to accommodate the additional features being evaluated (type of equipment used) will be included.

Hospital Initials

Hospital

Number Date Patient's

Initials Age Sex Operation

Comments /

Specifications InvolvementComplications

Consultants Initials

Table 7.1 Basic surgical logbook headings

Figure 7.10 Context dependent key word selection for logbook cases

29_{Confidentiality and Security must be maintained in accordance with the Data Protection} Act – and the user should be registered voluntarily with the Information commission.

7.3.5 Virtual classroom facilities in VOEU

Case based learning is supported with automatic linking to cases of appropriate selection for user expertise, and tied in to the learning resources in the library. A catalogue of cases is available to the user based upon their experience (see Figure 7.11). In the current version this includes context-dependent keyword searching, and the ability to construct new courses from established material with images and links to video possible in the cases. The proposed functions for development are:

 Support for the educational and training responsibilities of the department.

 Facility for users to prepare on-line educational material, using a case-based structured approach.

 The feedback loop for user performance in tests

 Development of feedback based upon written trainee responses

Figure 7.11 A screen shot of virtual classroom facilities in VOEU

7.3.6 Discussion fora facilities in VOEU

This is a shared workspace that is secure for members of different discussion fora. The moderator regulates communication. Users can thread the discussions and target specific topics, see Figure 7.12. In the current version the functions include:

 Lists of active forum participation

 Ability for users to create new fora.

 User roles as participants and moderators.

 Automatic private discussion forum generated for paper authors linking to their draft articles.

The intention is for this to evolve into themed discussion fora with issue tracking and user monitoring by agents of broader discussions.

Figure 7.12 A screen shot of discussion fora facilities in VOEU

7.3.7 Personal profile facilities in VOEU

This is where the user develops a personal view of their postgraduate training and continuing professional development including individual learning agreements. All the involved staff groups (stakeholders) should be able to access the system to include and obtain the information commensurate with their duties (see Figure 7.13).

In the current version it is possible for the user to track Case progress. Users can update their password,subscribe to courses, initiate learning agreements and maintain

their profile. Their Learning Agreements are negotiable with the tutor, considering curriculum, syllabus and clinical post issues. There is dependency on Feedback forms to improve the service. To improve the service further it is proposed to build the forms into the e-portfolio in the form of a ‘Dynamic’ CV, providing support for CV generation based upon experience and activities. This will offer access to the journals and databases that they have previously organised permissions for by adapting the roving profile inside the hospital. By building upon the plans for pervasive access mentioned above, intelligent agent monitoring of activities will assist users to access available resources in conjunction with other organisations. This may be extended to support study-leave administration for hospital staff in accordance with the hospital requirements.

Combining the above tools within one working environment, the virtual university infrastructure (113) aims to meet the needs of orthopaedic surgeons to combine clinical, educational and research responsibilities via a platform accessible over the internet. VOEU was specifically established to address the issues of data access, presentation and development of a structured learning environment for the training of novice surgeons, which it has achieved, though a key by-product of this is simulation integration and access to the operating theatre.

Figure 7.13 A screen shot of personal profile facilities in VOEU. The User profile links in their clinical experience with their educational programme

7.3.8 Administration facilities in VOEU

This section of the service is available to the administrators to facilitate user education, forum management, notices and user records, see Figure 7.14. Whilst this currently supports an alert (Notice board) system that all users can employ to target specific groups of individuals instantly along with Library, Trials Template and User Management, the intention is for this to expand also, with the following functions:

 Pervasive access to resources and tools.

 Delivery of services using a modular approach.

 Prioritisation of tasks in accordance with user demand to ensure primary tasks are achieved in time and secondary tasks are completed in order of priority.