Spring 2013 The Blue Ridge Academic Health Group Health Professions Education: Report 17. Accelerating Innovation Through Technology 1 Reproductions of this document may be made with written permis- sion of Emory University’s Robert W. Woodruff Health Sciences Center by contacting Anita Bray, James B. Williams Medical Education Building, 1648 Pierce Drive, Suite 367, Atlanta, GA, 30322. Phone: 404-712-3510. Email: abray@emory.edu. Health Professions Education: Accelerating Innovation Through Technology is the 17th in a series of reports produced by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official positions of Emory University. This report is not intended to be relied on as a substitute for specific legal and business advice. Copyright 2013 by Emory University. 2 Report 17 • Spring 2013 MISSION: The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommendations for academic health centers (AHCs) to help create greater value for society. The Blue Ridge Group also recommends public policies to enable AHCs to accomplish these ends. Members and participants (August 2012 meeting) MEMBERS S. Wright Caughman, MD* Irene M. Thompson, MD Executive Vice President for Health Affairs, Emory President and CEO University; CEO, Woodruff Health Sciences Center; University HealthSystem Consortium Chairman, Emory Healthcare Bruce C. Vladek, PhD Don E. Detmer, MD, MA Senior Adviser, Nexera Consulting Professor of Medical Education, Department of Public Health Sciences, University of Virginia Steven A. Wartman, MD, PhD President. Michael V. Drake, MD Association of Academic Health Centers Chancellor, University of California at Irvine Michael A. Geheb, MD Executive Vice President, Physician Planning and IN VITED PA RTICIPA N TS Operations; President, Oakwood Physicians, Stephen E. Carson Oakwood Healthcare, Inc. External Relations Director, Massachusetts Institute of Technology; OpenCourseWare, MIT Gary Gottlieb, MD, MBA President and CEO, Steve Levin Partners HealthCare System, Inc. Director, The Chartis Group Michael M. E. Johns, MD+ Lloyd B. Minor, MD Professor, Emory University School of Medicine and Rollins Carl and Elizabeth Naumann Dean School of Public Health; former Chancellor and former Stanford University School of Medicine Executive Vice President for Health Affairs, Emory University Charles G. Prober, MD Darrell G. Kirch, MD Senior Associate Dean, Medical Education; Professor of President, Association of American Pediatrics, Microbiology & Immunology; Stanford University Medical Colleges George Sauter Steven Lipstein Director, The Chartis Group President and CEO, BJC Health Care James O. Woolliscroft, MD Mary D. Naylor, PhD Dean, University of Michigan Medical School Marian S. Ware Professor in Gerontology, Director, NewCourtland Center for Transitions & Health, University of Pennsylvania School of Nursing STA FF Kenneth S. Polonsky, MD Anita Bray Executive Vice President for Medical Affairs, Dean, Division Project Coordinator, Woodruff Health Sciences Center, of Biological Sciences & School of Medicine, University of Emory University Chicago Gary L. Teal Claire Pomeroy, MD, MBA*+ Chief Administrative Officer, Woodruff Health Sciences CEO, University of California–Davis Health System; Vice Center, Emory University Chancellor for Human Health Sciences; Dean, School of Medicine ED ITOR Mark Richardson, MD Elaine B. Steen, MA Dean, School of Medicine, Oregon Health & Science Policy Analyst University Arthur Rubenstein, MBBCh ED ITORIA L A N D D ESIG N CON SU LTA N TS Professor, Department of Medicine, University of Pennsylvania School of Medicine Karon Schindler Peta Westmaas Fred Sanfilippo, MD, PhD Emory University Director, Emory-Georgia Tech Healthcare Innovation Program, Emory University John D. Stobo, MD Senior Vice President, Health Sciences and Services, * Co-Chair University of California System + Co-Planner Contents Health Professions Education: Accelerating Innovation Report 17. Through Technology Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 The destination: A multi-faceted vision for health professions education . . . . . . . . . . 4 The changing landscape of higher education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Essential components for building online capacity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Leveraging technology for health professional education innovation . . . . . . . . . . . . 10 University of Michigan Medical School: Focus on continuous learners . . . . . . . . . . . . . . . . . . 11 Stanford University: Flipping the classroom . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 New York University School of Medicine: Toward a knowledge syncytium . . . . . . . . . . . . . . 15 Johns Hopkins Bloomberg School of Public Health: Extending reach and impact . . . . . . . . . 15 University of California Irvine School of Medicine: iMedEd . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Emerging and maturing educational approaches . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Electronic health records as a needed skill and learning tool . . . . . . . . . . . . . . . . . . . . . . . . . 16 Spaced education: Applying cognitive science to improve knowledge retention . . . . . . . . . 16 Virtual patients: Health care’s flight simulators . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Simulation centers: The pinnacle of education technology? . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Potential benefits and limitations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Obstacles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 Enablers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Emerging research agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Institutional initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 National initiatives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Previous Blue Ridge Reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 1 Introduction Achieving these objectives will impact health professional schools’ curricula, faculty, infra- Our academic health centers are white-knuckled structure requirements, and budgets in addition in fear that their historic missions of education, to requiring changes in organizational culture. service and research are threatened from the While the tripartite mission of an academic health outside. . . . Yet, a greater threat may lie within center (AHC) yields organizational synergies, it the halls of academe. If we remain dedicated to also results in the educational enterprise compet- minor revisions of past educational approaches, ing with patient care and research for limited our prospects will be dim indeed. (Don E. Detmer, resources. Moreover, some of the needed changes MD, 1997)1 are beyond the control of academic health centers. Indeed, well-intentioned unilateral actions may We are reaching a tipping point where education have unintended consequences. Hence, there is a and educators can use technology to reach almost need for coordination and thoughtful participa- every person on the planet inexpensively. How- tion of all the stakeholders involved, including the ever, the result may not look like the conventional organizations that accredit schools, certify and university experience we recognize today. These license health professionals, and pay for patient are exciting times for educators, but it remains to care. The task of educational reform is vast and be seen how these developments will change the complex; multiple actors must align their poli- structure of education, influence the purpose of in- cies; uncertainty abounds and is exacerbated by stitutions, and shape the role of professors. These the changes under way within the health care developments may feel threatening, but they also system; and scarce resources make it critical that offer exciting opportunities to reach a much larger any changes be made with great care and thought. and broader audience with our lectures, to spend Despite a growing sense of urgency, progress has more time advising and mentoring students, and been slow. As a result, the evolution of educational to improve the overall learning experience for all. approaches has not kept pace with market changes (Stephen Carson and Jan Philipp Schmidt, 2012)2 and innovations in health care delivery, and health professional educational processes are not aligned Over the past decade, a multitude of organiza- with health system needs. tions have called for the reform, overhaul, and Meanwhile, online learning (also known as transformation of health professions education.3-16 e-learning, Internet-based learning, Web-based Although there may be differences in emphasis instruction, distance learning, computer-aided among these groups, there is widespread agreement instruction) is on the rise and creating waves, if on the nature of needed changes. In general, health not a tsunami, for higher education.17 In 2012, professions education needs to do the following: online learning reached a new milestone with n Expand focus on new areas that are foundation- the emergence of massive open online courses or al to the success of clinicians in the 21st century “MOOCs” and accompanying for-profit and non- (e.g., working in teams, patient-centeredness, profit platforms that provide access to MOOCs. communication, informatics, population-based Of particular note, Stanford’s free online course and evidence-based care). on artificial intelligence attracted 160,000 students n Strengthen ability to measure competencies of from 190 countries (with 5% of students complet- learners. ing the course); a president of a top-ranked uni- n Improve efficiency of the educational process versity was ousted in part for failing to respond and address issue of costs required to become a quickly enough to the online course environment health professional. (but was later reinstated); and The Chronicle of n Be responsive to the learning styles of students. Higher Education, The New York Times, and Time n Prepare students to be lifelong learners. each focused on MOOCs and the reinvention of n Produce an adequate number and appropriate higher education within the span of a month.17-22 balance of health professionals. These developments are occurring against the 2 backdrop of increasing questions about the ever recommendations for moving toward that desti- rising cost and value of traditional residential edu- nation. Given the anticipated fast pace of change cation.23 Despite facing ambiguity on the effective- in online education, the report challenges AHCs ness of online educational approaches, perceived to embrace a small set of immediate actions that threats by faculty, and additional costs for already can be implemented while the longer term recom- burdened budgets, universities have been forced mendations are being progressively adopted. This to grapple with the online learning movement and report will not explore in depth the full range of to determine whether and how to incorporate it actions that are needed to achieve optimal reform into daily operations, and they are being pushed of health professions education. The Blue Ridge to do so at a more rapid pace than they are accus- Group recognizes that the recommendations in tomed to moving. Higher education institutions this report are insufficient stand at a pivotal juncture, with opinions divided How can health to achieve the ultimate on what the future holds. Some observers predict professional schools end goal but believes that that higher education will change more in the and AHCs leverage there are actions that can next decade than in the past 100 years and that education technology move toward the endpoint 50% of the colleges and universities operating in to jump-start needed and that, by building the United States in 2013 will not exist in 2063.24 changes in health momentum and gaining Other analysts contend that it will take a decade professional education experience, larger changes for solid business models for MOOCs to emerge, and accelerate innova- may be stimulated. and still others caution that some for-profit online tions that will pave To understand how education companies entering the market are a the way for longer AHCs should respond “sack of vapor.”25, 26 term and larger scale to the need for dramatic These disparate developments—the need for transformations? changes in health profes- health professional education reform and the sions education and the online movement—present leaders of AHCs and rapidly changing higher education landscape, the health professional schools with a compelling, Blue Ridge Group surveyed initiatives and institu- indeed critical set of questions that motivates this tions on the frontier of higher education and report: health professions education innovation. These In light of the complexity associated with “bright spots” do not provide a simple answer to needed reforms, what can health professional how to reform, transform, advance, or overhaul schools and academic health centers do in the health professions education.27 They do, however, near term to make progress toward the envisioned help us understand the forces that are shaping future for health professions education? higher education and highlight how AHCs can How can AHCs and health professional take advantage of emerging tools to jump-start schools capitalize on the potential benefits offered progress toward our desired destination. by online learning and computer-assisted instruc- The rapid pace of change and daily reports of tion to move toward our shared vision for health new developments in the online movement re- professions education? quired the Blue Ridge Group to take a snapshot in How can health professional schools and time (i.e., fall 2012) as the basis of its analysis. This AHCs leverage education technology to jump- report focuses on health professional undergradu- start needed changes in health professional educa- ate education (e.g., in schools of medicine and tion and accelerate innovations that will pave the nursing) rather than the entire education con- way for longer term and larger scale transforma- tinuum being impacted by online learning (i.e., tions? elementary school through continuing profes- The Blue Ridge Academic Health Group (Blue sional education). Ridge Group) begins this report with the end- point—the desired destination for health profes- sions education—and ends the report with a set of 3 The destination: A multi-faceted vision methodologies/tools that best suit their learn- for health professions education ing styles. n nable each student to achieve mastery in his/ E Two key concepts underpin the work of the Blue her domain while also gaining proficiency in Ridge Group. First is the need for AHCs to meet functioning effectively in a multi-disciplinary, the needs of society as well as the individual needs inter-professional team; in a learning health of the patients they serve and the students they care system; and as a lifelong learner. teach. Second is the concept of a value-driven n inimize the time required to become compe- M health system and the need to maximize return tent by exposing students to knowledge that is on investment for dollars spent in health care, truly relevant and providing experiences that education, and research. Building on the vision are essential to achieving competency. for health professions education that has emerged n e integrated over time as health professionals B over the past decade, the Blue Ridge Group explic- move from undergraduate to clinical practice itly applies these two concepts to its understand- (or in the case of physicians, from premedical ing of what health professions education should to undergraduate medical to residency and fel- offer in the future and articulates the vision for lowships, to practice). health professions education from the perspective n e affordable. B of four key stakeholders. From the faculty member’s perspective, health From society’s perspective, health professional professional education should do the following: education should do the following do the following: n e valued, supported, and rewarded by the B n roduce an adequate number and appropriate P organization (i.e., academic health center). balance of health professionals as needed to n rovide opportunities for innovation and col- P meet the needs of the population. This includes laboration across disciplines and institutions. achieving greater representation of historically n rovide opportunities to engage students in P under-represented minorities across the health learning activities that promote collaboration professions. and personal growth for teachers and learners. n nsure that all health professionals are com- E From the academic health center’s perspec- petent in their respective domains, proficient tive, health professional education should do the in working in teams that include patients and following: families and that cross a range of settings, and n ttract a diverse population of students. A able to work in a learning-oriented and technol- n ngage faculty and allow them to focus on E ogy-facilitated health care delivery system. skills and knowledge that are best transmitted n roduce health professionals who are prepared P through personal interaction with and among to evolve in response to the changing needs of students. the population and the health care system. n apture and track costs and quality outcomes. C n ield a positive return on public investment in Y n e self-supporting. B health professions education. Some of the changes needed to achieve this From the health professional student’s per- vision depend on actions by groups outside of spective, health professional education should do AHCs. For example, time must be found to ad- the following: dress new areas in the curricula without increas- n e flexible, B ing the length of training. Rather than add these n llowing students to move as quickly or a important areas on top of the existing curricu- slowly through the content as needed to gain lum, institutions will need to reduce time spent mastery, taking into account their knowledge on some areas within the current curriculum. and strengths upon entry to health profes- Yet schools cannot risk making these changes sional school and their ultimate objectives for unilaterally since students must pass the licensing practice, and board exams, which are based on the current cur- n llowing students to use the educational a riculum. In the case of medicine, the Federation 4 of State Medical Boards will need to agree to such The changing landscape changes. But equally challenging, all of the disci- of higher education plines that are currently represented in the cur- riculum will need to agree on the determination In fall 2010, more than 6.1 million students in of what constitutes “core” content and a realloca- degree-granting postsecondary institutions (31%) tion of time in the curriculum. A comprehensive were enrolled in at least one online class.28 The examination of such changes is beyond the scope growth rate for online enrollment slowed some- of this report but is a desired task that needs to be what in 2010 but continued to exceed the rate of “owned” by relevant educational organizations. growth in total higher education student popula- Rather, this report explores which elements of tion. The online movement is notable, not only the vision for health professions education can be for its size, but also for the many variations it supported through creative, thoughtful applica- takes. Traditional residential universities that offer tion of currently available and emerging online online certificate or extension programs have been learning approaches and tools that are accessible joined by purely online universities (both for- to and within the purview of AHCs. profit and nonprofit). The University of Massa- This vision for health professions education chusetts offers 25 different online bachelor degree creates additional requirements for the educa- options through UMassOnline and makes no tional enterprise of AHCs and health professional distinction between online and on-campus credits schools. Specifically, AHCs and health profession- earned.29 The for-profit University of Phoenix had al schools jointly need to do the following: more than 450,000 students enrolled in 2010.30 n Foster far greater flexibility in educational pro- Western Governor’s University (WGU), a private, cesses to accommodate the individual student’s nonprofit, multi-state online learning university starting point, learning style, life situation, and with 20,000 students, charges less than $3,000 for long-term objectives and to give students and tuition for a flat-rate six-month term and has not graduates far more control of when, where, raised tuition for four years.31 how, and what to study as they work toward This movement is by no means limited to achieving the needed competencies. higher education and reaches down to kinder- n Be more nimble with respect to modifying the garten. For example, more than 6 million unique curriculum and performance improvement users access the Khan Academy’s free library of efforts within AHCs, introducing advances in 4,000 videos each month. These short videos are clinical knowledge or pedagogy innovations aimed at K-12 learners, focus primarily on math based on the science of human cognition, and science, and are supplemented by problem adapting to changing demands for numbers and sets that enable students to demonstrate mastery types of health professionals, and overcoming of concepts.32 As time passes, increasing numbers timing constraints often faced in interdisciplin- of students entering college will have had some ary training. kind of online learning experience. n Provide as many opportunities as each student As Table 1 highlights, college and university needs to master competencies and capture and students are likely to encounter a range of course document student performance across time and types during their post-secondary education. settings. In some online courses, a student may hear a n Measure and track costs and effectiveness for recorded lecture that is synchronized to a set each component of the educational enterprise of slides, take online tests, and sometimes have (e.g., individual lectures and simulations) and the opportunity to participate in online discus- find efficiencies that save money for the institu- sion groups (with or without a faculty member). tion and time (and money) for students. In other instances, considerable resources are n Implement technological innovations that sup- invested in developing highly interactive learning port curricular changes and process enhance- modules that may include animations, interactive ments. diagrams, and simulations with embedded assess- 5 Table 1: The range of online learning experiences that have emerged in higher education28 Course type General description Traditional “Sage on the stage.” Content is presented orally or in writing. There is face-to-face interaction between students and instructors. Some technology such as “clickers” or student response systems may be used in large classes to facilitate student interaction. Web-facilitated Web-based technology such as a learning management system is used to support a face-to-face course. Course materials such as the syllabus and assignments may be posted online. Tests may be administered online. Blended/hybrid/ Substantial portion of content is delivered online; often reduces flipped number of face-to-face meetings; may use online discussions among students and instructors. Students may be expected to view a recorded lecture before class. Face-to-face sessions can then be in- teractive learning experiences designed to activate prior knowledge and solidify understanding. Online course The majority or all of content is delivered online; may use online dis- cussion; no face-to-face meetings. ments.30 Regardless of the level of interactivity reduce classroom space needs for universities, provided in an online course, a technological in- extend reach of the university beyond the campus, frastructure in the form of a learning management and eliminate the need for faculty to give the same system that allows content sharing and tracking of lectures each semester, thereby freeing them up student progress is essential. for other activities. Online courses offer students While the scale of online learning is impres- more flexibility with respect to when and how of- sive, much of it replicates what has gone on in the ten they receive knowledge as students can listen classroom for centuries and merely constitutes a to a lecture at a time of their own choosing and as change in distribution method.21 Although human often as they want. cognition research has expanded understanding Of potentially greater significance, online of how people learn, these insights have largely educational approaches offer tangible ways to not yet made their way into most physical or transform the educational process. There is grow- virtual classrooms. ing realization that traditional didactic lectures Nonetheless, applying online technology to are less effective at achieving student mastery of current teaching processes does yield benefits. A knowledge than lessons that incorporate student 2012 study that compared traditional lectures (i.e., problem solving.34, 35 By reducing time required three to four hours of face-to-face instruction per to lecture during face-to-face sessions, faculty week) to a hybrid format (i.e., machine-guided in- can increase time spent engaging students in struction combined with one hour of face-to-face discussion or problem-solving activities. Learning instruction) found that learning outcomes were management systems offer the capacity to capture essentially the same for the two formats.33 Cost data on individual learner progression, thereby simulations based on these results led researchers enabling a customized educational experience. to conclude that the hybrid instruction model ap- For example, the Khan Academy tracks student plied to large introductory classes offers potential progress in solving problems and when a stu- to reduce instructor compensation costs in the dent demonstrates mastery of a given concept, long run. In addition to allowing faculty to teach it recommends new topics for the student to more students in a single course, online courses explore. Further, as organizations compile data for 6 Table 2: Evolution in access to higher education courses and courseware Traditional closed courses OpenCourseWare (OCW) Massive open online courses (MOOCS) Students pay tuition for access Course materials originally Free courses that require reg- to content that is delivered designed for use within degree istration. MOOCs are offered face-to-face or online. Time granting programs are made during a finite period. Students frame for courses is controlled freely available for use at any have flexibility within the by institution. Online closed time. They are not intended to general structure of the course. courses allow students some serve as a stand-alone course, Students who meet require- flexibility within the overall and there is no opportunity ments may earn a credential that structure. Students who meet to earn a formally recognized verifies they have successfully institutional requirements earn credential. completed the course. a degree. populations of students, they have greater ability that includes an increasing number of open access to analyze the effectiveness of specific learning journals and textbooks. OCW and OER have been modules and to gain insights into how students enabled in large measure by the emergence of learn most effectively. public copyright licenses such as Creative Com- Two developments associated with the online mons, which gives licensors a standardized, easy learning movement—the idea of sharing course way to grant copyright permissions to their work content for free and the platforms that enable such while retaining credit for it.37 OCW content is sharing with large numbers of students—may not only supporting higher education around the ultimately provide the tipping point for the rein- globe, but it has also shown impact on communi- vention of higher education. As Table 2 outlines, ties. Two entrepreneurs in Haiti used MIT OCW online courses and course content have expanded content to learn about circuits to develop solar- from the traditional closed model to include open powered street lights for use in some of Haiti’s access to courseware and free course offerings poorest communities. from elite institutions. Although these innovations The growth of OCW highlights several impor- are focused on external audiences for colleges and tant lessons for higher education leaders: universities, they are also impacting the education n Educational content can be decoupled from of students on campus. those who create it. “Commoditizing” course OpenCourseWare (OCW) is based on the content enables more efficient creation and use. premise that there is value in freely sharing n There is strong demand for free content from courseware that has been developed for use in trusted sources. face-to-face courses.36 Courseware may include n There is a large pool of individuals worldwide syllabi, lecture notes, assignments, exams, and who seek to learn for the sake of learning. sometimes recorded lectures. It was originally n A common technological platform that enables intended for use as a teaching resource for educa- content sharing for a shared goal can foster tors around the world. Surprisingly, the major- greater and rather swifter collaboration than ity of users turned out to be students looking to previously observed in higher education. supplement their own instruction or self-learners While OCW and OER continue to grow in curious about the topic. OCW began with a single size and influence, they have been joined by a institution (Massachusetts Institute of Technol- growing set of shared learning platforms and ogy) in 2002 and in 10 years has grown into a massive open online courses (MOOCs). In late consortium of 280 institutions, 100 live OCW 2011, MIT formed MITx to support education on sites, and 21,000 courses. OCW inspired a broader campus and around the world. This online inter- movement of Open Educational Resources (OER) active learning platform organizes and presents 7 Overview of a MOOC In 2012, MITx offered a free online Circuits and and actively sought feedback from participants to Engineering (6.002) course for which 154,000 improve the learning experience.38 Some learners individuals registered and more than 7,100, developed enhancements for the course such or approximately 5%, passed the final exam. as online text viewers for mobile devices, while Students for this course ranged in age from 14 others requested that the website for the course to 74 and represented 160 countries. The course be maintained after the course concluded so included video lectures and demonstrations, prac- that students could continue interacting via the tice exercise, homework assignments, exams, and discussion forums, and still others used content an online interactive lab designed to replicate its from MIT’s OpenCourseWare project to create real-world counterpart. A team of professors and their own follow-up course (i.e., 6.003z Signals teaching assistants supported a discussion forum and Systems).39 course material to enable students to learn at their to establish edX, a nonprofit online learning own pace, includes online laboratories and discus- platform that offered seven free courses in 2012. sion forums, enables assessment of individual The edX Consortium has expanded to include the students’ work, and allows certification from University of Texas with its nine academic institu- MITx for students who demonstrate mastery. tions and six health science centers, UC Berkeley, The sidebar describes the first MOOC offered Georgetown, and Wellesley, with future plans to by MITx. MIT has since partnered with Harvard include several international universities. Table 3: The four spheres of MIT’s educational portfolio40 External OCW (OpenCourseWare) Global MITx (MOOCs) n Comprehensive publication n IT-caliber M online courses of materials used in MIT with assessment and certifi- courses (~2,150 courses) cates n Targeted at learners and edu- n argeted at top-level learners T cators worldwide n aterials developed by M n Online communities faculty n Dissemination platform for n elect portfolio of courses S MIT faculty n nline communities O n elivered on edX platform D Internal MIT Residential Residential MITx n Campus-based education n nline O courses and modules n Faculty innovation in educa- for use in MIT’s residential tion education programs n Re-imagines residential edu- n argeted at MIT students T cation via experiments n nline communities O n Blended online and class- n elivered on edX platform D room learning n xperimentation into how E n Enhanced by MITx, OCW, online courses can enhance and edX technologies campus-based instruction 8 As outlined in Table 3, MIT’s educational ary 2013, the American Council on Education’s portfolio has evolved to include four inter-related College Credit Recommendation Service recom- spheres of activity. As a result of its leadership mended college credit for five courses offered by in open courseware and nonprofit approach to Coursera. Another organization, Course Gateway a shared learning platform, MIT has positioned (http://www.coursegateway.com/), seeks to meet itself to expand the impact of its faculty glob- global demand for post-secondary education and ally through OCW, extend its reach to students is focusing on “licensing and bundling online who can successfully complete MITx courses, courses to provide customized curricula to both and create an infrastructure that allows continual single and aggregated institutional buyers.” learning about effectiveness of its instructional ap- This is a rapidly evolving market with new proaches and extends the capacity of its faculty for players and concepts appearing almost daily. For residential students by reducing the time required instance, in fall 2012 four open education sites for lecturing. (Peer 2 Peer University, OpenStudy, Codecademy, MIT is not alone in this arena. In 2010, Ud- and MIT OCW) launched a “mechanical MOOC” emy (www.udemy.com) was launched as a way to teach a computer programming language with- for individual instructors to share their online out a professor using existing open courseware, course content for free or for a small fee that goes online tools, and an email distribution list.42 to the instructor. In 2012, two Stanford Univer- It is also an uncertain market. Past efforts to sity professors offered an artificial intelligence monetize online learning failed,30 and revenue course online for free. More than 160,000 students streams for these newly formed companies have registered for the course and although only 5% not yet crystalized. Nonetheless, the rapidly finished it, 8,000 students in one term consti- changing milieu has created the sense that univer- tute considerable reach. Of note, the course was sities need to jump in or risk getting left behind. designed with short lectures (i.e., eight minutes) And while free access to university courses is and many problems that force students to learn by growing exponentially, consumers will be faced doing. Along the way, faculty modified the course with the need to judge the quality of the content based on feedback from students and determined offered. when quiz questions were unclear based on the The growth of MOOCs and the learning man- number of students who missed them. Further, agement systems that support them pinpoint the students developed enhancements for the course power of having access to vast amounts of data on such as interactive tools for practicing what they how students interact with courses and how well were studying and translating the course into they master the content. A new era has arrived for other languages. The professors who offered this the evaluation of the effectiveness of alternative course went on to found Udacity (https://www. instructional approaches. The potential to signifi- udacity.com/), a for-profit venture for offering cantly increase our understanding of the factors MOOCs that as of October 2012 had 400,000 that influence teaching effectiveness and learning registered students from 125 countries and offered and to build curricula and face-to-face and online 14 courses. courses that are based on that science represents a In 2012, two other Stanford professors created potentially huge leap for higher education. Coursera, a company that “partners with the top Sharing content among institutions also of- universities in the world to offer courses online fers the potential for dramatic change in higher for anyone to take, for free.”41 Both Coursera education by reducing the costs of transmitting and the universities incur costs in developing the knowledge to students while improving the and offering the courses; contracts stipulate that quality of the learning experience. Rather than if a revenue stream emerges, the company and every college and university offering the same set universities will share it. As of October 2012, 33 of lectures each semester, they could choose to universities had joined Coursera, and 200 courses use recorded lectures from their own institution were in the course catalog. This set of universities or elsewhere and use their time to work with stu- creates a pool of 1.4 million students. In Febru- dents on activities that promote true mastery of 9 knowledge and critical thinking skills. Given the agement system to create and manage the content considerable resources it takes to create interac- as well as an institutional learning management tive online learning modules, development costs system with embedded analytic tools to provide can be shared among institutions. Faculty and student access to content, support interactive students can also provide feedback to the creators elements, offer both normative and summative of the recorded lectures or interactive modules, assessments, and track student progress. Further, thereby improving the quality of the course over institutions that seek to share their content need time. to decide whether to join a shared learning plat- Robust online learning offerings provide form (e.g., Coursera, edX, Udacity, or others) or institutions and students greater flexibility and to offer their content as OpenCourseWare. Final- control. Students may be able to select from a ly, organizations need to develop internal capacity set of learning activities developed for different to support the development of online learning. learning styles that help them achieve mastery of Faculty need support in both technological and content, perhaps in less time. Faculty can obtain pedagogic dimensions of designing, creating, and immediate feedback from students on what is or implementing online courses or modules. They is not working in the course and make adjust- also need guidance on copyright and intellectual ments immediately if they so choose. All of these property issues associated with creation of online features contribute to the potential to improve the courses. Looking ahead, the learning manage- quality of educational processes while managing ment system for health professional schools will the cost of those processes. At their best, online need to support and integrate with e-portfolios learning technologies enable teachers to design that enable competency validation for students lessons that take advantage of advances in cogni- and practitioners throughout their careers. tive/learning science in a way that the traditional lecture format fails to do, to provide a way to capture data on whether and how students are Leveraging technology for health learning for further analysis and a deepening of education innovation the understanding of what works, and to respond to students’ needs for flexibility in schedule as Online learning and computer-aided instruc- well as differing needs in time and approach for tion efforts are already under way in many health mastering content. professional schools. These tools are being used to facilitate knowledge acquisition, improve decision Essential components for building making, strengthen visual diagnosis (enhancing online capacity perception variation), improve skill coordination, The infrastructure for the educational process has practice rare and critical events, conduct team become more complex with the advent of online training, and improve psychomotor skills.43 They learning and shared courses. While the basic range in level of interactivity for students, degree elements of sharing content, interacting with of fidelity in accurately simulating the intended students, assessing students, and credentialing task or environment, and resources required to students remain the same, what once required a develop. Table 4 presents examples of ways that professor, a classroom, and exam bluebooks now health professional schools are using technology requires a way to convert content into an online in support of education. format, store that content, provide access to the The challenge for AHCs and health profes- content asynchronously, interact with the students sionals is to determine how these approaches can online, assess students’ mastery of content, and be used to strengthen their educational processes track progress over time. Thus, in addition to fac- in the near term and to make progress toward a ulty and physical space for blended courses, the new vision for health professions education in online educational infrastructure must include the longer term. As they grapple with this chal- authoring tools and/or a learning content man- lenge, AHCs and health professional schools must 10 consider the potential benefits, costs, limitations, phases of education there is a clear goal always in and effectiveness of the technologies and ap- mind—namely, the preparation of an individual proaches under consideration. There are scant to provide clinical care for patients—a doctor. data to answer these questions. Thus, as discussed For decades we have presumed that time on task subsequently in Emerging Research Agenda, equated with appropriate levels of mastery of significant attention must be given to formulating the abilities needed to become a physician. Over and implementing a robust research agenda. In the last recent decades there has been an ever the meantime, organizations will be well served growing call for competency-based rather than to learn from efforts within and outside of their time-based approaches to medical education. The walls. Toward that end, several approaches to le- explosion of technology-based learning and assess- veraging online technology and other educational ment tools potentially positions medical educators technologies within health professional education to move forward with competency-based educa- are presented. tional models. (James Woolliscroft, MD, 2012) University of Michigan Medical School: Focus The University of Michigan Medical School on continuous learners (UMMS) approach to building online learning The end is the beginning. Medical education capacity is shaped by several factors. UMMS is a continuum. However, for the initial formal begins with the competencies needed to graduate Table 4: Examples of online learning and computer-aided instruction tools currently in use or in development at health professional schools Online learning infrastructure (accessing content/measuring outcomes) n earning management system for accessing online courses and modules and L tracking progress within them (within institution) n hared learning platforms (e.g., Coursera, OCW) S n Portfolios for building longitudinal records of student and faculty performance e Knowledge transfer/acquisition n nline/blended/hybrid/flipped courses (see Table 1), interactive learning O modules such as case studies n pps for learning or practicing a specific skill A On-demand access to knowledge n nline access to entire curriculum O n vailability of key resources on iPad or related technology A n ustomized search engines for accessing institutional resources and beyond C Practicing skills and testing knowledge n irtual patients V n irtual microscopes V n imulation centers S n imulated emails to assess knowledge, professionalism, and communication skills S n paced education games S n erious games S n vatars A 11 and the student’s personal goals. These competen- at the core of the University of Michigan Medi- cies extend beyond mastery of facts to develop- cal School’s approach to achieving competency- ment of skills, attitudes, and habits associated based medical education. The interactive tool with excellence in practice and lifelong learning. currently being developed as part of a compre- Thus, UMMS is working to create tools that allow hensively integrated learning architecture will students to practice synthesizing disparate infor- support self-directed learning by helping students mation and accessing information and resources articulate their personal goals and plan their from a variety of sources as well as self-assessment learning experiences, monitor their progress, and reflection. UMMS’s approach is also moti- reflect on their experiences, and access resources vated by the understanding that students do not at the UMMS and beyond. It will also provide study the way that faculty did and are more likely access to targeted learning objects tied to specific to follow their own pattern of learning. Finally, competencies. UMMS’s view that technology can enhance learn- The student portfolio will be supported by a ing and student assessment is balanced by rec- range of online technology that is already being ognition that rigorous evaluation of whether the used to support self-directed learning and en- actual transfer of skills is achieved is imperative. hance traditional face-to-face classes. Among the The student portfolio (see Figure 1)44 will be initiatives under way at UMMS are the following: Figure 144 12 n First- and second-year lectures have been digi- sequences were available, with 263,987 views to tally recorded for ubiquitous search and access 29 UMMS videos and 38,925 views to 214 UMMS by students. lectures. n The Professional Skill Builder (PSB), a web- based, multimedia, interactive case simulation Stanford University: Flipping the classroom program, allows students throughout their four Burgeoning and constantly expanding medical years to work through clinical cases to practice knowledge, the new generation of technologi- history taking, physical examination, and di- cally savvy and enabled learners, and the rising agnostic test selection, thereby reinforcing and costs of higher education demand the exploration integrating classroom and clinical learning. of more efficient and effective modes of health n Third-year students have access to additional professional education. The ability to produce and online cases through a subscription to iInTime, deliver high-fidelity content to local and widely designed to address gaps and stimulate self-di- dispersed learners on innovative platforms creates rected learning when students do not encounter the opportunity to fundamentally alter the way specific core clinical conditions. in which health professionals can be educated. n The histology class is taught using virtual (Charles Prober, MD, 2012) microscopy throughout the first year of medical school (www.med.umich.edu/histology/cour- The Stanford School of Medicine approach to seinfo.html). leveraging online learning is built upon a model n Simulated electronic mail has been tested as that delineates three types of knowledge (mate- a way to improve third-year medical student rial) that students will encounter. (See Figure 2). electronic communication skills with patients First, there is the foundation or core of knowledge and family members. that all students across all schools of medicine n Advanced Medical Therapeutics is a self-direct- must master. Second, there is knowledge associ- ed, interactive, on-line course that is required ated with “deeper dives” that individual students for fourth-year students, designed so that they or institutions may choose to explore according build applied knowledge in the clinical context to learners’ personal interests and passions or and fully participate in the course while travel- institutional strengths and priorities. The oppor- ing for residency interviews. tunity to individualize learning experiences is an n iSeek allows all medical school students, faculty, important element of this model. Third, mastery and staff to search and view all online educa- of both types of knowledge is aided by “science- tional materials (including streamed lectures based, interactive, compelling, and patient-cen- and PowerPoint presentations) in the under- tered material” that serves to engage the learners graduate medical school curriculum, with fu- in ways that underscore the relevance of the core ture capabilities planned to search the medical content and facilitate long-term retention of criti- literature and electronic health record. cal knowledge. Looking ahead, UMMS is testing the use This model is exemplified in the recent re- of digital avatars in advanced communication design of the medical school’s core biochemistry scenarios and, in collaboration with Coursera, course, which eliminated most of the traditional developing blended lecture snippets with embed- lectures. In the place of lectures, instructors ded assessment to deliver full courses online. developed short online presentations that students Looking more broadly, UMMS has been an active were expected to view prior to class. Class time participant in open.michigan, an open courseware primarily was devoted to interactive discussions initiative of the University of Michigan that allows of case studies that highlighted the biochemical faculty to share their educational resources such bases of various diseases. Student attendance for as downloadable lectures, YouTube videos, and the optional interactive sessions rose to more than SlideShare presentations with the global learn- 80% from 30% attendance at the lectures the prior ing community. As of October 2012, 98 UMMS year.45 Other interactive approaches identified for faculty were participating and 13 M1 and 10 M2 future flipped classes include multi-station exer- 13 Figure 2 Science-Based Interactive Compelling, & Patient Centered Material Based upon each school’s unique methodologies Minimum, Foundational, & “Evergreen” Material Based upon each school’s and student’s specific areas of interest and emphasis cises, team-based problem solving, game playing, by reading materials and other resources). debates, live patient presentations, standardized In August 2012, Stanford University created patient interviews or examinations, and high- an Office of the Vice Provost for Online Learning fidelity medical simulations. (VPOL). This is only the third vice-provost-level The Stanford Medical Interactive Learning office created by the university in approximately Initiative (SMILI) was developed to underscore the 20 years and underscores the university’s com- need to develop richly interactive sessions to com- mitment to online learning. In November 2012, plement any online instruction. SMILI facilitates the VPOL invited faculty to submit proposals for the education of teachers and learners in the peda- online and blended courses that would provide an gogical basis and structure of interactive learning; innovative learning experience and include a plan organizes, conducts, and assesses pilot projects; and for researching the impact on student learning. provides resources to help with the design, produc- This seed grant program has funded 31 faculty tion, implementation, and assessment of courses projects from across the university, including 10 at utilizing some of the new learning strategies. the School of Medicine. SMILI’s web presence (http://med.stanford.edu/ Stanford also is pursuing collaboration oppor- smili/) was developed to expand understanding of tunities such as developing platforms for host- the benefits of interactive learning and to encour- ing the didactic content and working with other age faculty to become involved. SMILI provides academic health centers to contribute to content specific guidelines, based on pedagogical research, creation and strategies for the interactive sessions. on how to structure effective video lectures (e.g., The long-term goal is to improve medical educa- eight to 15 minutes in length, focused on a specific tion domestically and to facilitate distribution of topic, enhanced with embedded quizzes, reinforced medical knowledge globally. 14 New York University School of Medicine: To- laborate in virtual teams (http://cloud.med.nyu. ward a knowledge syncytium edu/ecosystem/) By establishing the Division of Educational With funding from the Macy Foundation, DEI Informatics (DEI) in 1987, New York University collaborated with the NYU College of Nursing (NYU) created the foundation for leading-edge to develop a shared curriculum for nursing and use of information technology in support of medical students (NYU 3T: Teaching, Technology, medical education. This division seeks to create a Teamwork). The program comprises web-based knowledge syncytium, “a learning and problem- learning modules, interdisciplinary team virtual solving environment which supports access to patient assignments, a mannequin-based inter- information unfettered by time and space.”46 In professional simulation, and a clinical cross-over addition to building the infrastructure necessary where nursing students shadow a physician to support online and computer-aided instruc- and medical students shadow a nurse. Prelimi- tion within NYU, DEI has focused on providing nary evaluation of the program showed that the students with access to all curricular content, computer-assisted instruction improved students’ creating applications that foster student-centered knowledge and that students showed positive learning and that allow students to practice skills changes in their attitudes.47 The curriculum, as often as needed, and sharing their content with including the web-based modules, virtual patient other schools. DEI plays a key role in the imple- curriculum, and simulations cases are freely avail- mentation of NYU’s new medical school cur- able from the NYU DEI site. riculum, C21, and in collaboration with the NYU College of Nursing developed a curriculum to Johns Hopkins University School of Public strengthen inter-professional education. Health: Extending reach and impact In addition to putting the entire curriculum While Johns Hopkins University’s (JHU) inter- from undergraduate to graduate medical educa- est in part-time education dates back more than tion online so students can look ahead or back, 100 years, the Bloomberg School of Public Health DEI’s activities include developing the following: (BSPH) established JHU’s first formal distance n e-Portfolios that will integrate qualitative and education division in 1996. Motivated by the quantitative data on instructors and learners need to support researchers who were working on n The Virtual Microscope that replaces uses of BSPH projects around the world, BSPH initially physical microscopes and allows students to offered five online courses for 36 students. Today, navigate, annotate, and collaboratively view BSPH offers 113 for-credit online courses for full- high-resolution digital histology slides. (This and part-time students working toward master’s code has been released as open source.) degrees. In 2005, BSPH launched its open course- n WISE-MD modules that are web-based educa- ware project as a way to get critical content in the tional tools, designed for integration into the hands of people who need it—especially public third-year medical student surgical clerkship health workers grappling with urgent issues in the curriculum. The modules present a compre- field. Today, BSPH provides access to the course- hensive picture of patient care, including core ware for more than 100 courses. In 2012, JHU knowledge, technical skills, professionalism, joined Coursera, and in a short period of time and the clinical reasoning skills that guide the had eight courses on the platform and 175,000 physician’s decision-making process. These students registered for these courses. modules are available for licensing through Like MIT, BSPH used OCW to extend its UMed (www.med-u.org). reach and meet global needs for its content. The n The BioDigital Human that allows students to degree-granting online programs provide flexibili- view life-sized digital content on a screen in the ty to students who need to fit their studies around anatomy lab as a supplement to their experience a full-time job. All of JHU’s schools now offer with cadavers online programs, with 16,000 students enrolled n VP21, a web-based experience that allows each semester. These programs are profitable and students to manage virtual patients and to col- help maintain the fiscal strength of the individual 15 schools. Interestingly, previous conversations available prompts and clinical decision support among the schools did not result in agreement to within the EHR also are educational tools. In a share a common learning management platform 2010 survey of medical school deans, more than despite the potential to save costs by doing so. 90% of respondents thought that excluding stu- With the arrival of Coursera, however, there was dent notes from patient records would negatively unanimous interest in signing a university-wide impact education. A 2008 survey of third-year agreement, which allowed the schools flexibility medical students in outpatient clinics reported on when and how they posted courses on the that students asked more history questions and Coursera site. ordered more clinical preventive tests as a result of EHR prompts.48 University of California-Irvine School Yet many hospitals do not allow students of Medicine: iMedEd to enter notes into EHRs because of concerns UC Irvine has built a digital, interactive learn- about violations of Medicare fraud regulations on ing environment for its students. Since 2010, the student notes and teaching physician use of such iMedEd Initiative has provided each entering notes. Recent developments in the form of data student an Apple iPad that houses the entire first- “handles” may offer institutions a way to work year curriculum, including outlines, handouts, and around this constraint. In short, all data entered textbooks, as well as hundreds of medical applica- by a student could easily be tagged with a unique tions (apps). The tablets have been updated to handle that allows faculty to review student notes include course materials required for the second and for student notes to be excluded from the offi- and third year as students have progressed forward cial/legal record.49 Alternatively, schools can pro- in their studies. Complementary technologies such vide access to EHR systems specifically designed as digital stethoscopes and portable ultrasound for students. The University of Victoria developed devices with supporting instructional content the Interdisciplinary Electronic Health Record enhance the learning experience. To maximize the Educational Portal (UVicIED-EHR Portal), a web- benefit of this educational platform, lectures have based portal that provides students with access been transformed to include short, topic-based to multiple EHRs as a way for them to interact podcasts and small-group discussions. with the systems using “dummy” data and provide exposure to different EHR designs and features. The portal allows educators to “teach students Emerging and maturing how to effectively and efficiently use a HIS [health educational approaches information system] in the safety of the classroom and laboratory setting.”50 Technological advances, cognitive science, and new perspectives on existing educational tools are Spaced education: Applying cognitive science widening the range of educational approaches that to improve knowledge retention health professional schools can use to enhance the Spaced education (SE) is an online learning learning of their students. methodology based on psychological research that shows that educational encounters repeated Electronic health records as a needed skill over time increase acquisition and retention of and as a learning tool knowledge and that the process of testing alters All health professional students need to learn how the learning process to improve knowledge reten- to use electronic health records (EHRs) to be pro- tion.51 SE can be applied across a wide range of ficient. They likely will encounter different EHRs topics and shared among institutions. In one trial over the course of their education and careers, so of a spaced education game focused on anatomy, they need a general understanding of EHR sys- histology, cardiology, and endocrinology, students tems and their effective use as well as exposure to received an automated email containing a link to different kinds of EHRs. Further, the increasingly multiple choice questions.52 Upon submitting an 16 answer to a multiple choice question, the student Simulation centers: The pinnacle received the correct answer, a summary of the of education technology? curricular learning points, explanations of why Human patient simulation (HPS) uses manne- the answers were correct or incorrect, and links to quins or models to offer students an immersive, additional educational material. The game would active experience; engage emotional and sensory repeat the question in three weeks if answered learning; foster critical thought and communica- incorrectly; six weeks if answered correctly. The tion; and animate basic science in clinical context. goal of the game was to retire 100 questions so Such experiences require learners to synthesize the length of the game depended on students’ knowledge and demonstrate skills before putting baseline knowledge and ability to learn and retain them into practice. Simulation centers provide a knowledge from the SE questions and answers. way for individual students to train for specific, This game was well accepted by medical students complex tasks and for multi-disciplinary groups and demonstrated effectiveness in teaching core of students (and practitioners) to build compe- content and validity in testing medical student tence in functioning as a team while grappling knowledge. with realistic patient scenarios. Further, HPS allows students to demonstrate competency in Virtual patients: Health care’s flight simulators specific areas. In nursing, simulations are often Virtual patients or computer-based clinical case part of the screening process by employers. simulations present students with real-life clini- Eighty-seven percent of nursing schools are cal scenarios that enable them “to emulate the using high-fidelity mannequins and are spend- roles of health care providers to obtain a history, ing millions of dollars in resources and faculty conduct a physical exam, and make diagnostic time revamping curricula to incorporate simula- and therapeutic decisions.”43 Virtual patients are tion.55 In some instances, schools are anticipating often viewed as a safer and more efficient way for a future in which nurses will need to demonstrate students to apply relevant knowledge and practice proficiency in simulations to retain their licenses. clinical skills. They provide a way for schools to In other cases, nursing schools are striving to ensure student exposure to both common and expand their capacity. NYU College of Nursing rare clinical conditions. Virtual patients vary (CON) has doubled in size to 800 students since in their design, implementation, and effective- 2007 and is challenged to find clinical sites and ness.53 They are accepted by students, particularly faculty to teach the increasing enrollment. As students who have had limited clinical contact.54 a result, NYU CON has committed to replace Compared with no intervention, they are associ- 50% of undergraduate clinical hospital time with ated with higher learning outcomes. Compared simulation. with a non-computerized intervention, there is Medical schools are making large investments no or only a small effect. Beyond quantitative in simulation as well. In 2010, UC Irvine School improvement, however, virtual patients address of Medicine opened a 3,000-square-foot, state-of- logistical barriers and provide opportunities the-art simulation facility that includes a multi- for students to work in teams on the cases and disciplinary critical care area that can be used to provide interactive learning opportunities that can simulate an emergency department trauma bay, a fit into the schedules of busy practitioners. This full-scale operating room, a critical care unit, an educational technology shows great promise as obstetrics suite, or a patient ward.56 Task trainers a way to tailor learning experiences to the needs support diagnostic and therapeutic skills develop- of students but also requires rigorous evaluation ment. These facilities are being used to prepare to determine which formats and implementation medical and nursing students, residents, fellows, approaches are most effective. practicing physicians, and EMS personnel. They are equipped with teleconferencing and video recording so that teaching can be shared globally. A recent meta-analysis of 609 technology-en- 17 hanced simulation training studies that compared enabled by education technology: simulation with no intervention (i.e., no train- n uthentic contexts for learning and assessment A ing) concluded that simulation “is consistently n ncoupling of instruction from place and time U associated with large effects of knowledge, skills, n tandardization of instruction and assessment S and behaviors and moderate effects for patient n reater ease in sharing content within and G outcomes.”57 The authors noted that key questions among institutions remain on when and how to use simulation most Table 5 presents the potential benefits that effectively and cost-efficiently. Another recent stakeholder groups are likely to experience when meta-analysis of the effects of simulation training institutions implement educational technology. in central venous catheterization concluded that While educational innovation enabled by simulation-based education was associated with technology offers many potential benefits, it does significant improvements in learner outcomes and not currently address all aspects of health profes- with improved patient outcomes in some areas sional education. Importantly, it does not fully (i.e., fewer needle passes and pneumothorax) but replace personal interaction among faculty and was not associated with reduced risk in arterial students that are required for humanistic and puncture or catheter-related infections.58 ethics education and absorbing professionalism. The National Council of State Boards of Nurs- It cannot replace role modeling, patient interac- ing has embarked on a three-year, 10 institution tion, or real-time supervision and accompanying study that will compare the clinical competence of opportunities to observe practices such as “fuzzy three cohorts of students who experience differ- logic” (i.e., decision making with imprecise data). ent levels of simulation as nursing students (50%, It cannot assess or teach emotional intelligence 25%, and 10%). Researchers will collect National and empathy. Educational technology can help Council Licensure Examination pass rates for the students be fully prepared for their first interac- study students and will track the students through tions with patients, but only through real experi- their first year of practice. Final results are ex- ence can students achieve true mastery. Purpose- pected in 2014.59 ful integration of these approaches into the full continuum of health professional education and continuing education remains a challenge. Potential benefits and limitations The benefits of educational innovation enabled Obstacles by technology can generally be characterized as improving the quality and efficiency of the There are significant obstacles to achieving the education process. These technologies offer vision for health professions education presented health professional schools the means to improve early in this report (see Table 6). The first hurdle quality dimensions of specific concern for their to overcome is the collective inability within the students—tailoring learning experiences (includ- health care community to imagine a different ing the need for repeated practice to master skills) future for health professions education. Health and adapting to diverse learning styles, supporting education leaders must articulate a compelling team learning that fits into the varying schedules vision that will enable myriad individuals and of health professional students, and assessing and organizations to imagine a fundamental change tracking competency of students. They also offer in the paradigm of health professions education the potential to educate increased numbers of and stimulate them to take actions that lead to the health care professionals who are better prepared envisioned future. Equally important, organization- within and across disciplines to produce higher al cultures and leaders must adapt to implement value health care for patients and society at a needed changes and support the new paradigm. reduced cost per student. These benefits derive Organizational culture must shift from hierarchi- in large measure from four capabilities that are cal, autonomous, competitive, individualistic, and 18 expert-centered to collaborative, team-based, ser- petencies beyond knowledge recall, including vice-based, mutually accountable, and patient- (or the ability to use technology student-) centered.60 So too, future leaders will need n Ability to move to the next level of training to focus on collaboration and team work, transla- upon competency demonstration independent tional science, strategic thinking, and breakthrough of formal training cycles/dates approaches rather than individuals, basic or clinical While there has been some progress in these science, tactics, and incremental approaches. They areas, such as the 2011 expert panel that identified will need to be competence-centered rather than core competencies for collaborative practice and knowledge-centered and will face a more diverse the newly formed National Center for Interprofes- workforce that values professional (including ethi- sional Practice and Education at the University of cal) fulfillment over status and titles. Minnesota, accelerated alignment of regulators, Systemic obstacles to achieving the vision payers, delivery organizations, and accreditation must be confronted on multiple fronts—from agencies around competency-based approaches pre-health education of students, to financing of is essential to building the foundation for a graduate medical education, to the health care reformed health professions education system delivery system. The standard pre-health curricu- supported by innovative use of technology. lum is not well aligned with emerging require- In addition to the broad challenges to health ments for health professions students. Constraints professional education reform, there are also on funding for GME slots prevent medical schools obstacles specific to the development and imple- from increasing the number of students to meet mentation of effective educational technology for anticipated health care needs. Within the deliv- health professional students. Some faculty may ery system, team-based approaches to providing feel threatened by or not prepared for the changes patient care are the exception rather than the rule, associated with widespread use of educational and there has been little attention to or invest- technology and may therefore resist organization- ment in team preparation by health care delivery al efforts to expand online learning and reduce organizations. As a result, students receive little the number of traditional lectures. Some may exposure to team-oriented patient care during resist having their lectures recorded or shared clinical rotations. with other institutions as it puts their teaching Perhaps most critical and daunting is the set under greater scrutiny. Faculty may also demon- of challenges associated with moving toward strate “institutional narcissism” and the belief that competency-based health professions education. only content developed at their school should be As illustrated in Figure 3, a host of organizations used to teach their students. This resistance stifles influence the education and certification of health collaboration among schools and curtails the abil- professionals. These groups face their own stake- ity to achieve economies of scale in creating and holders and financial incentives that are often in using content. conflict with desired changes in health professions Health professional school leaders lack education. Yet to make real progress toward the evidence to make the case for greater invest- desired competency-based education of health ment in this arena. They also lack information to professionals, these organizations will need to support decisions about which of the many and reach consensus on fundamental issues and invest ever-changing new approaches, platforms, and in the development of tools and infrastructure technologies will best fit an organization’s needs. that support competency-based education. Spe- Finally, as all health professional schools face tight cifically, the following are needed: budgets, the availability of funding for the invest- n Clear definition and continued refinement of ments required for these innovations is limited. competencies within disciplines and identifica- Capturing the potential efficiencies offered by tion of competencies that are common across these technologies will require AHCs to confront all disciplines difficult questions. By reducing the constraint of n National assessment tools that assess the com- lecture hall size, does this technology allow class 19 Table 5: Potential benefits of innovative education supported by technology Stakeholder Benefits Students n Learner control n W hen and how to learn n ble to access knowledge at any time A n ake as much or as little time to learn material T n pportunity to practice skills as needed O n stablish habit and skill of life-long learning E n E nhanced, realistic visualization n “ Learning science” approach increases likelihood that content will be mastered more efficiently and retained longer n E nhanced experience with learning processes n A ccess to vast repertoire of expertise n A bility to cover more topics in online modules than in didactic lectures n S hortened time to reach competency for some students and as much time as needed for other students n P erformance tracked over time so that able to demonstrate com- petency (shift from “time in chair” to attainment of milestones) Faculty n Increased engagement and satisfaction through greater interaction with students and opportunity for continuous innovation n I ncreased awareness of concepts and ideas that learners find dif- ficult to master n A bility to identify specific learning needs of individual students n I terative improvement in content and teaching methodologies n E ase of updating content and refining pedagogical methods n R educed time delivering repeated lectures increases time avail- able for more intellectually meaningful educational and scholarly initiatives Institution n Increased ability to adapt curriculum to societal needs n Increased nimbleness in making curricular changes n E nhanced collaboration and knowledge sharing within and among organizations n R educed risk to patients through use of safe, controlled environ- ments for teaching skills n I ncreased transparency and accountability regarding the quality and cost outcomes of the education experience n D ocumentation of learner behavior and outcomes is built into the system and can be used to improve processes n I ncreased ability to meet the needs of nontraditional students with other responsibilities, which may increase diversity of the student population 20 Table 5, continued Stakeholder Benefits Institution n Increased capacity to do the following: n E ducate more health professional students without replicating all costs n horten time (and potentially reduce costs) for some students S to achieve competency and complete training n E nhanced resources and new economies of scale n I ncreased capacity of existing physical plant and potential to reduce capital needed for new facilities n O ptimized faculty time via reduced repetitive lecture demands and increased time available for mentoring, educational innova- tion, focus on humanism and professionalism, communication skills, and scholarly contributions n D ecreased logistical problems of inter-professional education n I ncreased capacity to assess and analyze what is being taught and to manage curriculum n I ncreased alignment with expectations of 21st century students (Will use of educational technology become a way students dif- ferentiate among health professional schools?) Society n Health professionals better prepared to meet societal needs (en- hancing the quality of patient, family, and community care while making better use of finite resources) n P ublic resources for teaching health professionals are optimized sizes to be expanded so that costs per students are Enablers reduced? If schools are sharing online lectures, are fewer or greater numbers of faculty or subgroups Enablers that will support and accelerate diffusion of faculty (e.g., tenure track) needed? Do schools of educational technology among health profes- need faculty with a different skill set who are ca- sional schools fall into two broad categories—in- pable of developing and using online approaches stitutional enablers and national/collaborative and facilitating interactive learning experiences enablers. rather than offering traditional lectures? If the Institutional enablers include the following: teaching faculty of an institution changes shape n A clear statement of where the institution is over time, how will the patient care and research headed with educational process innovations missions be impacted? Will research related and greater use of education technologies to the educational enterprise receive increased (including online learning), why the institution recognition? AHCs will be well served to begin is making greater investment in these technolo- contemplating such issues as part of their strategic gies, and how expected benefits will be achieved planning so that they have time to implement an- n An organizational culture that embraces col- ticipated shifts over time (e.g., implement changes laboration, focuses on competency-based edu- as hiring opportunities emerge). cation, encourages breakthrough thinking, and is student- (rather than faculty) and ultimately patient- and outcomes-centered 21 Table 6: Obstacles Current learning state Future learning state Rigid hierarchy Flexible hierarchy Individual expertise and autonomy Team-based learning is valued anticipating team-based are valued clinical care n eam-based expertise T n ndividual roles requiring definition I n ompetency requirements defined by the role C n earning content requirements defined by the role L Learning is content oriented Learning is content and competency oriented n imulation used for competency learning and assess- S ment Inconsistent emphasis on profes- Faculty time devoted to professionalism with an under- sionalism standing of how health delivery metrics are influenced by professional behaviors (HCAPs, CGCAPs, engagement tools such as Gallup) Inadequate focus on EHR technology Emphasis on the role of EHR & informatics in tracking “pay-for-value” reimbursement metrics Inadequate focus on benchmarking Understanding how quality, safety, service benchmarks for individual patients and populations of patients, physicians, and care teams, are used to improve clinical processes and outcomes Faculty-centered Student/resident/physician-centered n ime on task proxy to knowledge T n ariable time to knowledge acquisition V acquisition n ompetency-based C n linical C and academic missions and incentives n Standards for sharing educational content and that are aligned with a new paradigm for health tracking students across settings and time professions education and practice accompa- n latforms for sharing content P nied by shared accountability across the AHC n ommunities of practice that share best prac- C for making needed changes tices n redible faculty champions who can share C n rganizations that are willing to share content O experiences and knowledge with other faculty (either for free or via licensing) n aculty who are supported in the transition F n research agenda to fill key gaps in our un- A through investments (i.e., time and resources) derstanding of the effectiveness of technologies to develop new skills and approaches n echnological and pedagogical resources, in- T In addition to the emerging shared learning cluding expertise and technical infrastructure, management platforms (e.g., Coursera, Udacity) which are adequately funded and developed to and open source content (OpenCourseware), keep pace with anticipated changes. several collaborative enablers focused on health National/collaborative enablers include the professions education are already in place. following: The Association of American Medical Col- n shared compelling vision for health profes- A leges (AAMC) Medical Education Research sional education that is embraced by the health Certificate (MERC) Program (https://www. care community aamc.org/members/gea/merc/) “is intended to 22 provide the knowledge necessary to understand In addition to providing a platform for sharing the purposes and processes of medical educa- content, iInTIME offers authoring software and tion research, to become informed consumers of training resources to support medical educators in the medical education research literature, and to the development of virtual patient cases. Further, be effective collaborators in medical education “the broad use of MedU cases fosters an active research.” The courses are targeted for clinicians cross-disciplinary community of medical educa- and other educators who desire to learn research tors.” skills that will enable collaborative participation in The MedBiquitous Consortium (http://www. medical education research projects. Strengthen- medbiq.org/) creates technology standards that al- ing medical education research skills among fac- low organizations to exchange educational content ulty will increase an institution’s ability to evaluate and track learner activities and profiles. These internal educational technology activities and to standards support flow of data to track profes- participate in multi-institution studies. sional achievement and share learning resources. The Institute for Innovative Technology in MedBiquitous emphasizes lifelong learning and Medical Education (iInTIME) (http://www.i- continuous improvement by practitioners as it intime.org/) was established in 2006 to advance seeks to enable better patient outcomes. medical education through the collaborative MedEdPortal (https://www.mededportal.org/) development, maintenance, and research of in- is a clearinghouse for high-quality, peer-reviewed novative and comprehensive computer-assisted health education tools. The free service is provid- instruction programs. Through MedU, iInTIME ed by the AAMC in partnership with the Ameri- provides a platform for sharing and accessing can Dental Association. The mission of MedEd- virtual patient cases and other medical education Portal is to promote “educational scholarship and programs for third-year students across a range collaboration by facilitating the open exchange of disciplines (pediatrics, radiology, genetics, of peer-reviewed health education teaching and internal medicine, family medicine, and surgery). assessment resources.” More than 10,000 national Figure 3 23 and international health education institutions in ers have found that these methodologies are more 195 countries are accessing and utilizing MedEd- effective than no intervention (i.e., no instruction) Portal content. Users include schools of medicine, and slightly more effective than or comparable dentistry, osteopathy, nursing, pharmacy, and to traditional teaching approaches.35 One meta- public health, as well as the general public. analysis of studies on Internet-based instruction The National Center for Interprofessional involving health professions learners concluded Practice and Education (http://www.ahceduca- that (1) compared with no intervention, on- tion.umn.edu/nexus-ipe/) was launched in Sep- line learning (Internet-based learning, or IBL) tember 2012 at the University of Minnesota with yielded large positive effects and that Internet- a five-year funding commitment from the Health based instruction was effective across a variety Resources and Services Administration (HRSA) of learners, topics, and contexts; (2) differences and four leading foundations. This public-private in effects compared with those of non-Internet partnership will identify ways to “improve health, instructional methods were generally small; and enhance patient care, and control costs through (3) some methods of IBL may be more effective integrating interprofessional practice and educa- than others.61 This study did not, however, find tion.” The center is focused on five core domains: evidence on which to base guidelines for future leadership; collaborative practice and health implementations of IBL. A subsequent study by system transformation; education and training; the same researchers focused on direct compari- research, evaluation and scholarship; and innova- sons of one IBL intervention for health profes- tive and novel models. sionals against another.62 Researchers identified OPENPediatrics (http://www.openpediatrics. a “modest number” of studies for analysis and org/) is an open self-directed learning platform therefore qualified their conclusions in terms of that promotes sharing of knowledge about care of “highlighting promising areas for future research.” ill children through three key functions—infor- They concluded that interactivity, practice exer- mation on demand, social networking capability, cises, repetition, and feedback improve learning and education on general principles and optimal outcomes and that interactivity, online discussion, practice in pediatric care. This beta test site is and audio improve satisfaction in IBL for health aimed at the global community, but once broadly professionals. available the learning modules on this site could Perhaps most important in these and other also serve health professional students and practi- early studies is the emerging research agenda for tioners in the U.S. Further, this approach could be this domain. The research agenda would include, adopted by other specialties. but is not limited to the following: n Do these technologies impact the applied knowledge and skills of health professional stu- Emerging Research Agenda dents and contribute to the continued refine- ment of competencies? The widespread adoption of information tech- n Which of these technologies are most effec- nologies has led to a corresponding growth in the tive overall, and does effectiveness vary across development of sophisticated, realistic teaching types of learners, stages of learning, and various resources. However, our understanding of how content areas? these resources might best be incorporated into n When should online learning or other edu- the curriculum is inadequate, as advances in what cational technologies (e.g., virtual patients, could be created often outpace our ability to un- spaced-education games, apps) be used? derstand how they should be developed or used.43 n How can online learning be effectively imple- mented? Under what conditions could online What do we know about the effectiveness of learning be used exclusively to achieve student online learning or computer-aided instruction for competency? When does it best serve to aug- health professions students? In general, research- ment small-group learning? 24 n How do skills developed on simulators transfer adopted, and institutional hubris must be over- to patients? come. Greater investment at the institutional and n What is the cost-benefit of these technolo- national levels is needed to support diffusion and gies? Do these technologies yield savings in the evaluation of the technologies. Institutional and educational process within individual institu- national leaders need to increase awareness of the tions or across groups of institutions? Do they benefits of these tools and associated changes in improve quality of education? Is there a positive teaching processes, but they should also be cogni- return on investment? zant of the limitations of the technologies under n Can the effective use of these educational ap- consideration. AHC and health professional proaches and technologies be linked to im- school leaders should also understand that while proved patient outcomes? there is considerable potential in sharing content As a first step, researchers need to develop among institutions, how that content will be used shared frameworks for research, consistent defini- will vary because of differing needs and foci of tions of interventions and comparison interven- AHCs and schools. That is, one size will not fit all. tions, and common outcome measures.63 Work- ing from shared frameworks, interventions, and Institutional initiatives outcomes will permit replication across learner AHCs have varying levels of experience with groups and different educational objectives. educational technologies. Yet virtually all AHCs Further, as more institutions begin to use shared have implemented clinical information systems learning platforms, the data pool for analysis will and can draw upon that experience as they seek grow considerably and enable larger, multi-insti- to increase use of educational technologies as a tution studies. means of improving quality and efficiency of edu- cation processes. Just as with clinical information systems, AHCs and health professional schools Recommendations should follow a structured process for expanding use of educational technologies. They should The Blue Ridge Group concludes that innovative n Conduct a needs analysis that will serve as the use of educational technologies, including but basis for selecting which technologies and ap- not limited to online learning, offers the potential proaches to adopt to make progress toward specific elements of the n Develop business and implementation plans vision for enhanced health professions education. n Expand institutional capacity to support tech- These technologies can nological and pedagogic innovations n Facilitate greater flexibility for several dimen- n Evaluate effectiveness of implemented technol- sions of the health professional educational ogy and approaches to determine which should enterprise be continued, modified, or eliminated and n Create a wide variety of practice opportunities share results with the broader community for students Needs analysis—As a first step, AHCs and n Enhance quality and increase efficiency of health professional schools should do the follow- teaching processes ing: n Enable measurement and tracking of costs and n Identify organizational needs that can be met outcomes of educational processes through innovative use of education technologies n Capture and track student performance n Define the value that the institution seeks to To take advantage of these technologies, both capture through increased use of educational institutional and national capacity in the form of technologies a technological infrastructure and technical and n Inventory existing initiatives and resources pedagogic expertise need to be strengthened. To within their schools and across the university achieve desired efficiencies, core content must be including faculty, staff, students, and partners identified, platforms for sharing content must be already engaged in innovative approaches as well 25 as investments in technology already in place, dents can share their work, fund joint projects such as use of EHRs for teaching and research that cross departments or disciplines) n Increase organizational knowledge of external n Set specific organizational goals, develop clear resources that can be adopted expectations for faculty and staff, and align n ssess whether existing learning manage- A performance incentives to desired outcomes ment systems can support evolving needs (e.g., Expand institutional capacity—To expand greater use of online lectures, incorporating institutional capacity to develop and apply edu- content from other institutions, sharing content cational technologies that meet organizational with other institutions, creating student and needs, AHCs and health professional schools faculty portfolios) should do the following: n dentify the approaches most relevant for their I n Allocate time and provide training opportuni- institutional situation, student needs, and mis- ties for faculty to develop skills and gain experi- sion ence in developing and using new educational Business and implementation plans—In devel- technologies and approaches (e.g., developing oping the business plan, AHCs and health profes- online learning modules and leading more sional schools should do the following: interactive face-to-face sessions) n rticulate the business model for expanded use A n Establish support services that provide educa- of educational technologies within the schools tional design/pedagogic expertise and technical and across the AHC (e.g., does the institution expertise (e.g., app development, copyright seek to achieve efficiencies to offset costs, im- clearance and intellectual property for content prove quality for same costs, expand through- that is to be shared) put, capture revenues from new sources) n Upgrade or replace the existing infrastructure n dentify the level and mix of resources needed I to achieve a robust learning management sys- to capitalize on the technologies and innova- tem, authoring tools, student portfolios, faculty tions (i.e., financial, human, technological) and portfolios, ability to use content developed consider whether the needed faculty skill set elsewhere, and ability to share content with will evolve over time other institutions n dentify funding sources I n Encourage development of learning communi- n etermine the optimal mix of internal develop- D ties or communities of practice by region, pro- ment, institutional partnering, and outsourced fessions, common interests, or other delineators development to enable and accelerate knowledge sharing n etermine which platforms for sharing content D Evaluate effectiveness—To provide guidance are optimal on future educational technology initiatives, In developing an implementation plan, AHCs and AHCs and health professional schools should do health professional schools should do the follow- the following: ing: n Require that all educational technology initia- n etermine how they can build on existing D tives funded internally include an evaluation internal and external resources that measures effectiveness for learners and the n dentify ways to encourage a climate of innova- I degree to which organizational goals are met tion and breakthrough thinking (e.g., allocate n Support faculty training in health professions funding for pilots that test novel approaches to education research education technology) n Encourage participation in multi-institution n dentify champions and recognize efforts I studies already under way through existing communi- cation channels National initiatives n stablish mechanisms to bridge existing E The Blue Ridge Group identified the follow- “islands of innovation” (e.g., hold a university- ing actions to accelerate diffusion of education wide conference where faculty, staff, and stu- technology among AHCs and health professional 26 schools with the goal of improving the quality and tives (e.g., MedEdPortal), stimulating action on efficiency of educational processes and ultimately development of core and commodity curriculum strengthening the health professions workforce: components, achieving consensus on research n As a professional community, we must in- priorities, establishing pilots to test effectiveness, sist that accrediting, licensing, and certifying expanding awareness and creating a sense of ur- agencies align their processes to support the gency, and developing tools that organizations can innovations described in this report as well as use as they consider and implement educational the broader changes needed (e.g., movement technologies. toward competency-based education) for trans- formation of health professions education. n AHCs and health professional school leaders Conclusion and representatives of licensing and certifying agencies should identify “commodity” curricu- Most new movements start this way: hundreds lum components and encourage adoption as or thousands of individuals and groups, working a standardized core across institutions to gain in different fields and different locations, start economies of scale and allow faculty to focus on thinking about change using a common language, individualized and group learning experiences without necessarily recognizing those shared as a way to improve quality and efficiency in values. You just start following your own vector, the learning process. propelled along by people in your immediate n AHC leaders and national professional orga- vicinity. And then one day, you look up and realize nizations should increase awareness regarding that all those individual trajectories have turned the potential for technology to transform health into a wave. (Steven Johnson)64 professions education, including impact on quality, cost, and outcomes of education. The shortcomings in health professions education n AHC leaders and national professional organi- and the growing wave of online learning create zations should create a national collaborative unprecedented challenges and opportunities for to accelerate and coordinate development of a AHCs and health professional schools. Pioneer- framework and tools for assessment and dis- ing institutions are highlighting how educational semination of innovative educational approach- technologies and approaches based on cognitive es (including use of technology) designed to science can be used to address health profes- improve the quality and efficiency of health sions education deficits and offer greater value to professions education. students. Shared learning management platforms Collaboration will be key to achieving desired offer new ways for schools to share content, assess outcomes. The full benefits of these technologies effectiveness of various educational tools, and and approaches will be achieved only if institu- reduce costs. These technologies support innova- tions come together to do the following: tion and enable collaboration among schools and n Share best content across disciplines. To maximize the impact of on- n Ensure that content is inter-operable line learning technologies, AHC leaders need to n Share best practices and experience articulate a new vision, pool resources, confront n Rigorously assess impact of technology and structural barriers, and establish a mechanism for innovations and provide feedback on quality of sharing content and best practices. content n Identify opportunities for reducing costs by working together Specific goals for the collaborative would include creating a community of users and developers, identifying and publicizing existing resources that can help facilitate advancement of these initia- 27 References 15. lue Ridge Academic Health Group. Reforming B Medical Education: Urgent Priority for the Academic 1. etmer DE. Knowledge: a mountain or a stream? D Health Center in the New Century. Atlanta: Emory Science. 1997;275:1859. University; 2003. 2. arson S, Schmidt JP. The massive open online C 16. ohns MME. 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Future Perfect: The Case for Progress in a J 60. irch D. The main obstacle and key tool to linking K Networked Age. New York: Penguin Group; 2012. health sciences education: Presented at Annual Meeting of the Blue Ridge Academic Health Group; August 2012; Park City, UT. About the Blue Ridge Academic Health Group The Blue Ridge Academic Health Group (Blue Ridge Group) studies and reports on issues of funda- mental importance to improving the health of the nation and our health care system and enhancing the ability of the academic health center (AHC) to sustain progress in health and health care through research—both basic and applied—and health professional education. In 16 previous reports, the Blue Ridge Group has sought to provide guidance to AHCs on a range of critical issues. Previous reports identified ways to foster a value-driven, learning health care system for our nation; enhance leadership and knowledge-management capabilities; aid in the transformation from a paper-based to a computer- based world; and address cultural and organizational barriers to professional, staff, and institutional success while improving the education of physicians and other health professionals. Reports also focused on updating the context of medical professionalism to address issues of con- flict of interest, particularly in the relationship between academic health professionals and institutions and their private sector partners and sponsors; quality and safety; and improved care processes and in- novation through the use of informatics. One key report explored the social determinants of health and how AHCs could reshape themselves to address this critical dimension of improving health. The group also issued a policy proposal that envisioned a new national infrastructure to assure ongoing health care reform, calling for a United States Health Board; identified opportunities and the most critical challenges for AHCs and their partners as the Accountable Care Act (ACA) was implemented and examined ways in which AHCs could leverage their unique characteristics and capabilities through the ACA to improve health care, research, and training systems. For more information and to download free copies of our reports, please visit www.whsc.emory.edu/blueridge. 30 Previous Blue Ridge Reports See http://whsc.emory.edu/blueridge/publications/reports.html. Report 16: Academic Health Center Change and Innovation Management in the Era of Accountable Care. 2012. Report 15: The Affordable Care Act of 2010: The Challenge for Academic Health Centers in Driving and Implementing Health Care Reform. 2012. Report 14: The Role of Academic Health Centers in Addressing the Social Determinants of Health. 2010. Report 13: Policy Proposal: A United States Health Board. 2008. Report 12: The Emerging Transformational Role of Informatics. 2008. Report 11: Health Care Quality and Safety in the Academic Health Center. 2007. Report 10: Managing Conflict of Interest in AHCs to Assure Healthy Industrial and Societal Relationships. 2006. Report 9: Getting the Physician Right: Exceptional Health Professionalism for a New Era. 2005. Report 8: Converging on Consensus? Planning the Future of Health and Health Care. 2004. Report 7: Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century. 2003. Report 6: Creating a Value-driven Culture and Organization in the Academic Health Center. 2001. Report 5: e-Health and the Academic Health Center in a Value-Driven Health Care System. 2001. Report 4: In Pursuit of Greater Value: Stronger Leadership in and by Academic Health Centers. 2000. Report 3. Into the 21st Century: Academic Health Centers as Knowledge Leaders. 2000. Report 2: Academic Health Centers: Good Health Is Good Business. 1998. Report 1: Academic Health Centers: Getting Down to Business, 1998. 31 32 33