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New Directions in Medical e-Curricula and the Use of Digital Repositories

Fleiszer, David M. MDCM, MS; Posel, Nancy H. MEd; Steacy, Sean P.

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In the past, e-curricula, associated multimedia learning objects, and digital repositories have not been viewed as intrinsically related. However, ongoing development of electronic curricular material1 and the consequent integration of multimedia learning objects2 mandate that schools examine methods and processes for storing and accessing both text and the multimedia learning objects fundamental to these e-curricula.

This trend, in conjunction with a parallel increase in the scope and availability3 of digital repositories to effectively and efficiently support the use, reuse, and repurposing (the alternative use of similar or comparable material within a different context) of electronic content,4,5 suggests that it is time to explore whether e-curricula and digital repositories are essentially partners and integral components of a larger and more comprehensive initiative.

Upon first review, it may seem that decisions involving e-curricula and digital repositories are predominantly technical, and thus fall primarily under the mandate of interested faculty and their development teams; however, we believe that this perspective lacks an understanding of the global and long-term impact of the potential for affecting future e-curricular development, collaborative relationships both within and between schools, and potential partnerships among schools. In addition, development is resource intense, involving a considerable allocation of personnel, time and, not insignificantly, an extensive financial commitment. Therefore, initial directions and decisions have significant middle- and long-term consequences and represent a more considerable challenge to the institution than may be initially apparent. Although technological and pedagogical expertise should be included in the definitive appraisal and assessment of potential e-curricula, the issue is ultimately one of curricular development and content, and the final decision should be made by faculty at the highest levels, together with the dean. This proactive and comprehensive approach will help ensure that the requirements of the faculty are served and that global objectives are met.

e-Curricula and Multimedia Learning Objects

“Information transfer through technology is here and is growing”1 and electronic curricula are increasingly manifest in medical schools in North America.1,2,6 Individual teaching and learning methodologies among schools differ in extent and content, and include the development of electronic mainstream and adjunct material, Internet-based modules, interactive quizzes, case-based problems, simulations, and multimedia learning objects linked to specific concepts.

Multimedia is described by Kozam6 as the “ability to present active symbolic elements to create representations of objects in motion, and to present dynamic social contexts and events, to help students construct rich, powerful, mental models.” Multimedia is now generally developed in the form of learning objects and can include static or dynamic images, animations, electronic transparencies, and video and audio files.2 Generally, each learning object is created to exist independently and thus can be manipulated, used, modified, and reused within multiple contexts. This expansion of e-curricular content and the associated exponential increase in the number of multimedia learning objects necessitates a new analysis of the role of and potential for digital repositories, with specific reference to required functionality such as indexing, cataloguing, storing and timely accessibility and retrieval of material for teaching and learning.2,3,6,7 (See Figure 1 for an example of a multimedia object used by the Faculty of Medicine at McGill University in one of its courses.)

Figure 1.
Figure 1.:
A multimedia object. This object, a view of the human eye, is used by the Faculty of Medicine at McGill University in its Basis of Medicine course. The four “buttons” lined up across the bottom indicate the dynamic nature of the view of the eye and allow it to be assembled or disassembled by the professor while teaching. See List 1 for the standardized descriptors associated with this multimedia object.

Digital Repositories

The National Science Foundation8,9 is credited with originating the term digital library or repository, defined as “a set of electronic resources and associated technical capabilities developed for creating, searching, storing, retrieving and using information; an extension and enhancement of initial information storage and retrieval systems with the ability to manipulate digital multimedia data in any medium.”3

In medicine, the linking of automated clinical data and knowledge-based information to support health care, research, and education gained prominence in the early 1980s,9 and a digital presence further emerged with the support of government agency initiatives such as that of the National Library of Medicine in 1996. Until recently, the primary focus of these collections has been the dissemination of information and distribution of educational materials to clinicians, as well as patients and their families. With the Internet becoming a primary means of communication in society and a dominant source for health information,3,4,10 this perspective is now changing.

Building Digital Repositories for e-Curricula and Multimedia Learning

The integration of multimedia learning objects with e-curricula can increase the facility, efficiency and effectiveness of the educational encounter.11 However, since development is resource-intensive, the inefficiencies, high cost, and unnecessary duplication of images inherent in a “one-time use” approach need to be compared with the potential that digital repositories allow for the use, reuse, modification, repurposing, and sharing of multimedia learning objects,4,12 as well as facilitating the preservation of legacy material and fragile originals. Therefore, we maintain that a more comprehensive role for digital repositories needs to be recognized and established. These actions would assist medical schools and facilitate the development of comprehensive e-curricula that meet the requirements of curricular content and allow for future development in accordance with the philosophical and theoretical perspective of the medical school. In particular, the experience at McGill demonstrates this position. Initially, the school separated the development of the e-curriculum from that of the digital repository, and considered the repository to be a secondary and longer-term objective. However, it became increasingly apparent as the role of the e-curriculum expanded that the digital repository could not be relegated and would need to be a significant component of overall development. Presently, the repository serves as the foundation for the e-curriculum. This major switch in perspective has allowed for a more robust construct.


Those cognizant of the potential advantages of using a digital repository from the perspective of their developing e-curricula and its component multimedia learning objects are faced with three fundamental options:

Catalogue objects using methodologies specific to the school

In this scenario, learning objects will be designed without the use of a standardized metatagging schema and for specific modules or lectures only. Reuse or repurposing in other lectures or modules would be viewed as a secondary mandate. This approach reduces future possibilities for “mapping,” or making connections between repositories, and impedes the potential for sharing material. It also inhibits “interoperability,” which is the technical association between multimedia learning objects that reside in diverse locations, allowing for connectivity with other repositories. Therefore, this option represents the least efficient and least effective use of resources. It does, however, provide absolute protection and control over the use of the material.

Develop individual repositories using current metatagging standards

This approach permits the possibility of sharing material either within the school, or mapping to existing or future outside repositories. This, in turn, assuming the philosophy of the school permits, facilitates the use of multimedia objects irrespective of location and widens the magnitude and extent of available materials.

The creation of an e-curriculum is a substantial undertaking for a school, and further development from this point can be an extensive and expensive responsibility. Schools that choose to develop their own repositories and multimedia content need to reflect on the resources and energy involved in the creation, implementation, management, maintenance, and support that will be required. Conversely, they may be better able to resolve issues of privacy, access, and ownership of their images as well as the associated intellectual property.

Integrate multimedia learning object collections into an existing national repository

Amalgamation with existing digital collections would ensure wide availability of digitized material for medical teaching and learning, provide improved access to a continuously expanding warehouse of objects, augment the potential for repurposing material, and impact positively on the extensive resources required during the development of high-quality clinical and science-oriented multimedia.12 However, as is the case with all cooperative ventures and partnerships, there is inevitably some loss of independence, and decisions would be made through negotiation, compromise, and consideration of global issues from varying perspectives.

Issues to Consider

Schools that choose to develop their own repositories using standardized metatagging schemata, or choose to associate themselves with existing wide-scale digital repository initiatives, may be viewed as more pragmatic in their approach in that they optimize the number of available multimedia learning objects and assure greater flexibility in the future, as existing digital collections mature and evolve. Partnerships, whether formal or informal, facilitate this promise, furthering the assertion that the best material in each domain is available to participating schools. This approach is sustained philosophically by Borgman,3 who suggests that digital libraries be viewed as “enabling technologies” rather than as a proprietary software of databases. Also, Birenbaum8 argues that the location of the information is unimportant, ceding to a strategy wherein access, enhanced efficiency and efficacy, as well as the level of satisfaction of the users take priority. This approach is also supported by current developmental models of repositories, such as the Peer-to-Peer Distributed Model13 and the Federation Model5, each of which encourages interrepository integration of materials at various levels.

However, many schools may not yet be ready for the regional or national commitment required by a collaborative effort and may want to begin with the development of individual digital repositories. If this is the case, it is necessary to recognize that the development of a digital repository is a resource-intense undertaking and that a comprehensive commitment is necessary. Before initiating this process, the following preliminary steps are recommended.

Consult with Existing Developers

Researchers, developers, and educators are engaged in efforts to build communities of interest around digital repository issues.3,4 Several large digital repositories are currently online or well into development. Communication by representatives of the school with the project directors of these repositories will provide an expert review and consultation on a multiplicity of issues that they have encountered and resolved. Learning from the mistakes of others can be invaluable and save development time and resources. Initiation of this dialogue will permit ongoing discussion and potential future cooperation, if not collaboration, and will ensure that cross-repository mapping remains a possibility. Without this consultation, projects are likely to encounter and expend resources attempting to address difficulties or issues that have already been resolved by a more experienced development team working toward the same objective. Recent initiatives in the field include (1) Health Education Assets Library (HEAL)14; (2) Prospect—The National Medical Digital Repository15; and (3) eduSourceCanada.16

Review Current Metatagging Schemata and Standards

Useful, stable, consistent, and high-quality access is predicated on the uniformity of the metadata12; we recommend that repositories use standardized and consistent descriptors to explain and clarify multimedia objects. A stable addressing scheme for digital objects within individual collections guarantees a common functionality and interoperability among collections and the potential for the cross-referencing of a digital learning object.12 Conversely, if the semantics are not reconciled and different data sets are used—that is, if each data set uses a different classification scheme or coding, or if different terms are used—broad use of the repository becomes ineffective.10

Increasingly, the Dublin Core Metadata Element Set17 is perceived as providing a solution to the challenge of meeting these standardized requirements within a flexible framework, thus mitigating concern regarding metatagging schemata while allowing for the specialized vocabulary and requirements of the medical educator's community.9,18 The Dublin Core Metadata Initiative consists of current specifications of all metadata terms, including the original 15 Dublin Core elements, which have been formally endorsed.

In addition, the Dublin Core schema review the relationship between (1) a simple or singular object that stands alone, and (2) complex objects, which are made up of multiple simple objects (for example, a module or lecture) to permit appropriate cataloguing and subsequent use. The schema also accommodate the definition of mandatory and optional metadata elements, allowing individual schools to determine their own priorities to assess the issue of complex and simple objects, and ensure that the development team reviews and ultimately decides upon rules for the relationships between elements as well as those between parent and child objects. Recommended metatagging elements should include

  • title, a name given to the resource;
  • creator, an entity primarily responsible for making the content of the resource;
  • subject, the topic of the content of the resource (essentially the keywords);
  • description, an account of the content of the resource;
  • publisher, an entity responsible for making the resource available;
  • contributor, an entity responsible for making contributions to the content of the resource;
  • date, the date that the resource was created;
  • type, the nature or genre of the content of the resource. This could include multiple forms of imagery and data;
  • format, the physical or digital manifestation of the resource;
  • identifier, an unambiguous reference to the resource, or unique resource identifier;
  • source, a reference to a resource from which the present resource is derived;
  • language, language of the intellectual content of the resource;
  • relation, a reference to a related resource;
  • coverage, the extent or scope of the content of the resource; and
  • rights, information about rights held in and over the resource.

For metadata in general, comprehensive planning and cataloguing of this nature is a tedious exercise; however, it is essential to a project's success. It is necessary to ensure that the need for complete information be mitigated by a recognition that the contributors may call for quick and easy input functionality and to find a resolution or balance between these opposing forces.

An example of the use of Dublin Core–based standards as applied by the Faculty of Medicine at McGill is demonstrated in List 1. Alternatives to the Dublin Core schema include IMS19 and, in Canada, CanCore.20 These schema have common elements that allow for communication between repositories, and each has advantages and disadvantages.

List 1 The Standardized Descriptors Associated with the View of the Eye Shown in Figure 1
List 1 The Standardized Descriptors Associated with the View of the Eye Shown in Figure 1:
List 1 The Standardized Descriptors Associated with the View of the Eye Shown in Figure 1

Clarify Technical Specifications

Technical issues affect the relationships among the application's software components, the requirements definition, and ultimate project objectives. They include a review of current and potential future bandwidth requirements, server and server software specifications, data-management methodology, archiving and versioning, search functionality, software architecture and major software subsystems, subsystem interconnectivity, database architecture, and the definition of enterprise-level technologies (e.g., the use of Microsoft's SQL and .NET framework). Clarification of these issues should occur before project initiation10 during in-depth discussions between project directors and the development team, with the end objective of a repository design that can support the requirements of various users supported by numerous but generally accepted standardized systems. These issues are not intuitive to medical faculty, who would not approach them with the technical expertise required; thus, we recommend review with the appropriate technical experts. Unless this process is completed satisfactory, the end product will suffer.

Address Application Functionality

The characteristics of future users, including contributors, should be identified as clearly as possible before development, allowing the programming team to include, within their primary specifications, consistent and appropriate client or user interfaces, to facilitate easy data input and output.10 These should be prototyped, reviewed, and approved before project implementation. Additional issues must be addressed, such as a preliminary assessment of the target audience and a rigorous requirements-definition phase, including strategies to address electronic intellectual property rights, copyright, watermarking,3 digital content ownership,18 and privacy. Also, digital repositories must contain sophisticated and granular search mechanisms, methods allowing for simple and uncomplicated access, contribution, image downloading, and extremely robust storage capabilities.

Consider Quality Assurance and Testing

Quality assurance includes conceptual integrity, project tracking, definition of an operating procedure, establishment of a change control and a risk-management mechanism, identification of project deliverables, preparation of metrics for measuring project status through milestones, establishment of strategies to track and deal with defects, development of a system testing plan as well as actual testing and defect tracking, and finally complete supporting documentation. These issues, as well as formative and summative evaluations by end users, should be addressed continuously beginning in the development stage and throughout the project life cycle.

Establish Editorial Review

Editorial review is increasingly important as the project moves towards maturity. Contributions require examination by a review panel before cataloguing and inclusion in the repository. The editorial board should represent all of the domains of the contributors to the digital repository, irrespective of whether it is a local or national initiative, and should define, standardize, and maintain objective criteria for acceptance to maintain quality and avoid redundancies among the learning objects. This board should possess a formal annual-review mechanism.

During the development process, we recommend local testing of interrater validity of metadata, followed by interrater consistency with other repositories. We feel that this testing does not need to be extensive, if carefully planned, but should cover a variety of media types. The focus initially should be (1) examination of the input process and the consistency of terms and approaches taken by cataloguers; (2) review of descriptors and key words suggested that we suggested earlier in this article; (3) evaluation of target user's activities and preferences, as well as general search strategy; (4) determination whether initial development and cataloguing is consistent with both input and output user strategies; and (5) an assessment of the potential for future cross-repository mapping. This testing should be included whether the digital repository in development is meant to be primarily for use by an individual school or available on a more regional or national level.


Producing e-curricula and integrated multimedia learning objects is a resource-intense and extensive commitment for a faculty. The inclusion in the project plan of a digital repository for multimedia learning objects may appear to extend the project deliverables and cost, but in reality permits for a more effective global process. Since there is likely to be some similarity in the multimedia learning objects developed at different medical schools, any collaboration or sharing that allows for the reuse, modification, or repurposing of learning objects should be explored.

While acknowledging the complex challenges and costs inherent in each of the options reviewed in this article, current technology does make it possible for institutions to work together while still maintaining institutional integrity and pedagogical autonomy. The use of digital repositories to facilitate cooperative development needs to be analyzed and examined conjointly by medical schools currently invested in this process, and short-, middle-, and long-term objectives formulated that will allow for effective, efficient, and productive efforts, focusing on shared requirements for the development, storage, and use of multimedia learning objects and methodologies for collaboration.


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© 2004 Association of American Medical Colleges