IIMS 96 contents
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The virtual teaching hospital

May Wong, Edward Hettiaratchi, Elizabeth Post, Hoang Tran-Dinh and Christine Anne Brown
The University of Sydney & University of Wollongong
"The Virtual Teaching Hospital" (VTH) was developed to enable academic staff without formal training in programming or instructional design to produce integrated interactive multimedia learning modules based on patient case studies. These case studies are presented within the graphic environment of a hospital to promote the integration of basic science and clinical disciplines and to illustrate the relevance of the basic sciences to the various health professionals. Students can view patient profiles to observe the clinical reasoning process and the range of professional activities which draw on the knowledge base of the basic sciences to solve real problems. A sample module based on a stroke patient has been developed.

The theoretical basis of the Virtual Teaching Hospital

Constructivist philosophy

The constructivist view of the learner places them in an active, purposive mode, taking responsibility for their own learning (Driver & Oldham, 1986). Learning involves conceptual change. Talk and other informal modes of communication are important in enabling students to make ideas explicit and open to reflection and change. Constructivism has influenced the design of computer orchestrated learning environments through such propositions as the support for multiple perspectives or interpretations of reality, knowledge construction, and context rich, experienced based activities (Jonassen, 1991). The challenge, according to Jonassen, remains the evaluation of learning from such environments.

Black et al (1994) identified six principles of constructive design, ranging across student generation of knowledge, authentic situations, cognitive apprenticeship, the use of multiple contexts, cognitive flexibility of multiple perspectives, and student collaboration. Cognitive apprenticeship embeds learning in an activity and makes deliberate use of social and physical contexts. If the situated nature of cognition is ignored, the education system provides academic decontextualised knowledge which may not be robust (Brown, Collins and Duguid, 1989).

The complex and ill structured knowledge domain which must be accessed by a range of health professionals in dealing with patients in a hospital provides a situation where much of this theory can be tested in the design and functionality of an interface for learners across a range of disciplines. Hypercourseware (Siviter and Brown, 1992) is a conceptual framework for developing computer based flexible learning material on a large scale. The principle of the browser, which can cater for flexible needs, and which can be managed and updated, relinquishes the concept of fixed products, and places the emphasis on an ongoing and evolving process of organising educational resource material.

Case based learning

Within the health professions, case based learning using print resources has been occurring for some time. Case studies provide the context and activity so vital to situated learning. Each case study, however, is also unique, so cognitive flexibility is required to be able to spontaneously restructure one's knowledge, in many ways, in adaptive response to changing demands both within one case and also across different cases. Students need to be able to move from reproductive memory and rule following into complexity and the ability to transfer.

Advanced knowledge domains should not be presented as well structured, linear, compartmentalised, simply hierarchical and rigidly pre-packaged entities (Spiro and Jehng, 1990). Cognitive Flexibility Theory enables the student to learn by criss-crossing a conceptual landscape, and the instruction involves providing learning materials the student can actively explore under expert guidance. By crossing the landscape many different ways, knowledge to be used in many ways is taught in many ways. Learning complex content material requires multiple explanations, analogies and dimensions of analysis.

The design process - needs, learners and tasks

The Department of Biomedical Sciences, within the Faculty of Health Sciences at The University of Sydney, teaches Anatomy, Physiology, Chemistry, Physics and Microbiology to students from the following schools: Evaluations carried out by the staff of the Department of Biomedical Sciences showed that many students were unable to integrate material from individual topics and subjects or to perceive the relevance of basic sciences to their professional studies. Furthermore, prerequisites for most courses had been eliminated, so it was no longer possible to assume basic knowledge of physics, chemistry and biology.

Two attempts were made to overcome these perceived difficulties in Biological Science subjects. Firstly, various disciplines were included within the one subject. Secondly, case studies were introduced either as an integral part of subjects with small student numbers, or as tutorial sessions for large groups. Feedback from students indicated that this approach enhanced motivation and learning, but the limited availability of contact hours and appropriately skilled tutors restricted the use of case studies.

The development of computer based case studies offered a potential solution to these problems, and also the opportunity to enhance the nature and quality of the learning experience for staff and students. While staff had expertise in clinical and basic sciences, teaching, and support for case based learning, they did not have sufficient programming skills or awareness of recent applications of information technology to learning. The aim of the Virtual Teaching Hospital (VTH) project was to develop a courseware browser which would provide appropriate information access for students in a range of health professional courses, and a case study template which would enable academic staff to produce integrated interactive multimedia learning modules based on patient case studies. The ability to include multimedia resources to facilitate explanation, analogy, modelling of activities, and tap into the social, emotional and contextual aspects of cases was a bonus.

The design team moved to rapid prototyping of the browser interface and patient profile in HyperCard. As the case study material was compiled, the structure of its presentation unfolded. The patient was the central focus of the profile, and numerous views of the patient could be provided by a range of health professionals dealing with the case. This would give the students a range of perspectives on the one set of patient data. Teams of health professionals frequently work on cases, but it is not common for one health professional to have access to the thought processes of another. As the case material was compiled from the clinician in charge of the case, certain decisions of this medical expert were not clear to team members who were relative novices in the subject domain. This prompted the development of pre- and post-thoughts of the clinician, and a unique opportunity to tap the expert's thought processes on why certain questions were asked or tests ordered, and what the response was to certain results. This was tapping into the process of hypothesis formulation and self questioning which is often automatic, and not shared by experts in such situations as clinical rounds. By exposing this process, the relevance and scope of the required content knowledge to formulate such hypotheses was naturally shown. This material was presented in the student challenges.

Such case study profiles do not place the learner in a simulation situation. They present the time frame of the case in a retrospective fashion. The student is not selecting the interview question or test they wish performed. This program does not aim to replace the real case with an extremely complex simulation. The student can, however, explore the case at their own pace as often as they like with or without the expert guidance and thought processes. Students within one health profession can gain insight into the way other colleagues may approach the patient, and why certain pieces of information are vital to fellow health professionals. The opportunity is also there to involve the family of the patient, and to let health professionals consider the emotions and thoughts of patient, family and friends.

To complement the application of a complex network of knowledge within a case study, content resources were needed within the VTH for students to pursue material they perceived as clinically important. Here the browser nature of the general hospital interface provided the hooks for many types of content. Various rooms within the hospital would provide logical venues to seek out certain kinds of information, such as the laboratories or library, and the corridors could allow linkage of general material relevant to a hospital.

Staff within the faculty would be provided with the opportunity to develop material related either to a case study, or their content specialty. The classroom developed off the library as a logical place to find certain subject based content chunks. Staff could enter the multimedia construction process either at a familiar spot - presenting the content of their expertise, or they could tackle the more difficult task of re-structuring material to think of its relevance to specific cases. The browser also offered the opportunity to link content software already produced by other learning institutions.

The design of the VTH acknowledges the importance of the teaching staff not only in the production 6f learning material, but also in the support of this material when it is used with students. Process is the important keyword here, not product. This is an evolving design process within the Faculty, aimed at including staff in the technological innovations, rather than imposing change without consultation. The nature of the student tasks which drive them through the many resources of the Virtual Teaching Hospital will be determined and developed by staff members. Some of these tasks may be presented on computer, while other staff members may use case material as a stimulus for discussion, or content packages linked in the hospital as resource material for assignments. The wealth of possibilities will be unfolded through use and creative staff initiatives.

The Virtual Teaching Hospital at this point in development

The Virtual Teaching Hospital browser interface has been prototyped, and a sample case study based on a stroke patient is present within the patient profile facility. As other sections are constructed, they can be linked in to this current structure. Recently, the classroom structure was linked to the library. As befits the evolving nature of the VTH, it is anticipated that interface graphics will continue to change in response to staff driven design needs. Following is a brief description of the key sections of the VTH which have been developed, and the principal reasons for their design.

A hospital walk

Students navigate around the hospital via doorways and corridors which contain active signs. The aim is to acquaint them with the clinical environment and to provide information that would be relevant to each unit within the hospital. After registering at the information desk, students can visit the library or various wards and departments in the VTH. In the wards they can listen to patients relating why they have come to hospital. These sound snippets can be used as 'triggers' in problem based learning - they can be used by tutors as a focus for students to make hypotheses and decide what further information they require.

By selecting various objects in this graphic environment, students can get more information about various pieces of equipment or learn about various procedures. This informative hospital walk has great potential for development. Imagine the wall space for posters and equipment and floor space for a range of people. New innovations such as QuickTime VIZ will make the simulation more realistic.

The patient profile

The patient profile, in this case, Mr Roke, a stroke patient, exposes the students to the full breadth of a case study, including medical, social and emotional issues, without the concurrent load of facing real people in real time. They have a chance to see the relevance of the subject based content they are learning, from the perspectives of a range of health professionals. It is hoped this will: Once the patient profile is selected, the student is able to follow the events in the daily hospital life of that patient, including interviews, physical examinations, tests ordered, test results and consultations. Selection of any event enables the student to decide whether they wish to see a brief description of the event, gain access to the actual information, or gain access to a detailed analysis of the actual information, including the pre- and post-thoughts of the health professional dealing with the patient. Student challenges at this analysis level model the process of hypothesis formulation and self questioning carried on by the health professional.

The VTH classroom

The VTH classroom developed as a room off the library to provide content material that would in traditional courses be presented as lectures. Advantage was taken of the ability in interactive multimedia to present the same material in different arrangements with relative ease. A multiple perspective approach therefore allows students to proceed sequentially through multimedia annotated text, or to view one of the perspectives of this linear compilation in isolation. The perspectives isolated include pictures, diagrams, definitions, concepts, examples, analogies and questions By viewing any of these perspectives, the student is able to gain a view of the content landscape via another means of representation. Questions challenge their understanding of the content, and can be attempted at any stage. Within the linear presentation of the content, clinical relevance of specific topics is pointed out and where possible linked back to the case study.

Learner tools throughout the program

Anywhere in the VTH students can access a glossary of medical terms, and a notebook in which they can type their own notes to save to disk. Suggestion boxes have been placed in different parts of the VTH for students to report difficulties, offer suggestions for improvement, and request content which they would like to see developed. It is hoped in future that construction tools developed in the design process of the VTH will ultimately be handed over to the students, for them to compile their own case studies, glossary of terms and question banks for self testing.

What has been learnt from the VTH design process

The aims of this project were extremely high. Not only was it hoped that disciplinary boundaries would be broken, but also the boundaries in traditional content based learning that separate content from situation and process.

A courseware browser for use by different schools has been realised, but this is just the beginning of a very long term process which seeks to skill and involve academic staff in the construction and use of information technology for learning. What many staff have yet to realise is the difficulty in presenting material from the varied perspectives of clinical relevance. The desire to highly structure content and merely map that to the learner's mind has to be overcome, and constructivist principles of learning acknowledged.

The patient profile structure offers a unique opportunity to tap into the metacognitive skills of planning, monitoring and self regulating carried on by a range of health professionals as they interact with the patient. Self questioning and reflection are two skills which all learners need to acquire, and which are often not highlighted by lecturers. The multiple perspectives on content afforded by the different health professionals is also unique, and will require the collaboration of a real team of health professionals. As the students criss-cross the patient landscape from the perspectives of these different people, a range of interpretations and analyses could be presented.

In the development and maintenance of a courseware browser and its many associated resource links, staff will come to appreciate the crucial role of resource management - not only its organisation, but also its coding for re-use. Whole faculties will come to appreciate the construction of large information systems, and the need to constantly update and restructure as understanding develops. By experiencing this process, they will share what the student must experience as they seek to build their own personal information system to deal with the complex and ill structured professional domain they have selected.

Hopefully, academic staff will come to appreciate the multiplicity of solutions to the wonderful process of learning, and thus create a range of learning task tools to support students in their difficult journey from novice to expert. The VTH design experience has already provided the Faculty of Health Sciences at the University of Sydney with a considerable challenge - to invest the effort required to move to a situated model of learning which capitalises on the new developments in information technology.


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Driver, R. & Oldham, V. (1986). A constructivist approach to curriculum development in science. Studies in Science Education, 13, 105-122.

Jonassen, D. H. (1991). Evaluating constructivist learning. Educational Technology, 31(9), 28-33.

Siviter, D., & Brown, K. (1992). Hypercourseware. Computers and Education, 18(1), 163-170.

Spiro, R. & Jehng, J. (1990). Cognitive flexibility and hypertext: Theory and technology for the non-linear and multidimensional traversal of complex subject matter. In D. Nix & R. Spiro (Eds), Cognition, Education, and Multimedia: Exploring Ideas in High Technology (pp. 163-205). Hillsdale: Lawrence Erlbaum Associates.


The Virtual Teaching Project was supported with funds and equipment from: The project team wishes to acknowledge contributions made by: and support from:

Authors: Mrs May Wong
Lecturer, Department of Biomedical Science
Faculty of Health Sciences, The University of Sydney
PO Box 170, Lidcombe NSW 2141
Telephone: (02) 646 6289 Fax: (02 646 6520
Email: m.wong@cchs.su.edu.au

Dr Edward Hettiaratchi
Senior Lecturer, Department of Biomedical Science
Faculty of Health Sciences, The University of Sydney
PO Box 170, Lidcombe NSW 2141
Telephone: (02) 646 6326 Fax: (02 646 6520
Email: e.hettiaratchi@cchs.su.edu.au

Dr Elizabeth Post
Senior Lecturer, Department of Animal Science
Faculty of Veterinary Science, The University of Sydney
PO Box 170, Lidcombe NSW 2141
Telephone: (02) 351 2460 Fax: (02) 351 3957
Email: lizp@vetsci.su.oz.au

Dr Hoang Tran-Dinh
Senior Lecturer, Department of Biomedical Science
Faculty of Health Sciences, The University of Sydney
PO Box 170, Lidcombe NSW 2141
Telephone: (02) 646 6469 Fax: (02 646 6520
Email: BI_Tran-dinh@cchs.su.edu.au

Ms Christine Anne Brown
PhD student, Faculty of Education, University of Wollongong
Northfields Avenue, Wollongong NSW 2522
Telephone: 046 251 160 Email: C.Brown@uow.edu.au

Please cite as: Wong, M., Hettiaratchi, E., Post, E., Tran-Dinh, H. and Brown, C. A. (1996). The virtual teaching hospital. In C. McBeath and R. Atkinson (Eds), Proceedings of the Third International Interactive Multimedia Symposium, 426-430. Perth, Western Australia, 21-25 January. Promaco Conventions. http://www.aset.org.au/confs/iims/1996/ry/wong.html

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