15HIPPOKRATIA 2008, 12 (Suppl 1)HIPPOKRATIA 2008, 12 (Suppl 1): 15-22

ORIGINAL ARTICLE

The appeal of online education through distance

learning as an educational alternative is ever increasing.

Technological advances in medicine, aerospace, agricul-

ture, the environment, communications and education

permeate the world we live in. To support and accommo-

date the over-specialized knowledge available by differ-

ent experts, information technology can be employed to

develop virtual distributed pools of autonomous special-

ized educational modules and provide the mechanisms

for searching, retrieving, evaluating and rating, adapting

and revising educational content. In addition, research

has predicted that in the future more people will complete

their studies at home, as distance learning concepts con-

tinue to evolve. E-learning offers both synchronous and

asynchronous modes of learning thus enabling a student

to access information from anywhere and at anytime.

E-learning environments have generally been suc-

cessful and, therefore, nowadays the majority of the uni-

versities provide online courses in some way. Numerous

efforts to create e-learning courses have also been spent

within medical education as well, covering various the-

matic areas, including aviation and aerospace medicine.

However, there exist limited efforts attempting to cre-

ate an e-learning course on aviation and aerospace medi-

cine conformant and compliant with the international

Standard SCORM (Shareable Content Object Reference

Model). Furthermore, and to the best of our knowledge,

there has been no attempt in complementing a SCORM

compliant course on aviation and aerospace medicine

with the so called Healthcare Learning Object Metadata.

The remainder of this paper is structured as follows.

In section 2 we provide a brief account on current trends

and approaches in online Medical Education with empha-

sis in aviation medicine, while in section 3, a brief over-

view of the modules necessary for the creation of courses

compliant and conformant with SCORM is provided. The

following two sections focus on the technological issues

involved in creating the SCORM compliant course on

pulmonary disorders in aviation medicine, together with

the structure and the educational details of the speciic course, while in the last section, a discussion on key is-

sues of concern is augmented with insights into future

work.

Background Information

The importance of online courses and e-learning in

post secondary career oriented medical education has

been identiied in some recent studies alongside with the beneits of and demand for offering continuing education to health professionals1,2. Moreover, some researchers

conclude that e-learning may be a very useful tool, but

emphasis has to be placed upon appropriate designs tak-

ing care of the fact that certain educational goals have to

be met3 irrespective of the media used4; such educational

goals, however, may be electronically linked to online

material itself by utilizing the SCORM standard5,6.

An e-learning platform for Aerospace Medicine

Bamidis PD1,2, Konstantinidis S1, Papadelis CL1,2, Perantoni E2, Styliadis C1,2, Kourtidou-Papadeli C2, Pappas C1

1 Lab of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece2 Greek Aerospace Medical Association and Space Research

Abstract

The appeal of online education and distance learning as an educational alternative is ever increasing. To support and

accommodate the over-specialized knowledge available by different experts, information technology can be employed

to develop virtual distributed pools of autonomous specialized educational modules and provide the mechanisms for

retrieving and sharing them. New educational standards such as SCORM and Healthcare LOM enhance this process of

sharing by offering qualities like interoperability, accessibility, and reusability, so that learning material remains credible,

up-to-date and tracks changes and developments of medical techniques and standards through time. Given that only a

few e-learning courses exist in aerospace medicine the material of which may be exchanged among teachers, the aim

of this paper is to illustrate the procedure of creating a SCORM compliant course that incorporates notions of recent

advances in social web technologies. The course is in accordance with main educational and technological details and

is speciic to pulmonary disorders in aerospace medicine. As new educational trends place much emphasis in continuing medical education, the expansion of a general practitioner’s knowledge in topics such as aviation and aerospace pulmo-

nary disorders for crew and passengers becomes a societal requirement. Hippokratia 2008; 12 (Suppl 1): 15-22

Keywords: SCORM, Healthcare LOM, IEEE LOM, Continuing Medical Education, CPD, aviation medicine, online

education, aerospace medicine, pulmonary disorders

Corresponding author: Bamidis PD; Lab of Medical Informatics, Medical School, Aristotle University of Thessaloniki, Greece, Tel: +30-

2310-999310, e-mail: bamidis@med.auth.gr

16 BAMIDIS PD

An interesting aspect that is under continuous scien-

tiic discussions and developments over the last few years is the enhancement of medical education with 3D virtual

environments7-9, with the majority of them targeting to a

speciic area, e.g. mental illness10, or rheumatology11. It

seems that the use of such Internet-connected graphics

environments holds promise for public education as evi-

denced by research on the learners’ reactions12,13.

The ield of Aviation Medicine is not an exception in this evolving story. Many countries are currently using

e-learning courses to train medical doctors in the ield of aviation and aerospace medicine (USA, UK, Taiwan,

Germany, the Netherlands and others). Federal Aviation

Authorities in USA are offering online training courses to

international aviation medical examiners enabling them

to renew their authorization. In addition, British Airways

(BA) in the UK provide light and cabin crews with e-Learning projects. Aviation medicine programs have also

been delivered on CD-ROMs, designed to increase efi-

ciency when used in parallel with the Flight Crew simula-

tor check, but also achieve cost reductions by eliminating

the necessity for a medical trainer presence around the

clock. Such programs aim to provide light crew with up-to-date information about medical equipment on board

aircraft, life-saving skills, personal health advice and the

use of the MedLink service. BA had designed a one hour

training course which would be produced by Maxim14-16.

The 6th Panhellenic Clinical Aviation Medicine semi-

nar was organised in Skiathos Island, Greece, in late

August 2007, during the 5th International conference of

Aerospace Medicine organized by GASMA, the Greek

Aerospace Medical Association and Space Research. It

was accredited with 13 CME credits by the Hellenic Na-

tional Medical Association. This course was motivated by

the recent observation that a number of universities and

colleges have shown interest in developing courses in the

ield of aviation; however, there usually exists an inher-ent dificulty in achieving this, as only a few qualiied lecturers can be found among faculty members in most

universities and colleges. Since aviation technology en-

compasses various subjects in engineering, management,

medicine, and regulations, it is almost impossible to ind a lecturer who is qualiied to cover such a wide range of areas. On the other hand, providing students with a com-

prehensive knowledge background of aviation is deemed

very essential. Thus, a course at the entry-level, with the

scope of introducing various areas of aviation medicine

seems meaningful, as it may serve as a basic introductory

course for an aviation curriculum, currently under devel-

opment in various universities and colleges.

Moreover, postgraduate education is moving towards

blended learning solutions combining high-quality e-

learning with a mixture of paper-based material, classi-

cal or online meetings, CDs and other digital content, as

well as, material uploaded on the internet. This is true for

continuous medical education too; for example, what a

General Practitioner usually needs, is a real combination

of learning media and modes, well packaged and associ-

ated with appropriate learning objectives and outcomes,

and linked with formal routes to professional accredita-

tion5,17.

Material and Methods

E-learning environments

An e-learning environment can be characterized as

a Learning Management System (LMS) complemented

with synchronous and asynchronous communication

tools. Furthermore, an LMS compliant with SCORM18

refers to a suite of functionalities designed to deliver,

track, report on and manage learning content, learner

progress and learner interactions.

Two main user roles are encountered in learning envi-

ronments: “Student” and “Teacher”. Individual needs of

each role are obviously clear within classical educational

procedures, but those needs should also be reinforced and

transferred to speciications of interactive e-learning en-

vironments. The addition of a third use role, the “admin-

istrator”, is mandatory in such role-based e-environments

(Student, Teacher, and Administrator).

The user–Teacher should have the capability to

implement the following tasks:

1. Add/Modify Resources

2. Create/Update Glossary

3. Add/Invite User-Learner

4. Add/Participate to a Communication Module

5. Reset the Course

On the other hand, some other actions should be made

available to the learner (user-Student):

1. View Course Events

2. Add/Modify Personal Events

3. View/ Add to Glossary (depending on the proper-

ties of Glossary set by the User-Teacher)

4. View/Get Resources (Topic Labels, Text Pages,

Web Pages, Files or Web Sites and Directories having a

group of Files) that are available by the User-Teacher

5. Submit Tasks within a speciic time limit.6. Get Notiication for: Submitting Tasks, updated or

new Resources, announcements of Grades and Commu-

nication Modules that have been initialised or providing

new (updated) information.

7. Interact in Communication Modules:

• Create a new Forum (depending on the settings)

• Participate to a Forum

• Participate to a Live Chat

• Communicate through messages.

Security in e-learning environments usually follows

the Role-Based control model (RBAC), where there are

user to role and role to role relationships or, in some

cases, the Access Matrix Model19. In this front, continu-

ous research efforts are devoted to the social aspects of

security, the importance of identity20 or the provision

of new security and privacy frameworks and architec-

tures21,22.

Taking the above into account, one may be lost in

seeking for appropriate software tools that fulill the

17HIPPOKRATIA 2008, 12 (Suppl 1)

stringent educational requirements. The existence of

open source software environments like “Moodle”23, that

provide simultaneous use of synchronous and asynchro-

nous communications tools and SCORM compliance in

a reliable e-learning setting, meeting the needs of online

medical education, is not only a nice coincidence, but a

real opportunity to exploit24. Moodle is utilised by a large

community of users and supports numerous languages; it

has more than 38,500 registered sites.

E-learning Standards

The existence of educational material in one LMS

does not necessarily imply, that it is easily transferable

to other LMSs, due to compatibility, as well as, lack

of teaching attribute information. Teachers may cre-

ate their educational material according to the require-

ments of the LMS to be used for uploading their mate-

rial. To this extend the absence of common approaches

for creation, description and distribution of learning

objects creates compact borders for their eficient and effective use.

It was for this reason that Advanced Distributed

Learning (ADL), a U.S. Government initiative, devel-

oped SCORM18, enabling the production of learning ma-

terial fulilling requirements such as Interoperability, Ac-

cessibility, Reusability, Durability, Maintainability and

Adaptability; in this way, the learning material remains

credible, up-to-date and follows changes and develop-

ments of medical techniques and standards through time.

In the published SCORM book, ADL described the

Content Aggregation Model25, where it is depicted how

a SCORM object is divided into many Sharable Content

Objects (SCOs); furthermore, each SCO consists of ei-

ther one or many Assets. Asset is the basic building block

of a learning resource; the latter may be composed by

all those iles and different formats containing text, im-

ages, sound, animation, video that can be viewed through

a web browser.

Moreover, all Assets and SCOs are described in the

Manifest ile, an XML (eXtensible Markup Language) ile, named imsmanifest.xml along with the fundamental iles format. This special ile describes also the content structure and, therefore, it must exist in the root of the

content package (a package usually in ZIP format that

contains all the physical iles).One or more SCOs can be considered as a Learning

Object (LO); each learning object can be associated with

one or many educational objectives. A course composed

of one or many LOs and may also be given an overall

educational objective. A complete course composed of

many LOs with high cohesion and where the content is

integrated, may not easily be reusable. On the other hand

assets are reusable, but they do not provide a structured

content. SCORM offers the ability to have a coherent

course and at the same time to have access to the indi-

vidual assets. In this respect, reusability is maintained at a

higher level within a SCORM conformant and compliant

course (Figure 2).

Figure 2: Reusability vs Coherence.

SCORM and Web 2.0 tools

Over the last few years the emergence of Web 2.0

tools, namely wikis, blogs, podcasts and vodcasts, have

changed the way internet is used. Their application in

education was inevitable and is incrementally exploited

in various contexts of Medical Education26,27.

Such new educational tools may also be included in

SCORM either as a stand alone asset or within a SCO,

but always described by appropriate metadata (see Fig-

ure 3).

Figure 1: E-learning Environment Actions.

18 BAMIDIS PD

Figure 3: Web 2.0 tools in SCORM.

Learning Object Metadata

According to Wikipedia28 metadata are data about

data. An item of metadata may describe an individual

datum, or content item, or a collection of data includ-

ing multiple content items. Furthermore, in e-learning,

metadata can be used to discover resources, to organize

electronic resources, to facilitate interoperability, to pro-

vide digital identiication and to support archiving and preservation.

SCORM uses the IEEE Learning Object Metadata

(LOM)29 deinitions in order to achieve a description of the content package as a whole, but also contain metadata

about:

• Content Aggregation

• Content Organization

• Activities

• SCOs and

• Assets

Special demands and needs in medical education drove

the foundation of the MedBiquitous Consortium through

which SCORM for Healthcare is developed30. The major

(and only) difference from the “simple” SCORM is in the

metadata. That is, SCORM for Healthcare uses Health-

care Learning Objects Metadata(LOM)31, which extended

IEEE LOM with one more category, namely, “Healthcare

Metadata”, where “health-oriented” information, as well

as, information speciic to a medical course is described (e.g. CME credits).

Creation of SCORM course

A course compliant and conformant with SCORM

could be created either from scratch, creating the inde-

pendent html pages with the necessary scripts, the ims-

manifest.xml and the appropriate java scripts for the

communication with the E-learning platforms, or by the

use of a SCORM editor.

There exist both open source and proprietary SCORM

editors. One of the most known ones, that supports

Greek Language too, is eXe, the eLearning XHTML edi-

tor32. Furthermore, eXe is an authoring application that

assists teachers and academics in the publishing of web

content without their needing to become proicient in HTML or XML markup. It is primarily written in the

Python programming language and is based upon the

open source web browser Firefox; it has been developed

around formal elements, called instructional devices or

iDevices. These instructional devices include a range of

pedagogical forms e.g. objectives, advance organizers,

and learning activities which constitute the equivalent of

the ‘teacher talk’ in content resources designed for on-

line learning32.

The course creator (usually the teacher), creates by

the use of this SCORM editor the SCORM package, usu-

ally in a ZIP format. This Content Package contains all

the necessary iles, so as for the online course to be fully working. The only action that should be taken in order to

run the course in the e-learning environment is to upload

this Content Package into the environment. The content

package is then unzipped into its directory and it is ready

for use.

To this extend the users, learners and teachers, can use

the web 2.0 tools and the synchronous and asynchronous

modules that are provided by the e-learning environment.

All users are connected to the e-learning environment

through an appropriate interface provided via the internet

(Figure 4).

Figure 4: Overall creation of SCORM course.

Metadata Creation

The metadata decided to be used for the purposes of

this piece of work were those deined in the Healthcare Learning Object Metadata as proposed by the MedBiq-

uitous Consortium30, and following the http://ltsc.ieee.

org/xsd/LOM healthcarelom.xsd XML Schema Deini-tion.

Figures 5, 6 and 7 illustrate some of the categories

can be observed as an example. Figure 5 depicts the gen-

eral category containing the title, the course description,

the keywords, etc.

19HIPPOKRATIA 2008, 12 (Suppl 1)

Figure 5: Healthcare LOM – general category.

Figure 6 shows the educational category that groups

the educational and pedagogic characteristics of the

learning object; the way the course should be delivered

and the different kinds of features/items (modules) that

the course is composed of.

Last but not least, the classiication category among others contains all the educational objectives of the

course. It is very important that the description of educa-

tional objectives accompany the learning material itself.

(Figure 7).

Figure 7: Healthcare LOM – classiication category

Course Content Background

As already mentioned above, this piece of work ne-

cessitated the collaboration of researchers from the Labo-

ratory of Medical Informatics of AUTh and the qualiied specialists of the Greek Aerospace Medical Association

and Space Research , as well as, other professionals from

bodies such as the Hellenic Civil Aviation Authority and

the Aeromedical Center “IASI”. The common efforts of

these were essential in building up the quality standards,

and a structure for Professional Development Series of

seminars.

The irst course developed for this purpose, name-

ly, “pulmonary disorders in aerospace medicine”, is

presented below. The content of the course deals with

topics such as asthma, sarcoidosis, pneumothorax, trau-

matic pneumothorax, Chronic Airway Obstruction, pul-

monary blisters and lung bleds, pulmonary tuberculo-

sis, atypical mycobacterioum diseases, Interstitial Lung

Diseases, bronchiectasis, Lung Neoplasias and Malig-

nancies, lung thromboembolism disease, and obstruc-

tive sleep apnea.

Technically speaking, the modules used by the e-

learning environment are: text, slides, video, forums,

wikis; last but not least, multiple choice questions were

used for the assessing the learning outcomes on the learn-

ers’ side.

The educational goals of this course of the CME

activity were:

1. Update and improve the clinical skills of Pri-

mary Care Practitioners in Pulmonary Medicine. This Figure 6: Healthcare LOM – educational category.

20 BAMIDIS PD

stemmed from the fact that new treatments for Asthma,

chronic obstructive pulmonary disorders, deep venous

thrombosis, Sleep Disorders and Critical Care Medi-

cine are rapidly developing and become available. This

CME activity addresses these needs and satisies the need to improve the abilities of practitioners to diag-

nose, treat and properly refer necessary pulmonary

conditions.

2. Understand and evaluate the conditions under

which a pilot or a traveler with chronic or acute pul-

monary disease may fly, as well as, the precautions

they should take before their exposure to high alti-

tudes.

3. Comprehend the restrictions under which an ap-

plicant may become it to ly.

At the end of this course in pulmonary medicine, at-

tendants will have the knowledge to understand which

pulmonary disease is related to aviator’s health and per-

formance, measures to prevent derangements during

light and where to address in case a related problem oc-

curs.

Figure 8: The entry to the e-learning Environment.

Figure 9: A “Presentation module” of the SCORM compli-

ant and conformant e-learning environment.

Figure 10: A “Video module” of the SCORM compliant and

conformant e-learning environment

Figure 11: A “Forum module” of the SCORM compliant

and conformant e-learning environment.

Figure 12: The “Assessment (Evaluation) module” contain-

ing multiple choice questions in a SCORM compliant and

conformant way as it is presented in the e-learning environ-

ment.

Discussion

Technological trends alongside research on educa-

21HIPPOKRATIA 2008, 12 (Suppl 1)

tional and teaching strategies appear as key issues for

the advancement of continuing medical education34,35.

This paper outlined some of the efforts undertaken in

order to provide contemporary medical aviation topics

in e-learning forms by the use of the international stan-

dard SCORM. Such an approach facilitates the future

exchange of this highly specialized educational material

among the limited, anyway, specialist educators.

The paper illustrated the elements composing the

open source e-learning environment, MOODLE, which

accommodated the medical aviation course on pulmo-

nary disorders. The approach was lead by the notion of

creating the necessary procedures that can act as a guide-

line and pattern for future course developments.

To this extent, continuing medical education is fa-

cilitated with all those tools and standards required so

as to allow not only the electronic provision of CME

but its sharing among educators as well. Physicians and

general practitioners could use this e-learning environ-

ment to extend their medical knowledge and update

their professional level in terms of aerospace medicine.

Accordingly, specialised educators of aerospace and

aviation medicine may exploit the availability of this

environment in order to share highly specialized educa-

tional material31,36.

The impact of such an environment to the aerospace

medicine community, the health professional associa-

tions, as well as, society on the whole will become obvi-

ous in future years and after meticulous evaluations. In

this respect, this paper has not touched upon any of these

important issues, as its focus was on providing the neces-

sary procedures for enabling such an e-learning course

infrastructure, rather evaluating it. Evidently though, any

such effort must adhere to certain quality criteria in order

to become acceptable and to this end, the paper has dem-

onstrated the use of a standardized process that facilitates

this quality. In addition, national accreditation authorities

have deined a framework concerning such educational activities, and medical associations are proposing poli-

cies in order to promote CME through the Internet or oth-

er spatial and temporal distance technologies. In conclud-

ing, it has to be mentioned that our plan is to create and

evaluate the e-learning educational procedure through an

accreditation framework proposed by Bamidis et al17.

Acknowledgement

This work has been beneited from an INTERREG IIIA Greece - Bulgaria (Decision 300531/YD4388

01/11/2005; CrossBorderHealth project), and an IN-

TERREG IIIA/ARCHIMED grand (Contract Number

A.1.087; IntraMEDnet project) by the European Union

and the Greek Government.

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