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Summary of the ALNTalk Discussion: "ALN for Rural and Remote Health Workers"

by Sloan-C

This forum discussed some of the issues and opportunities for rural and remote health professionals accessing asynchronous learning options using the Internet.

It commenced by raising three points related to the problems and effects facing rural, remote and isolated health practice:

• Education and training for rural and remote Health Professionals;
• Continuing medical education by asynchronous means;
• Professional support for distant health professional by asynchronous means.

I. EDUCATION AND TRAINING FOR RURAL AND REMOTE HEALTH PROFESSIONALS

This discussion thread started by Joe Hovel with the assertion that many rural and remote health workers find it difficult to access traditional means of education and training as a result of the "tyranny of distance" or the financial burdens this imposes on small health agencies or private practices (in terms of travel and staff replacement costs as well time spent away from the home community).

He went on to suggest that asynchronous delivery of educational opportunities-accessed without travel costs-at the trainee's leisure and pace may well reduce some of this deficit. A number of web courses exist within the tertiary sector as well as in commercial arenas which afford this opportunity.

The ensuing discussion was started by Robert Hall (Robert.Hall@med.monash.edu.au), who described his experiences with an e-mail discussion group based on clinical cases and readings moderated from McMaster University department of Family Medicine two years ago. He mentioned the amount of work required by the moderator, suggesting it to be comparable to writing a distance learning program. He appeared disappointed that sessions petered out after three months, but estimated that learners discussed their ideas at times that suited them, taking about four hours over a week to achieve the equivalent to a face-to-face hour.

The thread also drew a number of participants to describe experiences with more sophisticated training options, such as Anthony Whitchurch (gual@onaustralia.com.au) at the Cairns Rural Health Training Unit. He described for participants their dial-up audiographic network of 40 remote health centers across Cape York Peninsula and the Torres Strait to the North of Australia. His unit offers a variety of training packages including Diabetes Education, Immunization, Women's Health, School Health, New Health Worker Orientation, Literacy, and X-ray Operator's course. During the monsoon season many of these centers are inaccessible so that these courses are the only option of ongoing education and training during this time of year. The services’ target groups include indigenous health workers, nurses and General Practitioners and they have found this form of training to be very effective. This was illustrated during a recent visit of a remote centre, when the health workers used the on-screen material to educate their clients about diabetes!

Similarly, Curt Madison (curt_madison@ddc-alaska.org) described circumstances of bringing village clinics in Western Alaska Internet access. Each of the clinics is staffed by indigenous health aides with about a year of formal training. A clear need for continuing education at a distance is currently addressed by asynchronous messaging using the Web. He went on to say that his organisation was looking for prepared courseware that encourages student-to-student interaction. At the same time they are beginning to create their own courses with the help of suitable software.

Janet Place (Janet_Place@unc.edu) in North Carolina found real limitations for web-based instruction because although most health departments have access to the Internet, few nurses know how to access it. In addition, she commented that nurses are continually pulled away from their training in order to meet the needs of patients, leading to frustration on everyone's part.

Joe Hovel then the fundamental question of how much employers value learning. He suggested that nurses are valued for their direct care input and are only given the opportunities to learn outside of hours of direct care.

Mike Gurstein (mgurst@ccen.uccb.ns.ca) works with a number of community Internet access sites throughout rural Nova Scotia. He alerted the discussion participants to experiments using the Net to obtain and provide health and wellness to be transmitted to specific Non-Government Organization’s who would provide this information to end users in an appropriate and selective way.

As a result of these descriptions of options and frustrations, Jeffrey Frakes (jefff@itis.com) wondered if there were on-line courses to be offered by commercial firms - particularly in the areas of management.

Inevitably, the discussion turned to the more technical issues and limitations of ALN on the topic of the sometimes complex educational needs in health and medicine. Tom Abeles (tabeles@ibm.net) developed a discussion thread on the choice of technology in remote learning. He suggested that health care education required strong visual and audio inputs to a training experience and feared that the current state of ALN on the net, as opposed to hard copy of video and audio tapes and text materials, was unable to provide the bandwidth required. Olin Campbell (campbejo@ctrvax.vanderbilt.edu) took the discussion at this point and suggested that streaming audio and video technologies were improving in quality. While not yet of a quality to analyze photos and X-rays, they were satisfactory for presentations. He also submitted that the available bandwidth is increasing and will be likely to provide the quality required in the next decade. He acceded that a textbook could provide content and graphics to training packages, with ALN providing discussion and collaboration between learners and providers.

Joe Hovel concurred that all methods of teaching and learning, and ALL vehicles were valid for some circumstances. However, given the opportunity to learn from anywhere in the world right now, the limitation of low bandwidth is worth putting up with for another year or two. He raised the issue of actual timely delivery of textbooks or video tapes. He suggested that (aside from copyright issues) these can be transmitted asynchronously to those where postal services take weeks-and that's a large part of the world. Even for large files, (e.g. a whole textbook in .pdf format) can be delivered at a trickle over the net anywhere in the world within a relatively short time.

Another concern not mentioned up to this point was the significant issue of time zones in relation to real-time discussions and/or teaching. He related being called on the telephone (for a "real-time discussion") at 4 am by a student from another continent-who got the direction of the rotation of the earth wrong.... and suggested that asychronicity was wonderful to address anyone in their own good time.

Olin Campbell raised the question "how much can we improve over the way both functions are currently provided in rural health?" in response to points made by Tom Abeles (tabeles@ibm.net). He was concerned about trying to provide "knowledge on demand" for the rural needs and suggested a more focussed approach of separating out the training function from specific information and intelligence that rural health care workers need and/or want to bring the most effective service to their clients.

He agreed that they need both training and performance support but was unsure whether the effectiveness of rural health care is or is not correlated to programs which result in "merit badges" for the workers. He suggests that this approach may, in part, dictate the choice of technology for delivery.

II. CONTINUING MEDICAL EDUCATION (cme) BY ASYNCHRONOUS MEANS

Joe Hovel suggested that a number of accredited demonstration sites were exploring legitimate options for asynchronous delivery of CME, to reduce the expense and inconvenience for medical practitioners in countries where licensing boards require a set minimum of CME credits to maintain professional or vocational registrations. He referred to the "Interactive Patient" site at Marshal University as an example.

This discussion thread was not taken up by participants, although several references were made to continuing medical education in other threads.

III. PROFESSIONAL SUPPORT FOR DISTANT HEALTH PROFESSIONAL BY ASYNCHRONOUS MEANS

Joe Hovel made the point that many rural and remotely located health workers find their professional isolation stressing-even distressing-at times, when peer support is routinely sought by their urban and metropolitan counterparts. An example is the simple and common telephone consultation with a colleague who is known to have more experience with a particular scenario encountered. In rural and remote areas of the world, access to colleagues is difficult to manage due to time differences, workload or distance (i.e., expense of long distance calls).

An example referred to was a dermatology consultation project under review in Australia, where remotely located General Practitioners could use inexpensive digital cameras to snap close-range photos which were e-mailed to a city-based specialist dermatologist for review and opinion - all via the Internet in an asynchronous and low-cost mode.

This discussion thread sparked some debate between Olin Campbell, Dave Romer (romer.4@osu.edu) and Joe Hovel over the limitations imposed by e-mail administrators who limit the size of e-mail files where systems will not deal properly with larger file attachments. Romer suggested that a good way to move large images at present is through http access, where the user has control over viewing the image and selecting where to store it. Joe Hovel raised the issue of authorized access and confidentiality, suggesting encrypted files as an option.

The quality of photos (and the quality available in .jpg files) was also mentioned, with an example made available Breast1.jpg for forum participants to see for themselves.

The Forums® software used to conduct this discussion conveniently allowed attachments of graphics files to messages, so that an attachment of the file was tried successfully as a demonstration of another option. Since these discussion forums can be restricted to specific individuals, this highlighted the opportunity for maintaining confidentiality.

IV. CONCLUSION

This forum drew a wide variety of health workers experiences and views on the issues of distance education, ALN and the technology to implement these for rural and remote health services. The discussion appeared often disjointed and left many thoughts and questions unanswered, just as is the case in face-to-face interactions. It appears that time delays between reading a message on screen, subsequent thoughts on the topic and the opportunity to get back to the discussion some time later (maybe days) leaves many threads hanging without comment. This is perhaps the distinguishing feature of asynchronous discussion, as it is apparent in most news groups and e-mail list server forums. Long-term users of these media tend to modify their response behavior and reply to issues of interest immediately, rather than letting time pass, but never go back to read ‘old’ messages again. As a colleague suggested of news group questions: "if you don’t get an answer within 12 hours, you won’t get one at all".

However, the forum also demonstrated the wide interest in web-based delivery of education and support, including ALN, and a keen sense of what is achievable right now and in the immediate future.

January 14, 1998