Rx for Learning

Ethel Bullitt had a severe case of medical student amnesia. After two years of cramming her brain with thousands of new biomedical terms, images of cells, symptoms of diseases and drug interactions, her memory had turned to mush. In a few days, the 25-year-old Tufts University medical student would have to report to her first clinical rotation in surgery. Her worst fear: forgetting everything she'd ever learned.

Bullitt began second-guessing herself: What is the proper way to listen to a patient's heart and lungs? What are the proper steps in examining the knee? So before she ever stepped into a teaching hospital, Bullitt went to her school's website and logged on to the Health Sciences Database -- a virtual medical student's brain containing lectures, lab slides, anatomy illustrations and her own notes -- and reviewed physical diagnosis procedures. "It's great to be able to have this kind of backup when you're feeling a little shaky, because surgery rotation is a grueling experience," she says. "You have to determine how the patient is doing, and you need to be sure you are right. The surgeons are basing some of their decisions on what you tell them."

Bullitt's experience is one example of how the Health Sciences Database is transforming the way Tufts trains physicians, dentists and veterinarians. No other medical school in the country -- and Tufts University School of Medicine in Boston is among the top-ranked -- has created this kind of KM system for students and faculty. Tufts credits the system with helping students to master course material more easily, keeping the curriculum up-to-date and increasing organizational efficiency. The system is becoming a national model for medical education.

TUFTS UNIVERSITY

Headquarters Medford/Somerville, Mass.

Core Business: Education

student enrollment: 8,500

faculty: 4,000

URL: www.tufts.edu

Not only did Tufts put together a model system, it did so at a time when medical schools and teaching hospitals face tremendous pressures. The demands of managed care have squeezed faculty time. Declining insurance reimbursements for patient care services have cut into revenue. And federal and state funding for treatment and research has diminished. Yet the system evolved in a culture of innovation and creativity at Tufts that stayed focused on continually improving education. "The challenge now is for IT to provide the tools to develop a potentially more effective model for educating medical students," says Bruce Metz, vice president of information technology at Tufts.

CIO awarded Tufts a 2001 Enterprise Value Award because its contribution to medicine far exceeds mere financial return on investment. "Educational institutions need role models, and Tufts is one," says John Glaser, vice president and CIO at Partners HealthCare System in Boston, one of this year's judges. "In training physicians and health-care professionals in a complex, volatile industry that is less amenable to time restraints, managing and keeping course material current and integrated is crucial. Tufts has taken on a very messy educational challenge, done an extraordinary job of sizing up that challenge and is doing some pioneering work."

Down from the Ivory Tower

Call Elizabeth Eaton a pioneer, but she prides herself on being a pragmatist. The director of Tufts' health sciences library learned in the late 1980s of a new project by the American Association of Medical Colleges (AAMC) in Washington, D.C., and the U.S. National Library of Medicine (NLM) in Bethesda, Md., to explore the use of technology in library information management at medical schools. Her mission: to get Tufts' foot in the door. The project meant obtaining the backing of two of the nation's most powerful medical organizations. It also meant money -- big money. Eaton wanted Tufts to stake its claim to the hundreds of thousands of dollars in NLM grants.

Vital Statistics

Cost: $455,000 for system development; $130,000 annually for operations and maintenance.

Hardware: A Unix server from Sun Microsystems runs the database and server software.

Software: MySQL, an open-source SQL relational database developed by MySQL AB and partners. Macromedia Dreamweaver for Web authoring; Adobe Illustrator, PhotoShop, Adobe Premier, Macromedia Director and Shockwave to create multimedia files for the Web; RealNetworks encoders for video and audio.

Network: WAN supports voice, video and data communications to 145 buildings on three campuses. Gigabit-speed Ethernet data network connects these buildings to the Internet 2, an ultra-fast academic research network. Remote access by password through the Internet.

Eaton got what she was after. Tufts received its first $241,000 grant in 1990. The medical school also chipped in startup funds. To decide how to use the money, she convened a planning team, including members from the health sciences library, the educational dean's office, IS and administration. The team held a marathon of more than three dozen focus-group sessions with faculty and students to find out how technology could help them teach and learn. From the long wish list, one item leapt out: a library of digital images of laboratory slides that faculty use to teach students how to identify cells, tissues and microorganisms.

Each semester, demand for these slides created chaos, especially just before exams, when hundreds of students would descend on the library to view the only two slide carousels that the university could afford to create. Faculty members were also distraught because over the years many slides -- some of them rare and more than a century old -- had been destroyed, misfiled or had disappeared from the library altogether.

The decision was unanimous: They would build a digital image library. The team chose to use database technology to build the system -- a decision that would prove to be prescient. "One of the most important things that we did was think database in terms of organizing the information," Eaton says. "Of course, librarians have been thinking that way for a hundred years, so it's not hard to understand how we got to that point. But a lot of schools didn't do that."

Choosing the right technology wasn't Tufts' biggest challenge. The greatest hurdle was changing organizational culture. When asked for her opinion about the database, Mary Y. Lee, a physician and the medical school's dean of educational affairs, told Eaton, "The students will not use the system unless it's connected to the curriculum." Eaton now had doctor's orders: create content, content, content.

And there was plenty of content to be had. In Lee's office suite towers a 6-foot-high by 4-foot-wide bookshelf, crammed end to end with three-ring binders stuffed with course materials for the first two years of medical school. The keepers of this information trove? The faculty. Handing over their slides to be digitized was one thing, but turning over their course materials was another. "Initially we had a lot of faculty -- screaming is too strong a word, but close to screaming at me -- saying that I was going to replace them," Lee says. "I was ruining medical education by replacing them with machines."

Winning faculty buy-in took a tag-team effort. Lee reassured faculty the system was not intended to replace traditional medical education methods. Metz explained how IT could help alleviate larger economic pressures facing Tufts by reducing costs and increasing efficiency. But Metz closed the deal by telling them the system could improve their effectiveness in the classroom. "In higher education, people have been teaching the same way for centuries," he says. "The truth is that they've been doing it very well. But to point out that a new model of education can work with a higher level of quality -- that gets people's attention." The team found insttructors who had been using the Internet since its early days and were eager to put their material online. Then, other faculty wanted to try the system too. Soon instructors began collaborating to create and integrate course content. "Initially, we had some very strong opponents who became extremely strong proponents after they started using it," Lee says.

When the site made its debut in September 1997, students raved to their instructors about having around-the-clock access to course material on the Web. "The great thing was being able to look at the slides at home," says Bullitt, who lives 20 miles from the downtown Boston campus. Using the website as a personal knowledge management system, she organized her course materials into her own folders and made frequent electronic notes. "It's like having an annotated textbook that I could use anywhere, anytime," she says.

In a sort of collective "aha!" faculty and students realized that the system could do much more than digitally duplicate textbooks and lab slides. Ideas for new applications and features snowballed. Eaton's development team worked nonstop to keep up with requests to put content online, including post-course evaluations by students and class schedules.

Despite the momentum -- and more grants -- the development team recognized that the system could not survive indefinitely on grants alone. So in 1999, the team began drumming up support from Tufts' veterinary and dental schools, adding some of their course materials to the database as a trial and proposing a budget in which all three schools would support the system.

Today, the system contains approximately 70 percent of the medical school curriculum and a smaller percentage of veterinary and dental school courses.

Number of instruction hours in the first two years of medical school: 8,270

It has evolved from a simple digital image library to a knowledge management system that integrates complex layers and levels of medical information across many disciplines. "It's more than just throwing a bunch of images into a file," says Richard Jakowski, a professor at Tufts' veterinary school. "You have to integrate them with text, put them in the right spot and make them mean something. Otherwise, you're getting a pop when you can make an atomic bomb."

A Big Bang for Education

Talk about a KM explosion at Tufts. Although there is little quantitative evidence so far that the system is directly improving students' comprehension or increasing exam scores, anecdotal evidence abounds that the project is creating value. Lee says students report they're learning material faster and more easily. Faculty say that lectures have become more interactive. The system also seems to be transforming traditional, didactic medical education at Tufts into a model of self-directed study more common in other graduate school programs. "That's what's so exciting about this," says Anthony Schwartz, associate dean for academic and outreach programs at the veterinary school. "Students learn best when you provide them with this kind of structure -- with links to where you would like them to go -- and then turn them loose. They're not only going to learn what they need to get through school, but they're going to explore areas they couldn't otherwise."

Tufts is the only health sciences school in the country that has integrated its curricula so that students can transcend course-, discipline- and profession-specific boundaries. "The interdisciplinary implications of this system are very powerful," Schwartz says. For example, medical students studying salmonella in humans can link to veterinary school material to learn about the source of the bacteria, its effect on chickens and cattle, ways it is transmitted to humans, prevention and treatment. "These kinds of concepts can be ttaught not by new courses, but by cross-disciplinary linkages so that students have a direct understanding," he adds.

More than 100,000 connections between courses and atoms of content within the system help students understand. Because the data is entered in Lego-block-like chunks, changing or updating course material is much easier than manually re-creating entire courses on paper. "If you're teaching Shakespeare, you don't have to worry about Shakespeare becoming obsolete," Metz says. "But medical and science [information] could have a short half-life, so that when it's time to update course material, it makes sense to do so in a modular, digital form."

The beauty of the database is its flexibility, says Lee. "The model allows you to take chunks of information, manipulate it, reuse it and put it together in a way that suits your own unique needs. I think that's what's going to be so attractive to other schools."

Dozens of universities from as far away as South Africa have visited Tufts to see demonstrations of the system and its potential applications for medical education. The AAMC is exploring the idea of creating a national database of health sciences information, which would be available to all U.S. medical schools, based on Tufts' system. "It doesn't make any sense to have every medical school in the country replicate this," says Dr. Michael E. Whitcomb, senior vice president of the division of medical education, AAMC. "If we could develop something that all medical schools could use, it would be a tremendous advantage."

Eaton, Lee and Metz are thrilled that what began as a grassroots effort may benefit not only Tufts, but also the greater scientific community. "Part of our mission is to go beyond what we do on our campus and to make a contribution to the world," says Metz. "So we're very committed to the beginnings of a movement to use the system as a national model. It's part of what our mission is about."

Bullitt, who is in the middle of a clinical rotation in adult internal medicine this semester, continues to rely on the Health Sciences Database website for long-distance learning -- and to cure any future spells of medical student amnesia. Even after she graduates in 2002, she and other Tufts graduates can continue to use the system if they are staff members at any of Tufts' affiliated institutions. One of the most important lessons she has learned at Tufts, she says, is how to use technology as a tool to continue her education -- a lifelong task for medical professionals.

"That's the world we live in," she says. "You take what you've learned from your education and constantly add to it, and it's nice to build that habit now. This system isn't going to be a textbook I'm going to throw out in a couple of years because it's no longer accurate. It's always evolving."