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Chapter 62

Distance education
J. Tobey Clark
WHO Collaborating Center for Health Technology Management, Technical Services Partnership,
University of Vermont, Burlington, VT, United States

Introduction during the current century. Although the distance learning

initially started in publicly funded state schools and com-
Distance education has existed for nearly 300 years since munity colleges along with private schools, it now is of-
Caleb Phillips from Boston, USA offered training in short- fered by top universities such as Harvard and Stanford. In
hand via weekly lessons communicated via US mail. This the United States in 2011, a study showed at one-third of
was the start of “correspondence” courses. Distance learn- all the students enrolled in postsecondary education had
ing degrees were established in 1858 at the University of taken an accredited online course (Growth for Online
London as part of its external program offering (Wikipedia, Learning, n.d.).
n.d.). An advantage of this type of learning was that it served
the less-affluent student. In addition, Open Universities
formed to support this learning alternative.
Methods of distance education
The first electronic distance learning took place over the The two primary modes exist for distance education over
radio airways beginning in the 1920s. In the United States, the Internet: synchronous and asynchronous. Synchronous
public school systems and universities began to use radio education is scheduled educational sessions which may be
broadcasts for education. When television was established or not be interactive. This modality initially started with
as a common media source, this was also used for educa- a “talking head” approach with video of instructor lectur-
tion. Although educational television initially was not suc- ing in the classroom. Added to this approach was the in-
cessful, efforts by the California state universities were clusion of PowerPoint slides, videos, or other multimedia
productive in establishing telecourses via TV with later and, most importantly, interactive capabilities. Most have
successes put forth by the US Public Broadcasting Service interaction via a chat line with the instructor although voice
(Wikipedia, n.d.). communication and polling of the participants is now read-
The first quality interactive video/audio distance edu- ily available. The distance learning event may be recorded
cation began to take place over proprietary networks and for asynchronous presentation. A common synchronous
high-speed phone lines in the 1990s. Multiple high-speed method utilized typically for short courses and single pre-
Integrated Services Digital Network (ISDN) phone lines sentations is the webinar.
were ganged together to provide enough throughput for Asynchronous education is not scheduled with online
smooth video and audio communications. Companies such materials, quizzes, exams, and interactive activities avail-
as Polycom were major players during this time frame. able on an unscheduled basis. The 24 × 7 availability of these
The institution of the Internet has caused a paradigm courses offers maximum flexibility time wise for learning
change in distance education. When the standard Internet and is well suited for adult, working learners. Interaction in
Protocol (IP) was first created, local area networks at vari- the course takes place via written messages or audio/video
ous colleges and companies began to be interconnected posts to discussion boards, forums, wikis, and blogs.
into the global Internet. This allowed email to be sent and It should be noted that for today’s classroom courses,
received globally. The next technological step was the cre- there is also typically an online component. Materials for
ation of the World Wide Web which allows properly for- the course, assignments, schedules, etc. may be online,
matted “web pages” to display text and pictures via the while classroom activities focus on activities best suited to
Internet. However, the speed of the Internet did not allow the live classroom. This movement is called blended or hy-
practical interactive communications until the 21st century. brid learning. This has also led to a significant movement to
Internet-based distance education has grown exponentially the “flipped” classroom where students learn the concepts

Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00063-8

410 Copyright © 2020 Elsevier Inc. All rights reserved.
Distance education Chapter | 62  411

and topics online and then come into the classroom to com- Biomedical Anglia Ruskin Masters
plete their assignments, work in interactive groups, or per- Science MSc University
form laboratory exercises in the classroom. (n.d.-b)
A second differentiation of Internet-based distance Biomedical Nottingham Trent Masters
learning is paced versus self-paced courses. Paced courses Science MSc University
are education where readings, assignments and, for synchro- (n.d.-c)
nous courses, lectures, and presentations are all scheduled. Nano- University of Certificate
This is the most common method for university courses biotechnology Kaiserslautern
to allow completion over semester periods. Self-paced (n.d.)
courses typically allow complete flexibility in completion Risk University College
of individual assignments, but often have a course due date. Assessment and Cork
Everything is online with quizzes and exams typically au- Implementation of
tomatically graded with pre-written feedback regarding Health and Safety
incorrect answers. Students involved in self-paced courses Management
Program (n.d.)
typically are self-motivated to take the course to learn and
have the self-discipline to complete the course by the due Biomedical Ulster University BSc Honours
date. Science BSc (Hons) articulation
(n.d.) pathway for
Healthcare technology distance learning science sub
degree graduates
A number of educational institutions, associations, and
Medical and University of Courses
other organizations have distance learning courses in the diagnostic devices Bergamo
area of healthcare technology. The course topics and degree Also, general
(University of
programs include technical training, biomedical and clini- Bergamo, n.d.)
cal engineering, healthcare technology planning and man-
agement, and biomedical equipment technician education. Study portal/ Variety of US Twenty-one
distance learning universities masters level bio
Here are some of the offerings for healthcare technol-
portal courses and biomedical
ogy distance learning courses, certificates, and degree (Bio & Biomedical engineering
programs: Engineering courses
Masters, n.d.)
Program name Institution Type
Electrical Stanford Graduate
Clinical University of Masters in engineering University, Center certificates
Engineering Connecticut Engineering biomedical for Professional
(University of in Clinical courses (Stanford Development
Connecticut, n.d.) Engineering University, n.d.)

Biomedical University of Course sequence University of University of Programs in

Equipment Vermont with three 100% Management and Management and engineering
Technology online courses Technology (n.d.) Technology management,
Sequence and one lab information
(University of course technology,
Vermont, n.d.) and health
Biomedical and University of Leeds Postgraduate
Healthcare Ethics Certificate Bioengineering University of Masters of
(n.d.) (Distance Maryland Engineering
Health Technology University of Masters, diploma, Graduate
Assessment Glasgow and certificate certificate in
Commission, n.d.)
Program (n.d.) programs engineering

Biomed Online London Short course,

(n.d.) Metropolitan continuing In the United States, ABET accreditation is the standard for
University professional engineering. ABET has criteria for evaluating online pro-
grams. As of 2018, there are no online programs accredited
Biomedical University of Masters, diploma, by ABET for biomedical or clinical engineering (ABET,
Science MSc Greenwich and certificate n.d.) although 30 plus other engineering and engineering
(n.d.-a) programs
technology programs (disciplines) are accredited. There
412  SECTION | 6  Professionalism, education, and ethics

is an organization that accredits online programs—The the courses. The two bilingual courses developed—Patient
Distance Learning Accrediting Commission (University of Care Equipment and Technology, and Advanced Medical
Maryland, n.d.). Equipment Systems, resulted from a collaboration between
Webinar training is a common way for primarily work- the University of Vermont (Burlington, USA), Pontificia
ing clinical engineers and other biomedical technology pro- Universidad Católica de Peru (Lima, Peru), and Universidad
fessionals to learn. Some of the webinars and webinar series CES (Medellin, Colombia). The courses were offered by all
are coordinated by: three universities and later put on the online platforms at
Universidad Technological Nacional (Mendoza, Argentina)
● American College of Clinical Engineering (ACCE)
– Educational Webinar Series
and the Pan American Health Organization (PAHO) Virtual
– Clinical Engineering Certification review course
Campus for Public Health (Washington, DC). The PAHO
course was taught in both English and Spanish.
● Atlantic Canada Clinical Engineering Society for
The course learning objectives are to:
Clinical Engineering Professionals
● Association for the Advancement of Medical 1. provide a basic understanding health technology life
Instrumentation (AAMI) cycle, environment of care, regulations, preventing and
– AAMI University—topics for CE, BMET, industry correcting equipment problems, anatomy/physiology,
delivered primarily via live webinars and on-demand engineering concepts, and common medical equipment
webinars technologies,
● ECRI Institute 2. help students better communicate with clinical and other
– Various health technology topics healthcare staff involved with medical devices, adminis-
● MD Publishing tration, and equipment vendors, and
– Webinar Wednesday—various biomedical technol- 3. develop the student’s interest, and prepare them for further
ogy topics study and more advanced application of the principles.
● Engineering for Change
● Healthcare Information Management Systems Society
● University of Vermont, CertNOW CBET certification The course utilizes web-based content including text, pho-
review course tos, diagrams, flow charts, other figures, video, audio, links
to other websites, interactive tools, and other web attributes
Example online training program: to deliver content to students. The course is 100% online.
The areas covered for each medical technology included
University of Vermont
in the courses are:
Capacity building in the area of biomedical technology and
1. Device principles
clinical engineering is greatly needed. As online training is
2. Proper clinical application
rapidly advancing worldwide due to the availability of com-
3. Patient safety
munication networks and devices including computers, tab-
4. Common device/technique problems and resolution
lets, and smartphones, this can be a viable option with the
5. Maintenance and quality assurance
great advantage of accessibility. By using the information
6. Technology management (Table 1)
resources of the World Wide Web, the training can be robust
using online platforms. In addition, online training has no
costs or lost time for travel to a classroom, and asynchro- Student evaluation and grading
nous training allows maximum flexibility.
Ten quizzes—one for each module of one or more topics.
Virtual education was successfully applied by the
Two exams—cover the first and second half of the
University of Vermont in technical courses for the Americas
(Clark, 2012). Beginning in 2006, the University of Vermont
Five discussion questions and responses—the discus-
began development of basic and advanced online, interac-
sion questions require research and may cover con-
tive courses. The course development was funded by the Pan
troversial subjects. They promote engagement as each
American Health and Education Foundation. These bilin-
student has to not only answer the questions but also
gual (English and Spanish) courses were primarily for tech-
offer a response to another student’s answer.
nical staff in hospitals—facilities, electricians, electronics,
maintenance, and other technical personnel. They were also Over 1000 students from Colombia, Peru, Mexico,
suitable for those educated as engineers but without train- Venezuela, Uruguay, Costa Rica, Bolivia, Brazil, Uruguay,
ing in medical equipment. Other healthcare staff such as Paraguay, Chile, Argentina, Puerto Rico, Dominican
nursing, clinicians, and managers also would benefit from Republic, Barbados, Jamaica, Grenada, Antigua, St. Lucia,
Distance education Chapter | 62  413

TABLE 1  Topics covered in the Univ. of Vermont online biomedical technology courses.
Patient care equipment (basic course) Advanced medical equipment systems
Healthcare technology overview Advanced technology in health care

The environment of care Imaging: image quality

Regulations and standards Imaging: radiography

Quality assurance and preventative maintenance Imaging: fluoroscopy

Preventing and resolving equipment problems Imaging: computed tomography (CT)

Anatomy and physiology Imaging: nuclear medicine (NM)

Engineering concepts Imaging: magnetic resonance imaging

Electrocardiography (ECG) Imaging: ultrasound

Blood pressure monitoring Medical imaging networks

Pulse oximetry Telemedicine

Apnea monitoring Electronic health record/medical device interoperability

Fetal monitoring Radiation therapy equipment (RT)

Incubators and infant warmers Clinical lab equipment—basic

Phototherapy Clinical lab equipment—advanced

Defibrillators Surgical systems: minimally invasive/robotic

External pacemakers Surgical systems: electrosurgery

Infusion therapy devices Surgical systems: lasers

Ventilators Physical therapy equipment

FIG. 1  The planning and management course topics follow the diagram.

Belize, British Virgin Islands, St. Vincent, St. Kitts, Turks ­ anagement and has been taught annually at the University
& Caicos, France, Spain, China, Trinidad and Tobago, of Vermont, USA. In 2015, the course was then taught on the
Dominica, Barbuda, Guyana, Bahamas, Anguilla, Honduras, PAHO’s Virtual Campus for Public Health (Clark et al., n.d.).
Cuba, El Salvador, Panamá, Ecuador, Nicaragua, and the The original English course was translated to Spanish and
United States have taken these courses. adapted to Latin America with additional content created by
In 2008, a third 100% online course was independently Rossana Rivas. Rivas and Clark coordinated and taught the
developed covering healthcare technology planning and Spanish and English versions of the course, respectively (Fig. 1).
414  SECTION | 6  Professionalism, education, and ethics

The Healthcare Technology Planning and Management – Academic, YouTube, Industry

online course provides students with a basic understand- – Computer-based simulations
ing of the principles of healthcare technology planning and
Synchronous distance learning offers most of the
management using the life-cycle diagram developed by the
same advantages with the exception of participants hav-
Technical Services Partnership at the University of Vermont—
ing to be available based on a schedule. However, inter-
assessment, replacement, budgeting, acquisition, deployment,
active activities such as live discussions, group projects,
education, patient safety, and maintenance. Planning and
and timely question and answer are an advantage over
management is focused on not only medical equipment, but
asynchronous learning. Also, participants can see from
also clinical information systems and converged technolo-
the talking head lecturer areas of emphasis from voice
gies. Clinical engineering department setup, attributes and re-
and body language. The same is true for video chat rooms
sources are also presented along with professional and global
and project groups.
CE activities. Although quizzes and exams play a role in this
Disadvantages of distance learning fall into two primary
course, the discussion forum and reports are graded at a higher
buckets. The most commonly cited issue is the impersonal
weight for the planning and management course.
nature of distance learning. Not being in person with the
In the most recent course taught on the PAHO platform in
instructor and classmates takes away the human interac-
2017, the student selection process was coordinated from the
tion. Communication can be immediate regarding whatever
PAHO Washington DC office and involved interaction with
question pops into the student’s head or what idea the stu-
the WHO regional and country offices in the Americas. In
dent wants to share with his group. Live classes promote
all, 64 successfully completed the course with 49 graduating
comradery. The second disadvantage is related to the lack of
with excellence or distinction. The most engaging aspect of
hands on activities including laboratory exercises including
this asynchronous course was the quality and volume of dis-
building, testing, and repairing medical equipment. There
cussion board question answers and response to other partici-
have been some advances which try to provide a laboratory
pants. Students used real-world examples of their healthcare
experience in distance learning though simulations, tactile
technology planning successes, challenges, and experiences
feedback systems, and virtual reality.
in their countries in posting to the discussion board and for
the three required reports. Feedback from course participants
indicates that they wish to use the course learning to train oth- Future trends
ers in their health system in the concepts presented, apply the Distance learning will continue to expand in its use particu-
knowledge for projects such as implementation of electronic larly for useful purposes in blended/hybrid courses, for topics
health records, policies for acquisition requests, criteria for which lend themselves to online education such as computer
equipment replacement, and expanded resources for mainte- science, mathematics, medical terminology, and other courses
nance based on justification from the course. involving concepts that can be fully presented on a computer
screen or involve significant memorization. Interactive courses
will expand is use while self-paced, noninteractive courses
Advantages and limitations of distance may lose their appeal. One area sure to expand is learning
learning technologies geared for smartphone use. Smartphones are
Asynchronous distance learning has many advantages. The highly prevalent even in the low- and middle-income coun-
list below covers some of these: tries where the cellular networks provide better communica-
tion channels than wired or wireless Internet.
● 24 h/day, 365 days’/year access as online educational re- New areas of endeavor include virtual and augmented
sources always available reality. This is a technology being utilized not only by medi-
● Learning can take place such that it does not interfere cal professional for clinical simulation training but also for
with work or other activities training biomedical equipment technicians how to repair
● Cyberspace—no limitation on the location of the learn- equipment (Hayhurst, 2018). Another area of interest is the
ing, you just need a computer and connection creation of a virtual world which is a computer-based simu-
● No travel time or travel costs—gas, parking, tolls, or lated environment which may be populated by many users
tickets are required who can create a personal avatar, and simultaneously and
● A major advantage is that you have the full use of the independently explore the virtual world, participate in its ac-
World Wide Web resources tivities and communicate with others (Virtual World, n.d.).
– Documents

– Tutorials

– Case studies
– Scenarios Distance learning has expanded exponentially from the
– Videos time of correspondence courses due to the power of the
Distance education Chapter | 62  415

Internet and high-speed communications of video and au- management over the life cycle, world congress on medical physics
dio. The expansion will continue with the move to smart- and biomedical engineering 2018, IFMBE Proc., 68, 325–328.
phone use, virtual and augmented reality, and as a tool for Distance Education Accrediting Commission, https://www.deac.org/.
(Accessed 31 December 2018).
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Growth for Online Learning, Inside Higher Education News. http://www.
With the advent of distance learning options for clinical en-
gineering through degree programs, online globally avail- ments-slow-continue-grow. (Accessed 31 December 2018).
able courses, and webinars, the benefits will be increasing Hayhurst, C., 2018. Biomedical Instrumentation & Technology. vol. 52
for our field. (5), pp. 340–348.
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