Wednesday, October 10, 2012

On Quality Chasms, Interactivity, and Digital Textbooks

As has become increasingly the case recently, the time between this and my previous blog post is much longer than I would have liked. Many people argue that one should only write when one feels inspired, but I’m not one of those people; a writer writes, and I find that if I don’t write regularly, I get out of practice. Ray Bradbury offered advice to young writers, including that they should write a short story every week – at the end of the year, you’ll have 52 short stories and the odds that they will all be awful are pretty slim. Perhaps I should follow his advice and write a blog post every week?

But what I’d really like to write about today is a response to an editorial I read about digital textbooks. Last week, Arne Duncan stated that paper textbooks should become a thing of the past, and we should embrace digital textbooks. Justin Hollander wrote an editorial response to this declaration, arguing for the benefits of paper in education. You can read his editorial here.

It really is a well-written piece and offers may good arguments. At the same time, what Mr Hollander and many others fail to recognize is the power of technology to go beyond merely reproducing the written word on the digital screen.

At my job as a health services researcher, we are spending a lot of our time exploring something called “patient-centered care”. Though this concept has been around in psychotherapy for decades, it came into the forefront of health care and medicine in a report released by the Institute of Medicine.

That report, titled “Crossing the Quality Chasm”, was the second in a series of reports addressing quality issues in American health care, stating, “Between the health care we have and the care we could have lies not just a gap, but a chasm” (p. 1). Specifically, the issue is with the design of the system, which is not aligned with the needs of the current population – a population that has longer life expectancy and more ongoing, chronic conditions requiring a different management approach, is more mobile (so people may not see the same doctor their entire lives) and simply is more abundant (making it difficult for doctors to really know their patients’ situations and needs). The report provided recommendations for safe and effective care, specifically discussing patient-centered care as “encompass[ing] qualities of compassion, empathy, and responsiveness to the needs, values, and expressed preferences of the individual patient” (p. 48).

This report also discusses increased use of technology, to improve access to information, education, and care, so long as the technology is aligned with a patient’s individual needs, values, and preferences. That is, the technology should be customizable and tailored to the patient.

Perhaps you’re asking (or have been asking), “What does any of this have to do with digital textbooks?” Hang in there, kids; we’re almost there.

Patient-centered technology is not about simply digitizing information once recorded only on paper; rather, it is about changing healthcare delivery, efficiency, and quality, and creating a system that is truly patient-centered. People who merely take information from pamphlets and booklets and slap them onto a web-page are entirely missing the point. Where technology really shines is in its ability to shift in response to the user. The concept here is “interactivity”.

Let’s say I’m a physician who wants to teach my patients with diabetes about managing their blood sugar. In the past, I’d probably have them do some in-person training, perhaps with a nurse educator, on checking their blood sugar, giving themselves insulin, and all the other self-care that people with diabetes must do, and I’d probably send them home with some pamphlets. Of course, they would continue seeing me regularly, but so much of what people with diabetes must do involves self-care; they really must become masters of managing the condition.

With technology, I’d still do some in-person training, but I could also have them receive information from the pamphlets through a website or tablet app, where they can select what information to view, access embedded videos, and perhaps even take a quiz to assess their understanding and identify gaps in knowledge. I could even design this program so that, based on quiz results, they are given access to additional reading and videos to specifically address those gaps.

So let’s bring this back to education. Say I’m a student taking a statistics class. I read the section on measures of central tendency (mean, median, and mode), then complete a quiz. If my quiz results show that I’m having some difficulty with mode, I could be taken to additional sections that focus more heavily on that concept, provide more examples, or even take a different approach to presenting the information.

I can understand the hesitance to completely abandon paper. Paper should still have an important place in reading and education. There is something to be said for the ability to touch, to hold something in your hand, to hear the binding crack, to smell the ink on the pages. And when the choice is between reading a book on paper or reading a book on an e-reader, where the logistics of navigating pages is basically the same, it seems more a matter of personal preference than superiority of one medium over the other. Sure, the ability to search and carry more books without adding weight to one’s bag is nice, but may not be enough for the increased (at least initial) costs of converting from paper to electronic. 

But if we can capitalize on the technology at hand to supplement and tailor material, to really allow students to grasp core concepts so that we may expand upon them in the classroom and move toward mastery of the subject, then Mr. Duncan, I couldn’t agree more.

Thoughtfully yours,

 Institute of Medicine. (2001). Crossing the quality chasm: A new health system for the 21st century. Washington, DC: National Academy Press.

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