Electric Differential Multimedia Laboratory Bibliography
Michael P. D'Alessandro,1
Jeffrey R. Galvin,1
William E. Erkonen,1
Donna M. Santer,2
Joan S. Huntley, 3
Robert M. McBurney,3
Greg Easley3
Peer Review Status:
1Department of Radiology, Electric Differential Multimedia Laboratory, The University of Iowa College of Medicine, Iowa City, IA, 52242-1009. Address reprint requests to Jeffrey R. Galvin, MD, Department of Radiology, The University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA, 52242-1009. Phone: 319-356-7980 FAX: 319-356-2220
2Department of Pediatrics, Children's Memorial Hospital, Northwestern University Medical School, 2300 ChildrenÕs Plaza, Chicago, IL 60614
3Second Look Computing, Weeg Computing Center, The University of Iowa, Iowa City, IA, 52242-1009.
Abstract
We have developed a standardized approach for creating computerized
multimedia textbooks based on the principles that (1) multimedia
textbooks should resemble printed books, (2) creating multimedia
textbooks should be relatively inexpensive, (3) the multimedia
textbooks should be completely digital, and (4) the process should be
simple.
To facilitate this approach, we created The Annotator, an inexpensive, user friendly, multimedia authoring tool. The Annotator, a Hypercard-based program that runs on any Macintosh computer, helps authors rapidly create sophisticated radiologic multimedia textbooks. This program provides a Òtextbook-like shellÓ that can be filled with digitized media (video clips, audio clips, images, and text). This general approach is applicable to any multimedia hardware platform and helps overcome previous problems that have thwarted multimedia production. Most importantly, this approach allows the authoring of multimedia textbooks today that can be easily transported to any future multimedia platform.
Introduction
We think that multimedia learning is the future of radiologic
education, but the current state of multimedia learning in radiology
consists of a never-ending stream of prototype systems that never
become commercially available. Multimedia learning is defined as
using multiple types of media (text, video clips, audio clips,
images, and animation) to teach a subject. Although much has been
promised in multimedia learning, little has been delivered [1-4]. To
solve this problem, we developed a new approach to radiologic
multimedia learning, the multimedia textbook (MMTB). We define
multimedia textbooks (MMTBs) as multimedia computer programs that
simulate the intuitive user interface of a printed textbook while
having educational features far beyond those of printed materials.
Our radiologic MMTBs vary in size and, on average, contain nearly the
same amount of information as a review monograph. To date, we have
created three radiologic MMTBs: ElectricDiffuseLung (formerly
HyperLung), dedicated to teaching the imaging of diffuse lung
disease; ElectricAirway (formerly HyperAirway), dedicated to teaching
the imaging, diagnosis, and treatment of pediatric airway disease;
and ElectricLungAnatomy, dedicated to teaching lung anatomy using
radiologic, bronchoscopic, and surgical correlation. We are now
engaged in researching and producing additional radiologic MMTBs.
This paper resulted from our desire to share new insights about
creating MMTBs and their coming importance in radiologic education
and to encourage others to join in this endeavor.
Approach
When we started our work, 12 months ago, there were no simple or
inexpensive multimedia authoring tools. We therefore created The
Annotator™ (Intellimation, Santa Barbara, CA), a Hypercard-based
program that runs on a Macintosh computer (Apple Computer, Cupertino,
CA) and is an original creation of Joan Huntley and her associates at
ÒSecond Look ComputingÓ (Weeg Computer Center, The University of
Iowa, Iowa City, IA). Similar multimedia authoring tools are now
commercially available in the form of the Multimedia Viewer
(Microsoft Corporation, Redmond, WA) for Windows platforms and the
Voyager Expanded Book Toolkit (Voyager Company, Santa Monica, CA) for
the Macintosh.
We view ourselves as both a computer laboratory and an electronic publishing house. Our approach to the creation of MMTBs can be summarized in four points:
1. Make it look like a book. A serious problem with most existing radiologic multimedia learning systems is their lack of an intuitive user interface. This discourages the computer novices in radiology who are their intended audience. One of the potential strengths of multimedia learning systems is the significant amount of "nonlinearity" or "branching" that can be built into them. This is also a weakness as students may become "lost" while reading them and therefore give up in frustration. Today's students are accustomed to a linear presentation of information typified by a standard lecture format or a radiology review article. We think that, as the public becomes more familiar with multimedia learning systems, they will grow to appreciate and enjoy the power of the nonlinear presentation of information. Until that time, we think that multimedia learning systems should be intentionally designed to present information in a linear fashion yet support perusal in a nonlinear fashion [5].
Therefore, we patterned the MMTB after a printed book during the early design phase of our project. By creating MMTBs that are similar in form and function to a printed textbook, we hope to gain broad acceptance of multimedia learning within radiology. The instructional design of our MMTBs was evaluated by more than 100 radiologists at national radiologic conferences and during its formal testing as a learning tool and was refined according to their suggestions. As the MMTBs are built around the printed book metaphor, they contain a table of contents (Fig. 1) , discrete chapters (Fig. 2) , multimedia indexes (Fig. 3) , a dictionary, the ability to take notes in the margins of the book (Fig. 4) , the ability to print any portion of the book or any portion of your notes, the ability to search for words or phrases within the book, and provisions for self-examination. As a consequence of this structure, these MMTBs have a primary linear, non-branching pathway through them that gives the reader a sense of closure when finished. However, once comfortable with the MMTBs, readers can also use them in a nonlinear, branching fashion.
2. Make the MMTBs quick and easy to create yet sophisticated in their function. MMTBs should be both easy to use and create. Previous multimedia learning systems often were created as specialized Òone-of-a-kindÓ systems tied to specialized hardware platforms [2]. Although this approach optimizes a given multimedia learning system for the subject being taught, it has the disadvantage of requiring a customized system for each topic. The Annotator, on the other hand, is a generic "media processor" that handles media in the same manner that a word processor handles words. As a consequence, in addition to being used to create MMTBs, it is flexible enough to be used for almost any imaginable educational task (e.g., multimedia case studies and multimedia teaching files). Authors create the customization needed for their tasks by their arrangement of the text within each chapter of the MMTB. In our MMTB, text is the primary medium, because we are accustomed to learning from words. This text is ÒannotatedÓ (linked) to related descriptive media in the form of additional text, audio clips, video clips, images, animations, and links to other portions of the book.
The MMTB is created physically by running The Annotator or a similar multimedia authoring tool and feeding into it the individual text files of the textbook chapters. The Annotator then creates the MMTB shell, which automatically contains the table of contents and all text files organized into their appropriate chapters. The text imported into the MMTB is automatically formatted by The Annotator to make its appearance presentable.You then open the MMTB and review each page as you would a regular book. At this point, the author can annotate the text with media by creating software links between the words in the text and previously digitized and stored media. To do so, the author merely clicks on a word and selects a type of annotation (video clip, audio clip, image, etc.) from a pull-down menu. The author is then prompted as to where in the computer's file system this piece of media is located and clicks once on it, thereby making the link. No programming or Hypercard scripting is required. The MMTB is now ready to be used by students. Although you can protect the MMTB so that students cannot modify its contents, an option exists for the author to allow the student to modify the MMTB. This permits greater interaction than that generated by merely typing notes in the margin of the book. Students can create their own set of multimedia notes within the MMTB by copying, pasting, and rearranging the media. This turns the MMTB into an interactive learning environment that facilitates knowledge artifact and concept building, which in turn facilitates learning. Thus, the MMTB becomes a learning environment that supports knowledge presentation, exploration, and construction.
3. Make the multimedia textbook authoring tool affordable. Current commercial multimedia authoring tools are expensive - usually around $500. This discourages people who are curious about the creation of MMTBs from exploring the possibilities. To address this problem, The Annotator has been priced at approximately $60.00.
4. Store the media used in the multimedia textbook in a digital format and separate them from the multimedia textbook. Our media are totally digital and are stored in industry standard file formats in files that are separate from the MMTB. This has three advantages. First, this allows quick and easy updating of the MMTB. When you find a new or better example of a disease, you simply remove the old media from your master copy of the MMTB and replace them with the new version. Second, use of this device-independent approach to multimedia authoring, which keeps the media independent of the MMTB, allows easy transfer of the MMTB to new multimedia authoring tools or new multimedia platforms, be they desktop or handheld in size, as they become available. Third, this allows us to distribute our MMTB on any current form of digital optical storage media or those of the future and also permits us to distribute our MMTBs via high-speed computer networks.
Until recently, video clips and images could not be effectively stored on digital optical storage media because of the high cost of these storage media and the large amount of storage space needed. Analog videodiscs store 54,000 image frames per videodisc and emerged as the ideal storage media for multimedia learning systems. However, recent advances in digital video and digital image compression have combined with a decline in the cost of digital optical storage media to make digital storage and distribution of video clips and images a more attractive approach.
For these reasons, the consumer electronics companies are abandoning the use of videodisc players for the distribution of multimedia learning systems and are turning to digital optical storage media in the form of CD-ROM (Compact Disc-Read Only Memory) in their new consumer multimedia players. The medical community should follow suit.
Hardware Required to Create and Play Back a Multimedia
Textbook
The Annotator runs on any Macintosh computer, and therefore the
following recommendations are limited to the Macintosh. Clearly, this
is a rapidly changing field and, by the time this is published, the
list may be out of date. Similar equipment exists for other
multimedia platforms.
1. Since medical MMTBs should contain photo-realistic color images and video clips, we recommend for the creation of MMTBs the most powerful Macintosh II computer available to you. It should have a color monitor, 16- or 24-bit color video, at least 8 megabytes of RAM, a large hard disk drive (at least 200 megabytes), and some form of removable mass storage media such as a 44- or 88-megabyte SyQuest removable cartridge hard drive or a 128-megabyte removable cartridge magneto-optical drive.
2. A video digitizer board is necessary to digitize video clips, such as the VideoSpigot (SuperMac, Sunnyvale, CA).
3. A consumer camcorder like the Sony Hi8 CCD-TR81 (Sony Corp., Tokyo, Japan) is necessary to acquire the video. It should be emphasized that the recording of the video clips should be done using the best available equipment as the quality of the original video clips degrades when they are turned into digital video clips.
4. A SuperVHS video cassette recorder is used to play back video on VHS and SuperVHS format tapes into the Macintosh for video digitization.
5. A MacRecorder (Farallon, Emeryville, CA) can be used to digitize audio into the Macintosh if your Macintosh is not equipped with a built-in audio digitizer.
6. Finally, image digitizing equipment is needed in the form of a flatbed scanner such as the Apple Scanner to digitize line drawings and diagrams (Apple Computer, Cupertino, CA), a slide digitizer such as a Kodak Rapid Slide Scanner (Kodak, Rochester, NY), and an x-ray film digitizer such as the Lumisys DIS-100 digitizer (Lumisys, Mountain View, CA). Image digitizing equipment is very expensive to buy so it may be to your benefit to borrow time on someone else's equipment, as the amount of time you spend digitizing images during the course of a single project is really quite small. If this is not possible, the best solution may be to buy a mid-range slide digitizer costing around $5000, have slides made of all the images and diagrams, and then digitize the slides. You may lose some information by digitizing slides of the original media rather than the original media themself, but you will save a tremendous amount of money.
An evolving alternative approach to digitizing is Photo-CD (Kodak, Rochester, NY) in which 35-mm film in the process of development not only is printed on paper or slides but also digitized directly onto a CD-ROM that is readable by any properly equipped personal computer with a CD-ROM drive. These high-quality, 24-bit color, digitized images that Photo-CD produces currently cost $1 for each image digitized, with the price certain to fall. Using Photo-CD as a digitizing service tremendously simplifies the digitizing process for the radiologist.
7. We recommend using the following hardware for the playback of MMTBs: A Macintosh II computer with a color monitor and 16- or 24-bit color video, 8 megabytes of RAM, a hard disk drive, and a CD-ROM drive. Stereo speakers are a nice addition, as the speakers built into computers are usually not equipped to handle stereo sound. This computer hardware configuration currently retails for $3000, and we expect it to retail for approximately half that in the next 12 months, when Apple Computer bundles all this hardware into a single package in its version of a consumer multimedia player. Macintosh computers with 8-bit color or even 4-bit gray scale, as seen in some of the newer Macintosh PowerBook notebook computers, can also be used for playback with suboptimal but often acceptable results.
Software Tools Required to Create a Multimedia Textbook
1. A word processing tool is used for the creation of all text. We
use Microsoft Word for the Macintosh (Microsoft Corporation, Redmond,
WA).
2. An image-processing tool is used for the captioning and labeling of images after they are digitized. We use NIH Image (free from National Institute of Mental Health, Bethesda, MD) for 8-bit color images and Adobe Photoshop (Adobe Systems, Mountain View, CA) for 24-bit color images.
3. A video processing tool is used to create digital video clips. We use Adobe Premiere (Adobe Systems, Mountain View, CA).
4. An audio processing tool is used to create digital audio clips. We use Macromedia SoundEdit Pro (Macromedia, San Francisco, CA).
5. A paint/draw tool is used to create diagrams. We use Aldus Freehand (Aldus Corp., Seattle, WA).
6. An animation tool is used to create animation sequences. We use MacroMind Director (Macromedia, San Francisco, CA) for creating animation sequences and Virtus WalkThrough (Virtus Corp., Cary, NC) for the creation of virtual reality walk-through sequences.
7. A multimedia authoring tool is needed to create the MMTB. Currently, we use The Annotator (The University of Iowa, Second Look Computing, Iowa City, IA). We are also evaluating the Voyager Expanded Book Toolkit (Voyager Company, Santa Monica, CA) for the Macintosh and the Microsoft Multimedia Viewer (Microsoft Corporation, Redmond, WA) for IBM-PC-compatible computers running Windows.
8. A multimedia database tool is needed to organize and archive all the media used in the MMTB so they can be reused and repurposed in future MMTB projects. We use Aldus Fetch (Aldus Corp., Seattle, WA).
Creating a Multimedia Textbook
Creating a MMTB is very similar to creating a printed textbook. The
entire process requires careful attention to detail and excellent
planning on the author's part. The team should include a content
expert who creates the text and gathers the media, an editor, a
computer expert, and a graphic artist.
The following actions need to be performed before actually beginning creation of the MMTB:
1. Pick a subject that you know well. Try to pick a subject that involves dynamic processes and whose instruction would be aided by the use of sound and motion. This will take advantage of the capabilities the MMTB has over the printed textbook.
2. Allocate an adequate amount of time to create the MMTB. We estimate that an average-sized MMTB can be built in 1 month of daily (8 hr) work (about 160 hr).
3. Line up financial support. Financial backing is often obtainable from medical school education grants and pharmaceutical or medical imaging companies.
4. Identify computer resources at your institution. There are often multimedia experts who can help you solve computer hardware and software problems and locate digitizing hardware, which is very expensive to own but often inexpensive to rent.
5. Gather your media including text, teaching files, videos, pictures, schematics, and audio tapes. When possible, use your own media and case examples. Collaboration with colleagues in other fields is extremely beneficial and rewarding for both parties. When borrowing media from preexisting sources, always get permission from the original publishers. Finally, check to see when release forms must be signed by patients and have them do so.
6. Write the text for your project and place each chapter into a separate text file.
Once the above steps have been completed, creation of the MMTB begins in the following manner:
1. Digitize all your media into the computer and process them by cropping, captioning, and labeling them. This is the most time-consuming task in the creation of a MMTB, and it is ideally performed with the assistance of someone with a background in graphic arts or publishing. Save all media in industry standard file formats such as the ASCII text file format for text, the PICT file format for images, the QuickTime file format for video, etc. Name your media files using a naming convention that allows you to look at a file name and quickly understand its contents. Organize your media within your computer's file system so that all the text files, images, video clips, audio clips, etc. are stored in separate folders.
2. Create a multimedia data base. As you create your media, place copies of them into a multimedia data base. Over time, you will build a large data base of images, video clips, audio clips, animations, and text that can be reused in future projects. In essence, you are building a digital library of media. Not only can you publish MMTBs on CD-ROMs, you can also publish CD-ROMs containing solely medical media (e.g., CD-ROMs containing hundreds of CT scans, chest radiographs, video clips of sonographic examinations). Eventually, such multimedia databases and MMTBs will be accessible to institutions and individuals via high-speed computer networks.
3. Build the MMTB using a multimedia authoring tool that creates MMTBs. The actual creation of the MMTB is similar to editing a paper in a word processor, requires no programming, and takes about 8 hr of work, depending on the size of the MMTB.
4. Proof the MMTB for errors and inconsistencies.
5. Copyright the MMTB.
Publishing Your Multimedia Textbook
Our average MMTB is 50-200 megabytes in size and is too large for
storage on floppy disks. CD-ROM is the current storage method of
choice. By definition, this is a read-only form of digital optical
storage media that uses the same technology as CD audio discs and has
an extremely large storage capacity of 650 megabytes per CD-ROM.
Your MMTB can now be sent to a commercial CD-ROM mastering facility. The one-time mastering cost for creating a CD-ROM is approximately $2000. After the CD-ROM master is created, copies of it are made by commercial companies for $1-2 per CD-ROM. The CD-ROMs are returned to you, ready for distribution, shrink wrapped in standard CD jewel cases with labels of your design. Publishing the MMTB yourself also gives you the chance to revise your work continuously. As you sell out all your copies of a CD-ROM, you can use the opportunity to make a new CD-ROM master containing updates and revisions. The computer industry sees CD-ROMs as a cheap way to distribute large quantities of information and it is therefore becoming quite popular. One disadvantage of self publishing is that the author must provide their own technical support for their MMTBs, which can be time consuming. For this reason alone, authors may wish to have their MMTBs distributed by commercial electronic publishers.
Experience with the Multimedia Textbook System
Our laboratory is directed by three faculty within the department.
They oversee the acquisition of equipment and help prioritize
projects. The laboratory is managed by a full-time employee who is
involved in day-to-day operations and works with faculty who are
creating MMTBs. When a project is approved by the directors, a
faculty member writes the text and gathers media. A note is attached
to each piece of media describing the media's file name and its
caption. The laboratory manager then digitizes this media into the
computer and creates the MMTB, which is then proofed by the faculty
member before it is published. We assign at least one medical student
to each MMTB project to assist in the media gathering and
digitization processes. This has proven to be a highly enjoyable and
educational experience for the medical students. Our laboratory
manager maintains expertise in the sophisticated multimedia software
tools used in our laboratory and trains new users in their use and
provides support for them after the initial training period. We also
have strong relationships with individuals in our university
multimedia laboratory who render assistance with perplexing computer
problems. Each MMTB project is reviewed with the author once a week
to determine the progress to date and to identify and solve problems
that may have arisen during production.
The laboratory consists of a large, air-conditioned, secure office filled with the previously described multimedia hardware and software. We rent time on image digitizing hardware owned by others within our institution. We perform our own video and audio digitizing. We have a large library of current computer and multimedia texts and journals. In addition, we have a connection to the Internet computer network, which allows us to contact electronically colleagues for help and information and to share our media with our colleagues around the world.
Faculty time spent in the production of MMTBs is recognized, as far as academic advancement, as time spent teaching. Therefore, MMTB production by faculty counts as much towards promotion as normal clinical teaching does.
Conclusion
Today's multimedia author is faced with choosing from a number of
competing multimedia formats to author for. In time, the market will
develop a universally agreed upon multimedia format. Until then, by
following the approach we have outlined, you can start creating MMTBs
today that can easily be ported to any future multimedia format.
Acknowledgments
The authors thank Nola Riley for her secretarial assistance, Phyllis
Bergman for her editorial assistance, and E.A. Franken, Jr., for
providing the educational atmosphere and support to allow completion
of this project.
References
1. Squire LF. On teaching radiology to medical students: challenges for the nineties. AJR 1989;152:457-461
2. Jaffe C, Lynch PJ, Smeulders AWM. Hypermedia techniques for diagnostic imaging instruction: videodisc echocardiography encyclopedia. Radiology 1989;171:475-480
3. D'Alessandro MP, Galvin JR, Erkonen WE, et al. The instructional effectiveness of a radiology multimedia textbook (HyperLung) versus a standard lecture. Invest Radiol (in press)
4. Tessler FN. Computer applications in radiology education: a challenge for the 1990s. AJR 1989;152:1169-1172
5. Soloway E. How the Nintendo generation learns. Commun Assoc Comput Machinery. September 1991; 34:23-26
Figure Legends
Fig. 1. Table of Contents screen for ElectricAirway. Clicking the mouse on the title of a chapter takes you to that chapter.
Fig. 2. A typical page in ElectricAirway. Various windows are opened, showing media that are linked to text currently being read by the student. The chapter under study is clearly marked at all times, as is the place in the chapter. The student may return to the table of contents by clicking on the Contents button.
Fig. 3. An index of media within ElectricAirway, organized by type of media.
Fig. 4. Marginal notes on a MMTB. These notes, along with any portion of the MMTB, may be printed out for later use.
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