Electric Differential Multimedia Laboratory Bibliography
Michael P. D'Alessandro (1)
Jeffrey R. Galvin (2)
Donna M. Santer (3)
William E. Erkonen (2)
Peer Review Status:
1Department of Radiology, Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115. Address correspondence to M.P. D'Alessandro. Phone: 617-566-3339 FAX: 617-730-0465
2Department of Radiology, Electric Differential Multimedia Laboratory, The University of Iowa College of Medicine, Iowa City, IA, 52242-1009.
3Division of General Pediatrics, Children's Hospital and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115.
The authors have no commercial interest in any product mentioned in the text.
Introduction
Radiologists need constant, convenient access to current
information throughout the course of their daily work. Today, most
learning in radiology is obtained from the printed word in the form
of books, journals, and teaching files. This is supplemented by the
spoken word in the form of lectures and conferences. Although
learning from printed material and lecture has the advantage of
having been proved over time to be efficacious, these media share the
disadvantage of not being conveniently available for reference during
the course of daily work at the alternator or in the examination
room, where and when accurate and up-to-date information is needed
the most. Therefore, many important questions about patients' care
that arise go unanswered. We have developed a technique, using
hand-held digital books, to lower this barrier to searching and
retrieval. By placing in radiologists' hands a digital library of
radiologic information which can be carried with them wherever their
work takes them, radiologists' may rapidly acquire current radiologic
information which may then be incorporated into daily decision
making. We describe a technique for the creation of hand-held digital
books and describe their future use in radiology.
Methods
A hand-held digital book is defined as a computer program running
on a hand-held computer which may function as a digital bookreader,
such as the Apple Newton (Apple Computer, Cupertino, CA). The digital
book simulates the user interface of a printed book, allowing use by
computer novices and experts alike. In addition, it contains features
beyond those of a printed book such as easy portability, automated
searching and retrieval, and rapid updating.
Our hand-held digital book uses the Apple Newton as its digital bookreader. Currently available versions of the Newton have a screen that supports two scales of gray (black and white) and that measures 4 in. by 3 in. (10.5 cm. by 7.5 cm) in physical size and has a resolution of 340 x 240 pixels. No computer programming knowledge is required to create a digital book.
The text in the digital book is created by the author using any standard word processor, such as Microsoft Word (Microsoft, Bellevue, WA), running on an Apple Macintosh computer (Apple Computer). The text is entered into a word processing file, and the letter size, style, and line spacing are determined by the author. Any black and white images to be used in the digital book are entered into the word processor file at this time also. The file is then proofread for accuracy. Special Òmark upÓ commands are inserted into the file that identify the component structures of the digital book such as chapter titles, and the beginning and end of chapters. The finished word processing file is then run through a Macintosh software program called the Newton Bookmaker (Apple Computer). The output from the Newton Bookmaker is then run through a second Macintosh software program called the Newton Toolkit (Apple Computer). The end result is that these software programs translate the Òmark upÓ commands and automatically produce a digital book that can be read on the Newton. The finished digital book is then transferred from the Macintosh computer into the Newton via a cable connecting the two using another software program called the Newton Connection Kit (Apple Computer). The digital book is now ready to be carried in the reader's hand.
The hand-held digital book, once created, may be distributed in three ways. First it may be placed onto a floppy disk, loaded onto a Macintosh or Microsoft Windows / IBM-PC computer, and then transferred into a Newton via the Newton Connection Kit as previously discussed. Second, the digital book may be placed onto a memory card, a form of Newton memory expansion, and plugged directly into a Newton. Third, if placed onto a computer network, a digital book can be downloaded directly into a Newton equipped with a modem or downloaded into a Macintosh or Microsoft Windows / IBM-PC computer and then transferred into a Newton via the Newton Connection Kit.
Our hand-held digital book is entitled the HitchhikerÕs Guide to Pediatric Imaging. It is two megabytes in size and contains information on (1) 300 common pediatric diseases organized by organ system, including clinical presentation, etiology/pathophysiology, pathology, imaging findings, differential diagnosis, and references; (2) 100 common pediatric clinical presentations and their differential diagnoses and directed imaging evaluations; and (3) descriptions of common pediatric imaging procedures.
Newton digital books, including the Hitchhiker's Guide to Pediatric Imaging, simulate the look of a printed book to facilitate their use by computer novices. At this time, they contain primarily text, supplemented by black and white line drawings. The reader interacts with the digital book by means of a hand-held stylus that is used to touch, or tap, on the screen in order to issue commands. On opening the hand-held digital book, the reader is greeted with a title page (Fig. 1). The reader then taps on the overview button to obtain the table of contents listing the chapters within the digital book (Fig. 2). Tapping on a chapter title then takes the reader to the appropriate chapter (Fig. 3). Tapping the up or down arrows moves the reader forward or backward one page at a time. Readers may mark interesting pages with bookmarks, which may be referred back to when the need arises (Fig. 4). Readers may also annotate the text with digital ink by writing directly on the digital book with the stylus if they wish (Fig. 5). Furthermore, the reader may copy, save, or print any part of the digital book for future reference. Finally, the reader may quickly and thoroughly search the digital book for any word or phrase of interest (Fig. 6).
Discussion
Print and aural media, which must be searched manually, are
usually stored in libraries or offices apart from the radiologistÕs
workplace. This creates a barrier of distance and time to overcome in
order to use them to answer daily clinical questions. The first
radiology digital books were created for desktop computers and
distributed on videodisc and compact disk read-only memory (CD-ROM)
[1, 2]. These desktop digital books are searchable by computer, but
their ultimate usefulness is limited by their being bound to a desk
or table, usually in a library; thus they do not provide radiologic
information where and when it is needed. Hand-held digital books, by
virtue of their ease of use, portability, and search capabilities,
lower the barrier to obtaining information. They harness the search
and retrieval abilities of computers and place a digital library of
radiology information at the radiologist's fingertips, allowing
radiologists to rapidly and conveniently acquire and review
information at the time and place it is needed, such as just before a
procedure begins in the examination room or while images are being
interpreted at the alternator. Information obtained in clinical
context is also more likely to be retained long term [3]. Rapid,
convenient access to high-quality information is especially needed in
subspecialty areas. It is estimated that 90% of pediatric imaging is
done by general radiologists (Kirks DR, personal communication), who
have had an average of only 3 months of pediatric imaging training
during their residency. Pediatric imaging represents a small
percentage of their daily practice, yet they are responsible for
maintaining mastery of a large data base. Therefore, general
radiologists could benefit from the use of decision support tools,
such as digital books, for pediatric imaging.
The first and current generation of hand-held digital books are stored on small-capacity memory cards and contain primarily text with black and white images because of limitations of the current generation of digital bookreaders. Nonetheless, these first-generation hand-held digital books have three distinct advantages over their printed counterparts. First is their compact size. A large printed book is difficult to carry in the pocket, but without its images, it may be made into a hand-held digital book and placed on a memory card that weighs one ounce (28 g), which is then inserted into a digital bookreader that weighs less than 1 lb (450 g). Several digital books and a digital bookreader may easily fit in a pocket. Second is the capability to thoroughly and rapidly search and retrieve from a digital book any word or phrase of interest. This becomes extremely useful when the reader is searching through not just one digital book, but a library of digital books. Third is the ability of the digital book to be quickly and regularly updated and redistributed to its readers with the most current information. Printed books spend several years in creation and may go several years between revisions because of the structure of the publishing industry, whereas digital books can be revised and economically redistributed on an ongoing basis as the author sees fit.
The second and next generation of hand-held digital books will take advantage of a new generation of digital bookreaders, and they will be stored on large capacity CD-ROM. They will contain high-resolution color images, video, and audio, and several complete textbooks will fit on each CD-ROM. This second generation will have three further distinct advantages that will cement their superiority over printed books. First will be their ability to contain an almost unlimited number of gray scale and color images of higher resolution than those found in printed textbooks. Second will be their use of dynamic media, in the form of video, audio, and animation, to teach a subject. This use of multiple forms of media, or multimedia, affects multiple senses and increases the variety of ways readers can encode the information, increasing the probability that the information will be retained by accommodating individual learning styles [4]. By containing such high-fidelity media, these digital books will contain realistic patient simulations and will allow the reader to engage in active and experiential learning, further increasing the chance that the information imparted will be retained. Finally, these digital books will be modifiable by their readers, who may electronically annotate them with digital images, video clips, and audio clips from their own clinical experiences. The seamless merging of personal clinical encounters with their clinical references produces a union between clinical practice and theory.
However, hand-held digital books must overcome two obstacles before they will receive full acceptance from the radiologic community. First, the current user interface, which emphasizes ease of use, must be extended to encourage and facilitate information browsing to allow serendipitous discoveries to occur. Second, although current digital books allow easy and clear annotation of their content by use of digital ink, future generations must expand these capabilities to include more sophisticated forms of annotation, including hypertext, or cross-referencing, capabilities.
Hand-held digital bookreaders must surmount several obstacles. First, they must fall in price from $500 to a point where loss or theft of a hand-held digital bookreader will not be a major economic issue. They must be durable, water-resistant, and shockproof like any printed book, and their battery life must be extremely long. Finally, the screen of the hand-held digital bookreader must be large enough and its screen resolution must be high enough to be pleasant to read for extended periods of time.
In 1455, Gutenberg and the printing press created personal printed books, and in 1501, Aldus Manutius miniaturized books to their current hand-held form. These technological breakthroughs democratized knowledge by breaking it out of the hands of libraries and the wealthy and placing knowledge in the hands of the common man [5, 6]. Now, hand-held digital books take this process one step further by providing searching and retrieval capabilities, thereby placing that knowledge at the readers fingertips, wherever and whenever it is wanted. This will help transform the radiologic education process by making it learner-centered and putting radiologists in direct control of the information they need throughout their professional lifetime. Hand-held digital books hold the promise of creating better informed radiologists.
Acknowledgments
The authors thank Donald R. Kirks, and E.A. Franken, Jr., for
providing the educational atmosphere and support to allow completion
of this project.
References
Figure Legends
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