Rural areas are special challenges for health services developers and opportunities for the use of networking technology. EMTs, nurses and physicians serving rural areas often lack, or experience decline of, clinical knowledge and skills. To receive high quality training, rural care providers must travel to urban areas, leaving their communities with decreased emergency medical coverage. The travel can be inconvenient and costly, often with loss of income during travel. Consequently, rural care providers tend to avoid continuing education programs outside their communities. A significant factor of health care attrition in rural areas is this isolation from opportunities to maintain and improve professional knowledge and skills. Bringing continuing education to the care provider's community allows a high percentage of individuals to attend while also maintaining emergency coverage. Today this training consists primarily of lecture presentations and is dependent on the knowledge and teaching abilities of the instructors. The dissemination of medical training programs over multimedia networks promises major improvements in high-quality training for rural providers in their communities. This can result in improved performance of providers, improved medical coverage, and improved retention and consequent efficiency of the rural provider community. The challenge is how to develop networked health services and a network infrastructure which supports their delivery.

In a similar way, members of the Army National Guard, many living in small communities, are likely to benefit from medical training that is delivered using this kind of network infrastructure. Timely, effective training will increase the effectiveness and integration of reserve military when mobilized to meet state or national emergencies. With additional funding from the Defense Advanced Research Projects Agency, the scope of the Dartmouth component of NMIS has been expanded to consider this need, with consequent change in the activities and schedule of the project. These changes include:

1. Development of a different health training application (Preventive Medicine in the Combat Theater) that places greater Quality of Service demands on networked multimedia technologies than the program originally proposed for NMIS (Respiratory Emergencies in Children).

2. Development of a second, completely new application (Skills for Interpersonal Communication) that promotes transfer of technology from this project to the Army and National Guard.

3. Provision for, in addition to network-only delivery of content, CD-ROM/network hybrid delivery of content (for users who only have dialup only access to the network).

4. Changing the evaluation to include technical performance and user-level effectiveness, using testbeds provided by the Army Training Support Center (ATSC) and the National Guard.

In order to accommodate this increased scope, work on the health component of NMIS has been extended through February, 1998. This additional work is likely to provide additional benefit to the civilian medical sector, by bringing interim, CD-ROM/network hybrid technologies to that audience; a result is delivery of health-related education and training programs requiring high Quality of Service while awaiting the development of an information infrastructure that has sufficient bandwidth to deliver adequate motion video to the home or office.

Accomplishments

The Interactive Media Laboratory (IML) at Dartmouth has pioneered technology-based health care provider education and training. "Preventive Medicine in the Combat Theater" (PMCT) is one example of an IML-developed, award-winning, interactive multimedia program. PMCT illustrates a movement in interactive media design that promotes a combination of "interactive television" and computer gaming instead of "computer-based training." This results in a presentation that is generally more acceptable to learners, provides a narrative context for learning, and lends a more intimate and personal "feel" to the learning experience. "Preventive Medicine in the Combat Theater" is a public health training program, providing an immersive, highly experiential "reflective practicum" in dealing with infectious disease outbreaks. It makes extensive use of motion video, navigational interfaces, audio ambiance loops, and text documents. As such, it places great technical and performance demands on supporting network infrastructure. It thus is an excellent exemplar program to consider "high end" authoring and delivery of public health education and training in a networked, distance learning environment. PMCT was developed originally for the U. S. Naval Health Sciences Education and Training Command, using MS-DOS, CGA graphics and Laserdisc (analog video) technologies.

Dartmouth/IML, in collaboration with the Army Training Support Center (ATSC), has demonstrated the use of networks in health-care training with a prototype interactive multimedia program created by adapting "Preventive Medicine in the Combat Theater" for delivery on local-area networks (LAN). The program can also be delivered via CD-ROM/Internet hybrid approaches for those users who only have dial-up access to the Internet.

The health-care component of the NMIS Project is also collaborating with Army and National Guard network initiatives as required to demonstrate and analyze the delivery of networked health care education and training. National Guard infrastructure investment programs, such as Iowa's, provide outstanding network connectivity statewide - but do not yet offer advanced health care information and education services. Efforts will be made to link these state initiatives and remote facilities to NMIS-derived services.

As a result of expanded scope of work, the health-related section of NMIS will continue through February, 1998. This will include development of a prototype Digital Multimedia Distance Learning System (DLS) linking Army and National Guard members to training materials maintained on the DLS server at the Army Training Support Center (ATSC), Ft. Eustis, VA. The DLS will contain 1) a generic world-wide-web front end allowing end-users access to any distance learning courseware available in the digital library; 2) software infrastructure necessary to deliver high Quality of Service interactive media in real-time over the network (network/local CD-ROM hybrid; broadband/network-only); and 3) an asset management infrastructure allowing content developers and training administrators to add new applications to the DLS. In addition, three exemplar programs will be prototyped for use with the DLS; the three programs will represent a range of programs, placing varying technical demands on network communications and requiring varying degrees of skill and expertise among courseware developers. The performance of this system, with exemplar programs, will be evaluated.

The project will proceed in two phases. During Phase I, all functions of the prototype DLS will be implemented and demonstrated, along with a prototype of an exemplar training application (PMCT) and Internet/Web-based services to support that application; a preliminary technical and formative evaluation of the prototype DLS will be conducted. During Phase II of the project, the prototype DLS and initial exemplar program will be refined and an additional application will be developed, along with Internet/Web services to support the new application. Final technical and end-user evaluations (formative and summative) will be conducted; an "over the horizon" evaluation of future technologies for distance learning will also be completed. Phase I will be completed by end of July 1997, with demonstration of the initial prototype by mid-July 1997. Phase II will be completed by end of February 1998, with demonstration of the system by end of November 1997.

Future Directions

The leader of the health care component of the NMIS Project, Joseph Henderson, has been in discussions with Dr. Edward Baker, Assistant Surgeon General directing the Public Health Professional Programs Office of the Centers for Disease Control and Prevention. A proposal will be developed and considered during Summer, 1997, further to develop and apply NMIS technologies in support of public health education and training worldwide.

Dr. Henderson has also participated in discussions with the president of Appleton and Lange Medical Publishers, a division of Simon and Schuster, about the application of NMIS technologies as part of new media publishing efforts generally, and as applied to a new program on managing cancer-related pain (developed the Interactive Media Laboratory as part of research funded by the National Cancer Institute).

A result has been a likely transfer of NMIS technologies to health care, including distance learning in state and federal public health training, Army and National Guard education and training, and the participation of a major publisher in application of NMIS efforts to other, federally-funded educational research and development.