Online learning in Health Professions Education. Part 1: Teaching and learning in online environments: AMEE Guide No. 161

Abstract

Online learning in Health Professions Education (HPE) has been evolving over decades, but COVID-19 changed its use abruptly. Technology allowed necessary HPE during COVID-19, but also demonstrated that many HP educators and learners had little knowledge and experience of these complex sociotechnical environments. Due to the educational benefits and flexibility that technology can afford, many higher education experts agree that online learning will continue and evolve long after COVID-19. As HP educators stand at the crossroads of technology integration, it is important that we examine the evidence, theories, advantages/disadvantages, and pedagogically informed design of online learning. This Guide will provide foundational concepts and practical strategies to support HPE educators and institutions toward advancing pedagogically informed use of online HPE. This Guide consists of two parts. The first part will provide an overview of evidence, theories, formats, and educational design in online learning, including contemporary issues and considerations such as learner engagement, faculty development, inclusivity, accessibility, copyright, and privacy. The second part (to be published as a separate Guide) focuses on specific technology tool types with practical examples for implementation and integration of the concepts discussed in Guide 1, and will include digital scholarship, learning analytics, and emerging technologies. In sum, both guides should be read together, as Guide 1 provides the foundation required for the practical application of technology showcased in Guide 2.

Please refer to the video abstract for Part 1 of this Guide at https://bit.ly/AMEEGuideOnlineLearning

Video Abstract

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© 2023 AMEE. Published by Informa UK Limited, trading as Taylor & Francis Group

Keywords:

• Online learning
• online education
• distance learning
• educational technologies
• instructional technologies

Introduction: evidence for online learning and moving beyond pandemic pedagogy

‘[D]igital technology has become a central aspect of higher education, inherently affecting all aspects of the student experience’ (Bond et al. 2020).

Practice points

• COVID-19 accelerated the adoption of online Health Professions Education (HPE), but also highlighted frustrations and limitations, particularly in synchronous environments.

• Online learning has similar learning outcomes to face-to-face (F2F) learning, but blended learning (combining F2F and online delivery methods) can provide better learning outcomes than either alone. HPE should consider how blended learning can enable strategies such as multimodal, tailored, collaborative and dispersed methods, which improve learning.

• Incorporating effective teaching principles such as social learning, feedback, practice exercises, repetition, and interactivity are equally important in F2F and online environments and require careful planning for issues unique to online learning.

• Blended and Hybrid Flexible (HyFlex) designs are emerging methods of delivery that allow for improved learner choice and accessibility.

• Standards and principles (e.g. Universal Design for Learning) exist to guide the development of online curriculum.

• Curriculum design and research in online environments should always incorporate learning theories and instructional design principles, ideally with those that have their origins in online learning.

• Online learning may provide us with an opportunity to rethink and redesign HPE, using ‘education first’ principles.

Online learning in Health Professions’ Education (HPE) has a well-established foundation (Ellaway and Masters 2008; Masters and Ellaway 2008) and has been rapidly evolving over the last decade due to advances in software, hardware, learner preferences, and curriculum reform (Schwartzstein and Roberts 2017; Emanuel 2020). Despite these advances, HPE has typically fallen behind higher education in the adoption of online learning.

However, the emergence of COVID-19 led to a sudden and accelerated world-wide shift from face-to-face (F2F) teaching to online Emergency Remote Teaching (ERT) (Hodges et al. 2020) or Pandemic Pedagogy (Schwartzman 2020), with the focus on getting educational materials into online systems accessible to learners quickly, and with as little disruption as possible (Hodges et al. 2020; Daniel et al. 2021). This often entailed finding the closest online equivalent to F2F activities, using available resources, with little time to apply online education practices, theories or faculty development (Fawns et al. 2020; Stojan et al. 2021). Unfortunately, this led many to the incorrect assumption that online learning was inferior to F2F methods.

Decades of research have shown that online learning outcomes are similar to F2F outcomes (U.S. Department of Education, Office of Planning, Evaluation, and Policy Development, Policy and Program Studies Service 2010; Nguyen 2015), including in healthcare contexts (Cook et al. 2008; Pei and Wu 2019). This finding has been repeated in numerous systematic reviews and meta-analyses across multiple disciplines, and evolving technologies, and is known as the ‘no significant difference effect’ (DETA 2019). Despite unique advantages and challenges of different online modalities, contexts, teachers and learner groups, online learning at its core is just learning, and perhaps we should cease making a distinction between online and F2F methods, especially as the lines between the two continue to blur.

However, the question of equivalency remains fraught with ambiguity. First, online learning is heterogeneous. It is unlikely we would clump F2F modalities such as lectures, bedside learning, Problem-Based Learning (PBL), workplace learning and journal club together and consider them to provide the same learning outcomes. Similarly, webinars, online simulation, virtual cases, podcasts, and social media, are diverse modalities. In addition, online videos and polling apps are often used in F2F classrooms, and online learning may involve F2F participants (such as in HyFlex or remote classroom delivery discussed later), making the distinction between these modalities impractical or impossible.

Perhaps it is no surprise, then, that the techniques that improve outcomes in online teaching are the same in F2F environments, such as interactivity, feedback, repetition, and practice exercises (Cook et al. 2010; Cervero and Gaines 2015). In addition, learning design strategies that are proven to be more effective in F2F environments, such as distributed practice (spaced over time) and multimedia learning, can be facilitated with online learning (Cervero and Gaines 2015; Van Hoof et al. 2021).

Second, most studies have examined learning outcomes such as satisfaction, knowledge, and skill acquisition and rarely patient outcomes. In addition, there are other nuances to learning such as professional identity formation, mentorship, teacher and student burnout and cost effectiveness of online learning that need further examination (Castañeda and Selwyn 2018; Cook et al. 2021; Oducado et al. 2022).

Lastly, institutional and learning contexts in which online education occurs can affect learning with, and usage of, technology (Ellaway et al. 2014a,b), so one should avoid a naïve belief in a simple transplant of outcomes, methods, and approaches.

The most exciting and significant finding on the issue of equivalency is that blended learning (combining F2F and online methods together) provides better learning outcomes than either F2F or online learning alone (Liu et al. 2016; Vallée et al. 2020). Perhaps this is not surprising, as blended learning allows us to utilize the best aspects of both online and F2F learning while minimizing undesirable effects. For example, F2F components could provide immediate feedback and social connections, while online components help with dispersed and convenient learning.

Although this is not the place to conduct a detailed Strengths-Weaknesses-Opportunities-Threats (SWOT) Analysis of ERT’s impact on online HPE, we will loosely use this framework to Guide the rest of this introduction, highlighting some of the major issues raised by ERT.

The major strengths of ERT are that many teachers and learners who had no or limited experience with online teaching and learning have now had exposure and can see its benefits (Naciri et al. 2021). In addition, those health professions schools and institutions that effected infrastructural and organizational changes are able to develop their systems further.

Learners and educators alike have noted the benefits of flexibility and accessibility of online learning, particularly for those who otherwise might not have been able to attend educational activities due to time, distance, or competing priorities, such as work or family duties (Daniel et al. 2021). In some cases, the ERT pivot encouraged a learner-centric approach to education, such as being able to choose and revisit videos or modules where learning needs were greatest or receive automated individualized feedback such as quizzes.

With these strengths, ERT promised great potential for teachers new to online learning and provided a strong grounding on which to incorporate further pedagogically informed and technology-transformed HPE (Jeffries et al. 2022).

A weakness of ERT was that most health professions schools and institutions making this pivot were poorly prepared, and many teachers and learners had negative experiences; as a result, their perception of online education may be that it is limited, that not all subjects can be taught online, that communication and connection with others are severely constrained, and that online learning should be used in emergencies only. ERT also highlighted the ‘digital divide’ that students with limited or no access to hardware, internet, and safe spaces to learn in experienced, and global inequities of technology access (Schwartzman 2020).

These issues were frequently amplified by a lack of faculty development, technical problems with hardware, software, internet accessibility, and poor learner and educator orientation and digital literacy (Schwartzman 2020; Daniel et al. 2021). Problems with learner engagement, student sense of belonging, competing priorities and screen fatigue also played their part, and still need to be addressed through pedagogical design such as netiquette, peer collaboration, interactivity, and blended approaches (Naciri et al. 2021).

An opportunity fostered by ERT, therefore, exists: that of teachers’ and learners’ using their experience to move beyond merely replacing F2F practices to develop full-blown and pedagogically informed online education, building on benefits experienced, such as more flexible learning and increased accessibility to materials, patients, and activities, while learning from limitations and errors.

As a result, we have an opportunity to continue to build on the advances in online HPE that were restructuring education, albeit slowly, long before Covid-19 (including infrastructure, leadership, faculty, staff, and learner competence) to reflect a shifting understanding of what works in health professions education (Emanuel 2020; Price and Campbell 2020). This restructuring may provide an opportunity to move away from passive to more active learning opportunities, and narrow the know-do gap in educational practices. In addition, we can consider ways in which online learning may allow for opportunities that would not be possible with F2F methods, such as bringing large classrooms to the bedside or workplace, or training learners remotely, including in different countries (Jiang et al. 2021). This also provides us with an opportunity to invest in the faculty and staff development (FSD) needed to move beyond ERT into pedagogically informed ways of online and blended education.

Perhaps the greatest threat from ERT was a lack of current direction on how we should be using and exploring online learning, often related to the doubts caused by the weaknesses described above. This lack of direction may encourage teachers and students to revert to F2F education, settle into pre-COVID-19 comfort zones, and lose the value of their online experience. This is exacerbated by the relatively short duration of experience and research in best practices gathered in these new environments over the last two to three years, in contrast to lifetimes of experiencing, researching and/developing comfort levels with F2F techniques. It will also be important to maintain institutional support, including strategy, infrastructure, and faculty development in the absence of the COVID-19 crisis if we are to keep moving forward in our transformation of health professions education (O’Doherty et al. 2018).

The aim of this Guide is to provide guidance and direction for HPE online learning, by diminishing the weaknesses and threats, and building on the strengths and opportunities of online HPE. To accomplish this, we have divided this Guide into two Parts that inform one another.

The first Part will provide an overview of evidence, theories, formats and educational design in online learning, including contemporary issues and considerations such as learner engagement, faculty development, inclusivity, accessibility, copyright, and privacy. The Supplemental Appendix provides practical examples and implementation strategies.

The second Part focuses on specific technology tool types with practical examples for implementation and integration of the concepts discussed in Part 1, and will include digital scholarship, learning analytics, and emerging technologies. In sum, both Parts should be read together as Part 1 provides the foundation required for the practical application of technology showcased in Part 2.

We first begin with online learning theories as a fundamental, and often overlooked, starting point for online education.

Online learning frameworks and theories

A deficiency in online learning is the lack of theory employed in the research and curricular design of online higher education (Castañeda and Selwyn 2018; Hew et al. 2019; Bond et al. 2020). This is also true within healthcare settings (Bajpai et al. 2019). Online educational research and curricula are often based on empirical and practical experience rather than sound pedagogical design and appear to be guided by the notion that innovation, because of its novelty or practical need, does not require a sound grounding in theory.

The use of theories and frameworks for online learning helps us build on prior work, develops a common language and direction of study, enhances our understanding of online learning processes, allows generalization of results to other online contexts, designs sound curriculum and assessment, and helps learners understand their learning processes, all toward better learning outcomes (Bajpai et al. 2019; Hew et al. 2019). Ultimately, using online learning theories can allow us to rethink the way we provide online education in a way that maximizes student engagement and learning outcomes.

Previous AMEE literature provides an excellent introduction to general educational theories and frameworks (Taylor and Hamdy 2013), as well as a review of educational theories with online learning examples (Sandars et al. 2015). There are arguments about whether frameworks, models, and theories created specifically for online learning should be preferred over other well-established but ‘imported’ theories from F2F environments to the online environment. One example of an adapted model is Kern’s six-step approach to online curriculum development (Chen et al. 2019). This Guide briefly introduces three theories original to online learning, that we feel are accessible to the beginner (PICRAT model), intermediate (Community of Inquiry Framework) and advanced (Connectivism) online educator. There are many more theories, frameworks, and models of online learning, and readers are encouraged to explore these in more detail. Equally, educators should consider multiple theories in their research and curriculum development, considering the unique advantages, disadvantages, and context of each theory. Practical application of online theories will be further discussed in Part 2 of this Guide.

Passive-Interactive-Creative-Replaces-Amplifies-Transforms (PICRAT) model

PICRAT is a newer model of technology integration, gaining popularity particularly in the kindergarten to grade 12 (K-12) literature. It is accessible and easy to use for the beginner online educator, as it starts with considering teacher and learner roles in F2F learning and then comparing and extending this to the online environment. PICRAT builds upon and combines several prior models such as the SAMR and RAT, arguing for theoretical pluralism to enable different solutions in these complex online environments (Kimmons et al. 2020).

The PICRAT model looks at two main questions: how students interact with technology, and how teachers use technology in their pedagogy. The elements of PICRAT form a matrix, with one axis (PIC – Passive, Interactive, Creative) examining learners’ use and the other axis (RAT – Replacement, Amplification, Transformation) examining teachers’ use (Figure 1(a)). The goal is that ‘technology’s role should serve as a means to an end, not an end in itself – avoiding technocentric thinking’ (Kimmons et al. 2020).

Figure 1. (a) PICRAT Matrix: Use of video for teaching and learning using PICRAT Matrix: from passive (e.g., video conference) to creative (learners create video). (b) Community of Inquiry: 3 overlapping Venn circles each providing a definition of a type of presence (Social, Teaching and Cognitive).

Figure 2. Learning Modalities. Description: 4 overlapping Venn circles (Face-to-face, Online, Asynchronous, Synchronous), with examples of activities described at each intersection.

Figure 3. Synchronous learning scenarios. Description: HyFlex scenario depicts F2F instructor with group of F2F learners as well as individual online learners. HyFlex with remote classroom scenario depicts F2F instructor with group of F2F learners as well as classroom of online learners. Virtual (synchronous) scenario depicts online instructor and online learners.

Kimmons argues that, while technology such as e-modules or online quizzes can drive student interactivity, this prescriptive learning may ‘limit transferability and meaningful connections to previous learning’, but creative learning (where learners create artifacts such as videos and collaborative blogs) causes creative problem solving and deeper, contextualized learning, and therefore may be preferred over passive and even interactive learning (Kimmons et al. 2020).

When examining how teachers use technology, we consider the ‘RAT’ axis of the matrix. Like ERT, teachers starting to use technology will often use it as a replacement to F2F teaching with no improvement to their pedagogical practice. However, with more comfort and skills, technology can be used to amplify (improve, but not radically alter) or even transform (enable learning not achievable through non-technological means) pedagogical approaches.

PICRAT is intuitively easy to use and helps to facilitate conversations around complex sociocultural use of educational technology. It acknowledges that there is often no one ‘right’ way to use technology (no matrix square is inherently bad or good and each has its own benefits), and that different contexts require different creative solutions.

The Community of Inquiry model

The Community of Inquiry (CoI) model is one of the most widely used and studied online learning models and is well suited for intermediate online educators (Garrison et al. 1999). Three interconnecting presences: social presence (SP), cognitive presence (CP), and teaching presence (TP), create overlapping domains from which to start conversations around considerations in designing and researching online learning (Figure 1(b)).

Social presence refers to the ability to project oneself as a learner into the virtual learning environment and form connections with others. It is thought of as the building block to cognitive and TP formation (e.g. negotiating a safe learning environment or providing opportunities for learners to connect).

Teaching presence is the Instructional Design (ID), organization, and facilitation of learning. It is found to be a significant factor in student satisfaction and perceived learning (e.g. use of online rubrics for assignments or instructor video announcements).

Cognitive presence refers to how learners cognitively connect with the learning, often through cyclical iterations of four stages (triggering event, exploration, integration, and resolution). It involves group collaboration to socially construct and apply knowledge from different perspectives, as well as personal reflection, retention, and interpretation of information (e.g. online simulation or small group discussions).

In essence, ‘the group cohesion and open communication created by SP and the structure, organization, and leadership associated with TP lay the foundation to create the environment where CP, which is considered to be the most important element associated with higher-order learning, can flourish’ (Shea et al. 2014).

Connectivism

Connectivism is a more advanced theory, which prompts educators to consider how technology may assist in changing education systems from those that merely allow transmission of information from teacher to learner, to systems and networks that transform learning through connections. Connectivism assumes that we ‘derive our competence from forming connections’ through networks, with ‘integration of principles explored by chaos, network, and complexity and self-organization theories’ (Siemens 2005). These complex knowledge networks are formed and maintained through connections, diversity, and mentorship, and are more important than individual knowledge, which can be forgotten or quickly obsolete in twenty-first century healthcare. Some practical examples of connectivism include Massive Open Online Courses (MOOCs), social media or community of practice discussion boards (What We’re Learning From Online Education 2012).

In day-to-day Connectivist education, the aim is for learners to use the information afforded by the Internet to investigate untested ideas, create, and collaborate on material in electronic format, and even influence the course curriculum. The translation of this philosophy into practice is well-illustrated in what has become known as Connectivist MOOCs (cMOOCs) (Downes 2010; Siemens 2012) which were initially seen as central to HPE MOOCs (Masters 2011). The development and types of MOOCs in HPE will be discussed in more detail in Part 2 of this Guide, but for now, note that the philosophical elements of Connectivism can promote deeper learning and be embedded into courses to encourage students to collaborate and access materials beyond the core syllabus, although may require a departure from traditional course structures.

We now turn to examining different online educational formats. Readers should, however, take a moment to reflect on the importance of online HPE’s shifting from empirical research and curriculum design to being grounded in theoretical approaches, so that scholarship in the field is enhanced and education more robust and transferable.

Online educational formats

Online learning definitions and formats are diverse and continually evolving (Regmi and Jones 2020). Each format will appeal to different teachers and learners, will have its implementation difficulties, and will be influenced by different contexts. Below, we explore synchronous and asynchronous online learning as well as other variations such as blended and Hybrid-Flexible methods. We will refer to these formats as simply synchronous and asynchronous learning, acknowledging F2F formats also have synchronous (e.g. lecture) and asynchronous (e.g. reading) components (see Figure 2).

Synchronous learning

Synchronous learning occurs when learners are learning at the same time (data are sent and received in real time). Frequently used synchronous technologies include Zoom (https://zoom.us/), Microsoft Teams (https://teams.microsoft.com/edustart), and Google Meet (https://apps.google.com/meet/). In addition, other more immersive tools, such as Gather.Town (https://www.gather.town/), SpatialChat (https://www.spatial.chat/), and Wonder.me (https://www.wonder.me/), which allow learners to move freely and interact in a virtual environment, are emerging, and other virtual, avatar-based worlds such as Second Life (https://secondlife.com/) have been used in healthcare education for some time (Ghanbarzadeh et al. 2014).

As synchronous learning most closely mirrors F2F classrooms, it was more readily adopted in the pandemic (Stojan et al. 2021). A systematic review and meta-analysis of synchronous HPE showed comparable outcomes to traditional learning environments for knowledge and skill acquisition and was preferred by learners (He et al. 2021).

Typical features of synchronous learning software include screen sharing, chat, and audio/video sharing and nonverbal reactions/emojis. Other features may include polling, annotation, whiteboard, and breakout rooms. However, if these features are not available, they can easily be imported by using additional software such as polling software (e.g. Poll Everywhere https://www.polleverywhere.com or Kahoot! https://kahoot.com) or whiteboard software (e.g. Google Jamboard https://workspace.google.com/products/jamboard or Miro https://miro.com). In addition, there are many tools that can assist with making synchronous presentations more interactive such as Nearpod https://nearpod.com, Mmhmm https://www.mmhmm.app/home, and Prezi https://prezi.com.

Interactivity is the key to synchronous learning. Without interactivity, a recorded lecture could be more efficient (watching at 1.5× speed), convenient (at any time), and polished (without synchronous technological glitches). Despite this, learner engagement has been reported as one of the most challenging aspects of synchronous learning. This is concerning, given the correlation between learner interactivity and engagement with learner performance, motivation, and satisfaction in online environments (Cook et al. 2010; MacNeill et al. 2014; Bond et al. 2020; Händel et al. 2022).

Equity, particularly participatory equity, is important to consider when interacting in these environments (Reinholz et al. 2020). Not all learners have access to hardware, bandwidth, or safe learning spaces to fully participate in online learning. Others may feel more comfortable sharing in anonymous (polls) or non-verbal (chat) ways. Consider ways to ensure equal participation, such as waiting for five hands to be raised or online random name generators for assigning roles such as chat monitor or tech assistant (Reinholz et al. 2020). However, webcam non-usage involves many other factors than accessibility and privacy issues (Händel et al. 2022; Masters et al. 2022).

One such issue is videoconferencing fatigue, a component of computer-mediated communication exhaustion (Oducado et al. 2022). There are many hypotheses as to why communication in synchronous environments feels more exhausting, including interpreting two-dimensional and limited non-verbal cues, ‘mirror fatigue’, feeling physically trapped, and anxiety of projecting oneself into the virtual, sometimes recorded, environment. Some solutions to these issues are to turn off the self-view of your camera (while your camera remains on), make videos of participants smaller, take visual breaks/use audio only temporarily, or go for a walk during sessions when visuals are not required. Prior research has found attitudes toward videoconferencing was the strongest predictor of videoconference fatigue, and may be lessened by experience, support and active learning techniques (de Oliveira Kubrusly Sobral et al. 2022; Oducado et al. 2022). Frequency and duration of videoconferencing is also associated with fatigue, and points to best practices of shorter duration, more frequent breaks and use of blended methods and multimedia in online learning (Oducado et al. 2022).

On the other hand, there are many pedagogical reasons to encourage cameras to be on during teaching sessions, including visual feedback for engagement and emotional response, social interactivity, and effect on learner and presenter motivation and engagement. Several studies have shown that lack of webcam use is associated with poorer student course performance and involvement, and teacher frustration and insecurity, whereas webcam use has been associated with increased student verbal engagement in class (Händel et al. 2022). Factors related to positive webcam use have included smaller classes or breakout rooms, lecturer encouragement, a sense of open communication, and most importantly, peer use of webcams (Händel et al. 2022). Recommendations for improving webcam usage while still promoting equity and inclusion include addressing distractions and employing active learning strategies (Castelli and Sarvary 2021) and establishing netiquette (Kempenaar et al. 2021; Thomson et al. 2022). Netiquette considerations are listed in Supplementary Appendix 1.

Ultimately, engagement and interactivity, not webcam use, are key to synchronous learning, and there are many other ways to achieve this when videos are not an option due to bandwidth, privacy, or equity issues (MacNeill 2020; Khan et al. 2021). There are many articles (Khan et al. 2021; Nunneley et al. 2021), videos (MacNeill 2020), and online handbooks (Hyder et al. 2007) summarizing practical tips for synchronous HPE, which are summarized in Supplementary Appendix 2.

Synchronous lectures have similar outcomes to asynchronous recorded lectures (Brockfeld et al. 2018). However, there are advantages to synchronous learning, including providing a placeholder in calendars to allow structured time for learning, social learning, real-time feedback, and interactivity (Ranasinghe and Wright 2019). Many tools and techniques can be used both synchronously and asynchronously, and optimal learning likely involves combining both methods such as providing synchronous lectures in addition to asynchronous recordings after the lecture (Ranasinghe and Wright 2019).

We now turn our attention to asynchronous learning, but the reader is encouraged to reflect on why they may choose synchronous learning over asynchronous or mixed methods, decerning whether it is for habit, comfort, skill level, or pedagogical reasons, such as real-time interactivity and learner engagement.

Asynchronous learning

Asynchronous learning occurs when learners can participate from anywhere at any time. Common types of asynchronous learning include emodules, MOOCs, discussion boards, video, audio recordings, and other study material distributed via postings or shared files. Asynchronous collaboration can happen through built-in tools for peer and instructor interaction in the Learning Management System (LMS) such as discussion forums, or outside of the LMS via platforms such as Slack (https://slack.com), Twitter (https://twitter.com), or Flip (https://info.flip.com/), collaboration tools (such as Google docs https://workspace.google.com/products/docs, Miro, or Trello https://trello.com), or teacher/learner support through email, virtual office hours, and audio messaging.

Due to fewer technological requirements (such as bandwidth, hardware, and software), asynchronous learning was among the first forms of online learning in HPE. Traditionally, blended learning involved in-person classroom learning with asynchronous homework, such as online readings or discussion boards. This differed from flipped classroom learning, where asynchronous materials provided content, typically through emodules and videos, prior to F2F practical application in the classroom (Schwartzstein and Roberts 2017; Phillips and Wiesbauer 2022).

Asynchronous education is also attractive to higher education, as it accelerates institutions’ digital reach, allows potential monetization of content, and promotes digital scholarship with international impact. The promise of teaching vast student cohorts through administrative efficiency and scalability, greater learner enrolment through more flexible learning, and expanding academic reach can be an enticing argument toward investment in asynchronous education.

Benefits reported by learners regarding asynchronous learning include studying at their own pace, avoiding scheduling conflicts and increased productivity (Gillingham and Molinari 2012; Regmi and Jones 2020) Contrary to popular belief that younger learners prefer online learning, asynchronous learning seems to appeal especially to mature adult learners, particularly those with other life commitments, who appear to be better at time-management, agency and motivation (Harris and Martin 2012). Asynchronous learners are also able to tailor their learning, devoting more time to topics of interest or need and less to those already mastered (Phillips and Wiesbauer 2022). This may be particularly helpful for postgraduate or Continuing Professional Development (CPD) learners coming from different specialties or interprofessional HPE backgrounds (MacNeill et al. 2010; Chang et al. 2014). Asynchronous learning also allows for adaptive learning (Ruiz et al. 2006), utilizing tracking (engagement with material, assessment scores), computerized feedback and personalized learning (based on learner needs or assessment). This may help with efficient, lifelong, and competency-based learning.

The ‘anytime, anywhere’ advantages of asynchronous learning extend to HPE curricula that are difficult to arrange synchronously, such as during clinical rotations that involve fluctuating clinical duties, shift work, and rotating supervisors (Wittich et al. 2017), scheduling challenges such as interprofessional education (MacNeill et al. 2010), and accommodating dispersed CPD learners (Chan et al. 2018). Asynchronous learning also allows for just-in-time faculty development (Orner et al. 2022) and teaching/training (JITT) or point of care learning (Kuhlman et al. 2021), as it allows independent learning immediately before or after a teaching or patient encounter. Achievable, ‘bite-sized’ and accessible asynchronous learning can also enable CPD micro-credentialing and competency-based education through stepwise digital badge completion (2022 EDUCAUSE Horizon Report 2022).

Asynchronous learning has been associated with evidence-based, learning science strategies such as interleaving and spaced repetition (or distributed practice). Distributed practice occurs when learning occurs over multiple points in time. This time between learning allows for reflection, consolidation of learning in different contexts (interleaving), and the use of repetitive retrieval practice (such as quizzes or summary discussion boards) which have all been shown to improve learning (Maheshwari et al. 2021; Van Hoof et al. 2021). Interleaving allows learners to move back and forth, rather than sequentially, through concepts, contexts, and skills, to examine areas of overlap and distinction, making critical comparisons, rather than siloed mastery. Interleaving leads to improved complex problem solving and retention of information compared to blocked learning. Asynchronous learning can foster this type of varied and random practice through revisiting materials and quizzing/simulation/feedback in different clinical contexts, accessing links to supplemental related materials, and learning together with learners outside of their typical cohort (Van Hoof et al. 2022).

Furthermore, although there may be limitations, asynchronous online learning is beneficial in improving access, equity, and inclusion, especially in low- and medium-income countries (Gachanja et al. 2021), or in rural areas (including in high-income countries), where bandwidth may be limited or unpredictable. There may be cost savings, including reduced need for classrooms, administrative scheduling support, and travel costs (Ruiz et al. 2006). It also allows learners and teachers in different time zones to collaborate, enriching global learning networks (Chan et al. 2018).

However, asynchronous learning has a propensity for distractions, delayed learning, lack of immediate feedback, and learner disengagement due to the lack of social interaction (Nguyen et al. 2021). If asynchronous learning is optional or supplementary to core F2F or synchronous learning, asynchronous learning may be seen as less important, especially in the context of heavy clinical workloads and competing life priorities.

Monitoring learner engagement with material (such as time spent or number of posts) may not be reflective of learning, and there is less opportunity for learner-instructor immediate feedback. There is the danger that it may devolve to learners’ simply ticking tasks as ‘completed’ on a platform. However, this may be moderated by using AI analytics to track for ‘learners at risk’ such as employing multiple formative and automated quizzes and peer feedback (What We’re Learning From Online Education 2012).

Teaching in asynchronous environments can have up front time or cost constraints to create robust multimedia, but, once created, has the potential to be reused, freeing up time and reducing teaching costs (Ruiz et al. 2006; Phillips and Wiesbauer 2022). Furthermore, discussion boards can be time-consuming to read, respond and grade, but can be facilitated through automation, peer reviewing, and up-voting. Lastly, teachers must be much more explicit in asynchronous environments to foster social learning and learning expectations, such as group norms, objectives, and assignments, due to the lack of non-verbal cues, immediate feedback, and risk of misinterpretation (Maheshwari et al. 2021). Please refer to Supplementary Appendix 3 for practical tips on how to foster social and collaborative learning in asynchronous environments.

In conclusion, asynchronous learning is best suited for mature and self-directed learners. Although asynchronous learning allows for flexible, accessible, and tailored education, the lack of immediate feedback and non-verbal cues need to be carefully mediated by structure, and support. These threats may also be minimized by utilizing multi-modal learning as discussed next.

Multi-modal learning: blended, hybrid, and HyFlex

One of the major benefits of online learning is the ability to provide multi-modal methods to meet diverse learning objectives and learner needs. Figure 2 depicts this concept of overlapping learning methods and the various forms of learning that occur at its intersections.

Building on the benefits of multimodal delivery, distributed practice and interleaving, as discussed earlier in this guide, it is perhaps no surprise that blended learning, which combines F2F learning with online learning, has been proven to have better learning outcomes than either F2F or online modalities alone (Liu et al. 2016; Vallée et al. 2020). Also, learners report higher satisfaction when a greater diversity of learning modalities are used (Nguyen et al. 2021). Therefore, if we are not providing blended learning opportunities, are we in fact providing suboptimal learning experiences? This question deserves at least some valid consideration in curriculum and institutional planning.

Hybrid learning is similar to blended learning, but with online learning as the main mode of delivery, supplemented with F2F components (Concepts and Terminology for Integrating In-Person and Online Learning 2022). However, the term ‘hybrid learning’ has also been used in the literature (particularly in CPD) to describe synchronous learning where learners can attend either in person or online.

Another term for this is Hybrid Flexible (HyFlex), which we will use here to describe online learning that accommodates different learning modalities for different learners. HyFlex learning typically involves (frequently simultaneous) F2F teaching and at least one other online mode of delivery (such as synchronous or asynchronous or both), where learners choose their format of participation. While research suggests that most learners prefer F2F modes of delivery, complex life circumstances affect their choice of delivery method to flexible online options more (Malczyk 2019; Rhoads 2020). Higher education experts agree that by 2025, only a minority of learners will be either fully F2F or fully online, with the majority attending in blended and HyFlex formats (2022 EDUCAUSE Horizon Report 2022).

HyFlex was initially proposed by Brian Beatty and has many synonymous terms which include Dual Delivery (Holland 2022), Synchronous Hybrid (Palmer et al. 2022), Blended Synchronous Learning (Laforune and Lakhal 2019), and Comodal (Gobeil-Proulx 2019) although some have subtle differences, such as lack of learner flexibility to move between learning modalities.

The HyFlex model is based on four principles: Student Choice/Learner Control, Equivalent Learning, Reusability, and Accessibility (Beatty 2019). Learners have the ability to choose which path and pace best suits their needs, leading to increased appreciation for the flexibility of their learning and feeling supported by their teachers (Beatty 2019; Gobeil-Proulx 2019; Rhoads 2020; Lakhal et al. 2021). Learners can choose the speed of their learning by attending a F2F class and then revisiting materials that remain confusing or using fast playback speeds to scan material they already know.

Learner control can be both an advantage and a disadvantage. In F2F classrooms, learners follow a linear sequence of learning, controlled by the teacher; however, in online environments, learners can follow non-linear/branching paths through links, discussions, and social media feeds. This allows learner ‘buy-in’ and motivation in managing their own learning path at their own convenience, but may leave the learner feeling overwhelmed without direct feedback and added responsibility for their learning (Lin and Hsieh 2001), especially with younger undergraduate learners who may not have developed good study habits or have little knowledge base from where to start self-directed discovery (Bond et al. 2020). Structure, feedback (by LMS, teacher or peers) and features that support self-regulation can help with this (Rhoads 2020; Thomson et al. 2022). HyFlex learning allows learners to balance the convenience and control of online learning with the social connection, feedback, and motivation of F2F learning (Butz and Stupnisky 2016).

The second principle of HyFlex learning is equivalency, which refers to providing an equivalent, but not necessarily equal, learning experience. Note that holding a F2F class and posting the recording online for asynchronous viewing is not an example of a HyFlex design.

Instructional design must ensure that online modalities and interactivity do not become inferior to F2F learning, and that each mode has its own pedagogical considerations. Planning should consider content, interactivity, communication/support, and assessment across all modes of delivery, including recognition, inclusiveness, and participation of all classroom participants. Take, for example, training undergraduate learners in a busy clinical rotation in the emergency department, with multiple shifts and supervisors. Supplementary Appendix 4 depicts how supervisors can teach to learners across different program sites and shifts, while still maintaining peer learning and connections between multiple learners and supervisors.

A practical example of the third principle, reusability, is shown in Supplementary Appendix 4 by incorporating an asynchronous posting from an online participant into the F2F and synchronous class discussions the next week, thereby providing continuity of learning between groups and sessions. The asynchronous learner may see their posting in the F2F class recording and feel cohesion and recognition with other learners, while the F2F and synchronous learners might be prompted to read and participate in the asynchronous discussion board. Reusability also allows scaling and standardization of learning across modalities.

Lastly, accessibility as a fourth principle, builds on Universal Design for Learning (UDL) which will be explored later in this Guide.

HyFlex design is a relatively new model of online delivery, with very little evidence accumulated in HPE (Laforune and Lakhal 2019; Malczyk 2019; Zehler et al. 2021; Palmer et al. 2022). Limited research in non-HPE fields has often shown no difference in learning outcomes compared to F2F classes or between the different delivery modalities (Raes et al. 2020; Rhoads 2020). This is not surprising given the ‘no significant difference’ effect between online and F2F methods and that most learners stick to one learning method (F2F or online) during HyFlex courses (Gobeil-Proulx 2019). Most research to date has been exploratory and based on learner experiences, and implementation (Raes et al. 2020).

For institutions and teachers, HyFlex learning also requires fewer ‘brick and mortar’ lecture halls and complex scheduling arrangements, at possible cost savings. However, faculty need to be comfortable with uncertainty and ‘dynamic flexibility,’ since learners may change their mode of delivery at any time, affecting group composition and interactivity (Beatty 2019). Faculty development and support for these new delivery methods is important (Rhoads 2020; Lakhal et al. 2021), as is recognition to build and facilitate these multifaceted delivery modes. HyFlex teaching is difficult, and faculty may want to start small to ‘try out’ online teaching – typically with the ‘backbone’ of an asynchronous class and adding on either F2F or synchronous components. Lastly, developing HyFlex delivery methods allows the time for pedagogically sound course development with the ability to quickly pivot to fully online learning if required, avoiding future ERT (caused by pandemics, natural disasters, or public transportation issues) (Beatty 2019).

HyFlex design typically requires institutional support to provide additional software, hardware (multiple monitors, microphones, two-way cameras, and technical support) and classroom reconfiguration (Lakhal et al. 2021). Learners also need to be supported with the hardware, software, and skills to participate fully in these new learning environments. However, if obtaining this support seems daunting or not feasible, lower tech options are also possible (see for example Supplementary Appendix 4).

Online co-facilitation or an in-class technical support/room coordinator is essential, especially when first starting out, to help Guide interactivity, camera selection and technical support in these complex environments and ensure equal participation between F2F and online participants (Lakhal et al. 2021; Thomson et al. 2022).

HyFlex may be particularly important for HPE training programs with dispersed campuses and training locations (such as residency programs), or CPD offerings that involve F2F and remote ways to attend. Another benefit is for training that allows only small F2F numbers (e.g. operating or simulation rooms (Zehler et al. 2021), pathology labs, or patient exposures) where technology can help expand class size with remote participation. While HyFlex has numerous advantages and may help to negate many of the challenges faced with fully online learning, it may not be suited for all classes, instructors or institutions given the complexity, support, and willingness to embrace the change that HyFlex requires. However, it was not so long ago that the same was true about teaching in synchronous environments, which has now become commonplace and familiar.

In HyFlex and all online contexts, faculty development and experience are essential for successful online learning. Next, we discuss the importance of faculty development as a foundation for the next section on online educational design, which will guide readers through steps and guidelines for effective online curriculum development (Figure 3).

Online educational design

Online educational design cannot be discussed without first highlighting the importance of FSD in online HPE. FSD is essential to the development of contemporary competencies as a HP educator, and allows faculty to critically rethink their roles, challenge ‘big assumptions’ in education, enable pedagogically informed teaching practices, and redesign curriculum outside ‘one size fits all’ teaching practices (Mohr and Shelton 2017). Some argue that online FSD of online teaching competencies should be a contemporary standard and responsibility of institutions and HP educators.

Unfortunately, there is limited research in online FSD in HPE. Like other studies, the BEME scoping review on medical education developments in Covid-19 showed only two studies (1.6%) focused on faculty or professional development during Covid (Daniel et al. 2021). Compared to F2F, educators often have limited personal experience as a learner or teacher in online environments, fewer mentorship opportunities, and fewer FSD opportunities on which to build comfort and identity as an online educator (O’Doherty et al. 2018). This further drives empirical use and research of online learning, and a sense of institutional complacency with providing only F2F or basic synchronous teaching. Lack of training in theory, pedagogical design, and practical application experience may lead to educator identity dissonance and teaching resistance if educators self-identify as ‘technology immigrants’ and feel less connected to their learners and ineffective in these new environments (Ruiz et al. 2006; Maheshwari et al. 2021).

In essence, FSD (including cultural shift, time, resources, and training) and system-level factors are essential to integration of any online HPE. Readers are encouraged to consider Rogers Diffusion of Innovation Theory (Rogers 1983; Berwick 2003) and the Gartner’s’ Hype Cycle (Gartner Hype Cycle Research Methodology 2022) to learn more about factors influencing cultural shift in technology integration.

Including learners in curriculum design may also help build on the learner-centric and peer learning ethos of online learning while promoting Universal Design (see below) and learner engagement. It provides opportunities for student leadership, open communication/feedback between learner communities and educators, and an increased tolerance for technical and pedagogically new ways of learning (Peters et al. 2019). Lastly, learners may bring a skill set such as assisting with creating websites, videos, podcasts, or emodules or in online co-facilitation (e.g. leading a breakout room, or discussion board). However, this should be balanced with thoughtful planning and faculty development opportunities for these peer-teacher roles.

Instructional design for online learning

Instructional Design is the systematic process of planning, developing, executing, and evaluating learning experiences. It is worth noting that ID models are not learning theories but learning theories may inform ID models (Snell et al. 2018). The online learning theories described earlier, and design considerations described in the following section should be applied when developing online curricula. Ultimately, it is critical that learning drives technology use, rather than first selecting technology to drive learning. Following ID models and principles discussed below facilitates this ‘education first’ approach.

Although there are dozens of ID models, ADDIE and Kern’s six-step approach to curriculum development are two well-referenced models detailed further in Supplementary Appendix 5 (Snell et al. 2018; Chen et al. 2019).

Many ID models include variations of the following four steps (Demiroz 2016):

1. A needs analysis to determine the learning need;

2. Determining learning goals/objectives;

3. Designing, developing, and delivering learning experiences;

4. Evaluating, assessing, and feedback.

Below, we will review each of these four steps in the context of online ID, starting with Step 1, needs assessment. Rather than presuming what learners should know or be able to do, designing online instruction should begin with a thorough analysis of the knowledge, skill, or behavior gap. The gap determines learning needs, and learning needs inform both the design of learning activities and the evaluation framework. Online learning can help facilitate needs assessments, such as online pre-course surveys, quizzes, or simulation exercises, or using multiple online data sources (such as competency-based data or patient/system/organization needs analysis). These can inform curricula long before the education intervention starts, or iteratively throughout the course.

Building on the results of the needs assessment, Step 2 deals with the development of learning objectives. Bloom’s taxonomy of educational objectives (Bloom et al. 1956) was developed for F2F contexts and adapted to online settings. Supplementary Appendix 6 demonstrates an adaptation of Bloom’s to online activities and assessments.

Step 3, designing, developing, and delivering learning experiences is more complex, and begins with Mayer’s Cognitive Theory of Multimedia Learning (CTML) (Mayer 2010, 2014) to better understand how to design effective multimedia instructional material, such as videos (Iorio-Morin et al. 2017), emodules and presentations (Grech 2018).

Mayer’s Cognitive Theory of Multimedia Learning

CTML describes how people learn from words (both spoken and written) and pictures (both static and dynamic) that is congruent with research-supported principles in cognitive science and grounded in Cognitive Load Theory (Young et al. 2014). See Supplementary Appendix 7 for a visual depiction and further explanation of CTML.

The CTML is based on three cognitive science principles of learning (Mayer 2014):

1. Dual channel assumption: Learners process information through two channels; a visual channel that processes visual information; and a verbal channel that processes verbal information.

2. Limited capacity assumption: Learners can only process a few ‘chunks’ of information in each channel at any given time.

3. Active processing assumption: Meaningful learning occurs when learners can select relevant information, organize it into a coherent representation and integrate with prior knowledge activated from long-term memory.

Teachers can reduce the demand on their learner’s working memory by designing content in a way that helps learners select, organize, and integrate information by designing content that minimizes extraneous processing, manages essential processing, and fosters generative processing by applying the 13 principles of multimedia learning as described and applied using examples in Supplementary Appendix 8 (Maheshwari et al. 2021).

It is worth noting that the burden of cognitive load changes as learners develop mastery in a subject, therefore, materials should always be designed with the target audience in mind. For example, when first meeting with an online class, you may want to start with a simple online collaboration tool such as annotation in Zoom, and progress to more complex collaboration tools such as Miro as the cognitive load of group dynamics, technology use, and content mastery lessens over time.

Continuing with designing, developing, and delivering learning experiences, we now turn to UDL, including equity, diversity, inclusivity and accessibility considerations in online environments.

Universal design, equity, diversity, inclusion, and accessibility considerations

Universal Design for Learning, accessible design, inclusive design, design for all are different names though similar approaches to creating learning material and environments that improve access for people of all abilities.

UDL posits that three neural networks (recognition, strategic, and affective) are engaged when we learn. However, individual variability across these networks impacts how we process information. Learning material and experiences should be designed to accommodate this variability (About Universal Design for Learning 2022).

The UDL Guidelines is a tool teachers can use to implement UDL. The guidelines suggest course designers should provide learners with multiple means of engagement, representation, and action and expression. Supplementary Appendix 9 offers an adaptation of the most recent version of the Guidelines (updated in 2018) with suggested examples of how the principles can be applied in online medical education.

Designing for inclusive learning is crucial: UDL aims to help create learning experiences that are inclusive of all learners by offering varied and flexible learning options. The next iteration of the guidelines aims to specifically address systemic barriers that result in inequitable learning outcomes (About Universal Design for Learning 2022). In addition, there are numerous university-affiliated resources (Equity, Diversity, and Inclusivity (EDI) 2022), and work by Sanger (Sanger 2020) which offer concrete examples and strategies on how to promote learning across multiple cross sections of diversity. Your institution may also provide policies, reference material, and/or guidelines on promoting UDL and inclusive design in your teaching and learning environments.

UDL is distinguished from online accessibility, as, while UDL provides a framework for designing varied and flexible learning options for all learners, individual learners may require specific digital accommodations related to cognitive, sensory, or physical impairments (Ableser and Moore 2018). When creating online content, institutions need to apply web accessibility standards, laws, and regulations that govern how barriers to access should be removed. It is worth noting that many learners without impairments benefit from accessible content as well. For example, those learning in a non-native language may benefit from closed captioning or the ability to revisit the material at a slower play-back speed.

Although UDL is inherently inclusive and promotes accessibility, tensions between UDL and accessibility arise when (Ableser and Moore 2018):

• accessibility accommodations limit an instructor’s or institution’s ability to quickly develop and/or disseminate flexible learning content, and

• educational technologies do not meet accessibility standards or are not flexible enough to accommodate individual learner needs. For example, some learners may require closed captioning and others may find it distracting. Technologies ideally should allow for individual learner choice.

Institutions may outline how educators are expected to comply with regulations and standards regarding new and existing educational material. If instructors are working in isolation, then they may wish to refer to Supplementary Appendix 10 which offers common accessibility features that should be considered when designing or offering media online.

Accessibility and UDL design can be challenging to accommodate. Online accessibility remains fraught with contradictions. Take as one example, accommodations for learners with hearing impairments: on one hand, technology may allow closed captioning, volume augmentation, or the ability to closely read lips of other video participants. On the other, it may limit non-verbal cues of language interpretation or isolate learners who do not have access to hardware, software, or bandwidth. Ultimately, UDL instruction that is accessible takes time, skill, appropriate technology, and learner orientation. Even with this, there remain many roadblocks to implementation, but legislation, software improvements, and learner needs and preferences are helping to drive more inclusive and accommodating learning environments.

Step 4 of online ID: evaluation, assessment, and feedback is a large topic and has its own dedicated AMEE guide (Dennick et al. 2009). An updated Guide on online assessment is planned.

Digital professionalism, privacy, and copyright

We end this Part 1with a discussion of some considerations of professionalism, privacy, and copyright that ribbon through all aspects of ID. Although these issues are not unique to online learning environments, they are amplified, given the ease with which information can be accessed, copied, and distributed. Several recent AMEE Guides explore digital professionalism considerations (Ellaway et al. 2015; Masters 2020), and we will briefly discuss privacy and copyright considerations here:

Privacy: Privacy is a fundamental human right protected by laws that govern how governments, organizations, institutions, and individuals can collect personal information. Privacy laws are not universal and may be instituted federally, provincially/at the state level, or through other national regulatory bodies. Glenn Greenwald’s TED talk on Why Privacy Matters discusses why we should care about privacy and its implications in the digital age (Greenwald 2014).

Although the risks to privacy are omnipresent when online, there are some areas of teaching and learning that benefit from an open discourse. Below are some considerations that teachers and learners should consider in online environments (Bates 2015):

• What learner information are you obliged to keep private and secure? Information stored on servers (e.g. names and emails) may be governed by privacy laws where servers are located.

• What is the risk of using a particular technology where privacy could be breached?

• What areas of teaching and learning should be locked and available only to registered students (e.g. a secure LMS vs. open discourse via a social medial platform like Twitter).

Privacy considerations should be explicitly discussed and/or negotiated in online environments (e.g. should some discussions not be recorded to allow more open discussion? Are learners allowed to record or take screenshots of presentations?) This will often depend on group size, content, context and learner/teacher roles, hierarchies, and preferences, but, like many online learning issues, there is often not a ‘right’ answer. However, joint negotiation, open communication and being explicit about the learning environment will help to build trust and safety in learning. Your institution or regulatory body may also provide guidance or a policy on issues pertaining to privacy.

Copyright: Copyright laws legally protect an author’s original tangible product. Digital technologies make copying and distributing these materials easier. Teachers should be aware of the laws governing copyright in their respective countries, provinces or states and obtain appropriate licenses when including copyrighted material such as text, images, audio, and video in their educational content. Refer to Supplementary Appendix 11 for examples of content that is available for use without permission and creative commons licensing (https://creativecommons.org/) that educators can use when copyrighting their own online materials. It is important as a teacher to model proper use of copyrighted material and set guidelines for learners to do the same.

Conclusions

Part 1 of this Guide has covered a wide range of issues, including background evidence, theories, methods, contemporary issues, and design considerations necessary for a foundation in HPE online learning.

Higher education experts agree that by 2025, only a minority of learners will be either fully F2F or fully online, with the majority attending in blended and HyFlex formats. The evidence for blended learning and learner-centered advantages of online and HyFlex models reminds us that online learning is here to stay. In HPE, other trends such as competency-based training, dispersed training locations, and learner centered education are driving forces for online HPE to continue to evolve beyond COVID-19 experiences.

We have seen that online learning expands our educational options, with the possibility to transform HPE in ways that we could not achieve with F2F options alone, including multimodal, spaced, longitudinal, and learner centered education. However, we should avoid binary thinking of online vs. F2F delivery and move away from technocentric and empirical experimentation. Instead, we should use diverse blended methods using an education first and pedagogically informed approach. Faculty development, institutional support, and research into new approaches to HPE will allow us to reach beyond our comfort levels, address barriers and challenges and evolve our understanding of these complex learning environments, beyond COVID-19 ERT.

We hope that readers will now turn to Part Two of this Guide to examine specific online learning tools and practical examples, building upon and applying the foundational concepts we have examined in Part 1. Likewise, we hope readers of Part 2 refer back to Part 1 and its appendices, to inform the pedagogical use of tools and examples in Part 2.

Acknowledgements

The authors acknowledge the following: Yerko Berrocal for design ideas in the early stages of development; Rachel Ellaway for comments on a draft of the Guide; anonymous reviewers of an earlier version of this Guide for their insightful comments; Sinai Health, Division of PM&R and Baycrest Academy for funding to allow open access publication of this Guide.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Heather MacNeill

Heather MacNeill, MD, BSc(PT), MScCH(HPTE), FRCPC, is an Associate Professor in the Department of Medicine and Faculty Lead, Educational Technologies, Continuing Professional Development at University of Toronto, Canada. She has been teaching about, creating, and researching the effect of educational technologies in healthcare for over a decade, and together with Kataryna Nemethy, co-instructs a masters course on educational technologies for health professions education at University of Toronto (EdutechHPE). As a practicing academic PM&R physician, she incorporates educational technology into her teaching methods and has received several awards for her teaching and research with educational technologies.

Ken Masters

Ken Masters, PhD, HDE, FDE, is an Associate Professor of Medical Informatics, Sultan Qaboos University, Sultanate of Oman. He has been involved in education for several decades, and has published on medical informatics ethics, and has authored and co-authored several AMEE Guides on e-learning, m-learning, and related topics.

Kataryna Nemethy

Kataryna Nemethy, MSc, BMC, is a Lecturer at the University of Toronto and the manager of eLearning at Baycrest Academy with over 10 years’ experience in the field of eLearning, instructional design and educational technologies. As a graduate of Biomedical Sciences at University of Toronto, she is passionate about the interface between education, technology, and design. She consults as an instructional designer, eLearning developer, and medical illustrator/animator. Together with Heather MacNeill, she co-instructs the Edutech HPE master’s course through the Dalla Lana School of Public Health and the Teaching with Technology certificate course at University of Toronto.

Raquel Correia

Raquel Correia, MD, MSEd, EMBAc, is a practicing GP and the Program Coordinator of the Value-Based Health Care Graduate Diploma of the Chair of Value & Innovation in Health at the Université de Paris Cité, France. She has been involved in education for more than a decade and is part of the Technology Enhanced Learning Committee at AMEE.