SI521 "Open Educational Resources at the University of Michigan" Open Textbook/OpenHealth
As a subset of OER, Health OER includes a variety of materials, such as course materials, instructional videos, image libraries, podcasts, and brochures. Health OER offers many of the incentives and benefits that OER in general offer: increased access to quality educational materials, improved visibility and reputation of participating organizations, increased feedback and improvement of materials, and increased collaboration with professionals at other institutions. Health OER is unique due to the intensity of training and continuing education required in the health sciences as well as the fact that supply of health workers is scarce around the world. Since health professions require significant clinical training and hands-on experience, several in the field recognize the value of sharing their materials and do not feel that their enrollment is threatened.
The field of health OER is fairly new and faces several challenges in distribution and use, such as translating materials for the appropriate skill level or language and distribution in developing countries or rural areas where these materials are most needed. There is much more research to do this in this field, especially regarding outcome assessment, but due to the active involvement of leaders in health education and funding from large foundations, there is great potential for health OER to significantly impact health education.
In response to the global healthcare work shortage and the high burden of disease in developing countries, higher education institutions and health education organizations are seeing an increasing need for the access to and transparency of quality health education materials. These materials, many licensed as Health OER, are intended for a variety of users: faculty, students, continuing education for medical practitioners, NGO health workers, and self-learners. While these materials do not serve as a replacement for formal training, they allow cost-savings by sharing the cost of curriculum development and decreasing the cost of information access.
In 2000, member states of the United Nations signed the Millennium Declaration that began an ambitious plan called the Millennium Development Goals (MDGs) to significantly reduce global poverty by 2015. Three of the eight MDGs concern the global health. Due to the global nature of many health concerns, there seems to be more international collaboration in health OER than in other areas of OER. One such partnership is collaboration on health OER development established in 2009 between University of Michigan, a nonprofit organization called OER Africa, University of Ghana, the Kwame Nkrumah University of Science and Technology (Ghana), University of Cape Town (South Africa), and University of the Western Cape.
Health OER Defined
As a subset of OER, Health OER includes a variety of materials, such as course materials (open courseware or OCW), instructional videos, image libraries, podcasts, and brochures. AS mentioned in the previous section, Health OER offers many of the incentives and benefits that OER in general offer: increased access to quality educational materials, improved visibility and reputation of participating organizations, increased feedback and improvement of materials, and increased collaboration with professionals at other institutions. Health OER is unique due to the intensity of training and continuing education required in the health sciences as well as the fact that supply of health workers is scarce around the world.
The lecture materials, readings, presentations, and other tangible materials are only one component of the educational experience. This is perhaps most notable in the health sciences field. In a 2008 article to Medical Teacher journal, faculty and administrators from Tufts University note that, “Medical education requires a complex blend of education materials, experiential learning, and human interaction within a school structure.” 
Health OER vs Health Open Access
The earlier chapter on Open Access provided a distinction between open access – the lack of cost or technical barriers to view, which may or may not include the right to remix – and OER – which includes free access, distribution, and remix/adaptation. The same distinction is true of health open access and health OER.
Health open access is worth mentioning because many institutions are required to share the results of their federally-funded research due to the National Institute of Health (NIH) Open Access Mandate.  The mandate states that papers published after April 7, 2008 which use NIH research money must archive a free copy of the paper in the NIH open access repository known as PubMed Central.  . PubMed is a repository of scholarly journal articles with free access but traditional copyright restrictions. NIH authors still retain the copyright and may choose to retain all rights or license them through Creative Commons. In order to comply with the policy, many medical journals now submit the published versions of NIH-funded articles to PubMed within 12 months per the mandate but do so without author involvement.
Motivations for Health OER Creation and Use
There are many reasons why institutions, organizations, and individuals choose to invest in health OER.   Those reasons can be consolidated into seven core motivations: improvement of teaching materials, efficiency gains, professional development, institutional reputation, the global healthcare worker crisis, the global nature of health issues, and altruism. Each participating individual or group places varying degrees of importance on each of these motivations.
Improvement of teaching materials
This incentive is consistent across the OER field in general and the often the primary motivation given by participants. By extending the audience of the materials outside the classroom, there are more eyes on the materials. This is the reason why open source software has been as successful as proprietary software packages: since the material is freely and widely available there is increased opportunity for feedback and increased likelihood that someone will identify errors. Although the later characteristic may initially scare faculty members who are have not had their materials viewed outside the classroom before, we have evidence from MIT's pioneer OCW efforts that faculty received useful feedback from publishing their materials as OER. Since the higher education institutions that are participating in health OER are prestigious institutions with high rankings within the field (e.g. Johns Hopkins University, University of Michigan and Tufts University), we are beginning with high quality materials in the first place. Although they can and will be improved by sharing, we should be proud to share the high quality materials that we have. Furthermore, the increased sharing of health science curricula between institutions and across borders "will move us towards international standards of education and training." 
OER is an opportunity to demonstrate the high caliber of education at an institution. The health science schools participating in OER are renowned in their field: most are in the top 20 in the specialty within health sciences. OER is an opportunity for these institutions to showcase the talent of their faculty and the quality of their curriculum. The published health OER serves as a public portfolio, which can be used to attract faculty, research money, and prospective students. Since health OER is distributed with attribution to the individual creators, participating institutions have increased publicity through Internet searches for educational resources.
OER has potential to increase efficiency in content creation, sharing, distribution, and search. First, OER increase the ability to share educational content between institutions by removing copyright restrictions and accompanying licensing fees. Health science content is dense, specialized, and rapidly evolving.  Due to the strong reliance on current materials published by third parties in the latest science journals and textbooks, the amount saved in materials acquisitions and licensing fees due to OER could be substantial. In addition, by building upon lecture materials from other health science institutions of the same caliber, faculty members are able address gaps in curriculum content and shift some of their time from developing teaching materials to mentoring and research instead. Furthermore, by making these materials available freely and openly available and attaching descriptive metadata, faculty, professionals, students, and other users are able to spend less time on the searching process and more on learning. These efficiency gains complement the move within medical education to move toward more competency-based training as students and faculty have more time to devote to assessments (i.e. matching learning objectives with learning outcomes).
In many professions, education does not stop upon receiving a diploma or certification. This is especially true in the health sciences where practitioners are required to continue their medical education throughout their career. For example, within Michigan, physicians are required to complete fifty hours of continuing medical education (CME) annually. Physicians may complete this requirement through attending presentations, conferences, courses, or online classes. As health OER offers unlimited access to education materials, OER could serve as the basis of the online CME as well as further supplementary resources. Furthermore, since professionals pay for CME credit, there is potential for financial sustainability for OER development.
Global nature of health issues
Due to travel and immigration, medical professionals have increased exposure to diseases that may be acquired abroad. Consequently, global diseases are increasingly important in medical education. For example, one-third of the students at the University of Michigan Medical School conduct part of their clinical training abroad. Context is essential in global medical education, not only due to cultural norms but also because diseases can manifest themselves in different ways based on environment and the patient’s ethnicity. The transparency and sharing of materials across countries is essential to capturing and teaching these nuances.
Global healthcare worker shortage
There are large gaps in quality and of access to healthcare between developing and developed countries. In addition, there are large differences in quality and access to care within countries. The inadequate density and distribution of healthcare providers negatively affects health outcomes around the globe. In Africa in particular, too few health care professionals are being trained to meet local needs.  For example, sub-Saharan Africa has “24 percent of the global burden of disease, it has only 3 percent of the world's health workers.”  A key barrier in both developed and developing countries is the lack of instructor capacity to teach both basic and clinical sciences, complicated by the duplication of effort in developing learning materials that can be shared as OER.
In 2000, the United Nations member nations created the Millennium Development Goals (MDGs), an ambitious plan to drastically improve economic and social conditions in developing countries by 2015. The MDGs include eight goals ranging from education to poverty to the environment. Three of the eight goals focus on health specifically: reduce child mortality (goal 4), improve maternal health (goal 5), and combat HIV/AIDS, malaria, and other diseases (goal 6). There is evidence that increasing the number of healthcare workers improves both maternal and infant health. The existing healthcare shortage has, therefore, been an obstacle in meeting these goals.
The healthcare worker shortage also affects developed nations, including the United States. In 2001, the nursing profession within the U.S. experienced a shortage of 13%. In 2005, it dropped to 8.5%  but some estimate that it may increase to 20% if there is no intervention. 
The medical profession has a longstanding tradition of professional and humanitarian contributions especially with regard to teaching. The tradition dates back to a Greek doctor in the 4th century B.C. named Hippocrates. The original oath included the vow, “to give a share of precepts and oral instruction and all the other learning to my sons and to the sons of him who has instructed me and to pupils who have signed the covenant and have taken an oath according to the medical law, but no one else.”  In 1948, the World Medical Association passed the Declaration of Geneva. The updated oath begins with, "I solemnly pledge to consecrate my life to the service of humanity"  and replaced the Hippocratic oath in many institutions.
The altruistic motivation, though not the driving institutional factor, cannot be ignored as a faculty motivation. Faculty at both University of Michigan and Tufts identified their desire to share their materials and knowledge with those with fewer resources as a significant reason for their willingness to participate.  The altruistic motivation is also important for students who participate in health OER through the content clearing process (such as dScribes) or in other enhancement efforts such as adding metadata, translating into foreign languages, or contextualizing the materials for targeted audiences.
There is a diverse audience for OER across the health science disciplines of medicine, public health, dentistry, nursing, bioengineering, and kinesiology. There are many potential users within the health science institutions, namely faculty, instructors, researchers, and students. Within the academic sphere, there are also professional associations, such as the Association of American Medical Colleges (AAMC). As previously mentioned, there are great potential efficiency gains from OER at the institutional level. Furthermore, the increased availability and transparency of materials allows the students to continue their learning and skill development outside of the classroom.
There are potential users outside the health science institutions such as healthcare workers and self-learners.
As previously mentioned, the global healthcare worker shortage is one of the motivating factors for health OER. Healthcare workers include a variety of licensed professionals: doctors, nurses, pharmacists, and laboratory technicians. The profession also includes those without medical degrees, such as midwives, epidemiologists, health administrators, and public health program managers. Health care workers may be interested in health OER for their continued professional development or targeted uses such as public health campaigns.
Self-learners are people without formal health or medical training but are curious in learning more about a particular disease. These users are the minority the health OER audience due to the specialized nature of the field.
Health OER is a field that has brought together a variety of individuals and groups in the health sciences field. In addition to institutional participation, there are also individual professionals, professional and nonprofit organizations and associations, as well as charitable foundations. The appendices provided at the end of this chapter list those involved in health OER development. The following section will explore select health OER projects.
Tufts University Science Knowledgebase (TUSK)
In 1999, Tufts University launched TUSK which is an “integrated digital repository and curriculum knowledge management and delivery system” used by health science schools at Tufts and other institutions in the United States, Indian, Tanzania, Uganda, and Kenya. Built on open source software, TUSK strives to provide a complete curriculum by providing syllabi, reading lists, materials, learning objectives at the course and material level, and quizzes. In 2005, Tufts launched a complementary OCW effort. Now Tufts has made available nearly half of their School of Medicines didactic curriculum. Tufts OCW was built in parallel to TUSK with OER materials available in both repositoris: Tufts OCW contains only OER and TUSK contains OER as well as some closed educational content. TUSK serves as a course management system and requires a login for some features such as grades, case studies, and some of the materials.
MedEd Portal is a repository run by the Association of American Medical Colleges (AAMC) and the American Dental Education Association (ADEA). The repository contains peer-reviewed medical and oral health materials, including podcasts, tutorials, case studies, lab guides, quizzes, and assessment tools. Contributors are required to attach a Creative Commons license to their submissions. The MedEd Portal staff will review the submissions for any copyright, privacy, or endorsement issues. If the staff identifies any concerns, they are sent back to the author to clear. Once those concerns are addressed, the peer review process begins. To date, MedEd Portal has published approximately 1,300 resources. 
Johns Hopkins University
The Johns Hopkins University School of Public Health (JHSPH) has over 75 courses available as OER.  These courses include the syllabi, lecture slides, reading lists, discussion questions, and some video.
OER for Cancer
OER for Cancer (OERC)  is a partnership between the International Network for Cancer Treatment and Research (INCTR) and Multimedia Educational Resource for Learning and Online Teaching (MERLOT) to create an open content repository of cancer resources. Their mission is to "provide free access to advances in basic and clinical cancer research information in user friendly format" and "to contribute to the development of a research infrastructure and a research ethos for cancer care and prevention at a global level." The homepage allows the user to browse by high-level aspects of cancer (e.g. cancer control and cancer diagnosis) or by a specific cancer (e.g. colon cancer). There are placeholders for future homepages for targeted audiences, i.e. healthcare workers and patients and families.
University of Michigan
In 2007, Dean Wooliscroft of the School of Medicine declared his intent to publish the entire first- and second-year curriculum (i.e. the bulk of the classroom curriculum) as OER. Five of the twenty-six sequences that make up the first- and second-year curriculum were published in 2008 using the dScribe process.  The remaining sequences are scheduled to be published by the end of 2009.
University of Michigan Medical School also has a number of non-course learning materials that are currently being converted to OER: Professional Skill Builder, the Eyes Have It,  and Histology Virtual Slide List. The Open.Michigan team is working with the creators and lawyers to sort out legal permissions and technical access to make these resources freely and openly available.
Professional Skill Builder (PSB) is a suite of tools developed by the University of Michigan Medical School to help medical students develop acute skills necessary for physicians. The suite includes videos, sound clips, and assessments. The heart murmur library  is an example of one such module. PSB is currently open access and available only on Microsoft's proprietary web browser, Internet Explorer.
The Eyes Have It is an "interactive teaching and assessment program on vision care"  developed by the University of Michigan Kellogg Eye Center. It includes images, video, and quizzes.
The Histology Virtual Slide list is a collection of dozens of high-quality microscopic slides of human tissue. The slide collection is supplementary to the histology sequence and is distributed along with learning objectives.
University of Michigan Professor Rob Lash seek to combine OER and continuing medical education (CME) in a project called Open Med  Dr. Lash, a member of Office of Continuing Medical Education (OCME), plans to use OER generated by the University of Michigan Medical School as a component of the university's continuing education program. This portal, still in progess, will highlight the school's OER and target it to professionals in the field. In addition to the intrinsic benefits of OER, the Medical School will be able to generate revenue from the fee that users must pay for CME credit.
Hewlett Foundation Health OER Team
In November 2008, the Hewlett Foundation, who funds many of the projects mentioned in this chapter, announced a one-year program to develop a sustainable and scalable health OER program in developing countries to address the healthcare worker crisis. The 2009 program is a collaborative effort between the University of Michigan, a non-profit organization called OER Africa (headquartered in Nairobi), and four partner institutions in Africa: The Kwame Nkrumah University of Science and Technology (KNUST) (Ghana), University of Ghana (U-G), University of Cape Town (UCT) (South Africa), and University of the Western Cape (UWC) (South Africa). The four African universities (KNUST, U-G, UCT, and UWC) are creating the learning resources. OER Africa is providing policy and higher education administration expertise. University of Michigan is providing technical assistance with clearing the resources for copyright concerns and OER publication.
Evaluation: SWOT Analysis
Health OER is a relatively new field even in comparison to OER in general. In order to assess the progress and potential of health OER, this section will include a detailed SWOT analysis of the field. A SWOT Analysis is a strategic tool used to analyze the Strengths, Weaknesses, Opportunities, and Threats of a given program or policy. The strengths and weaknesses dimensions will refer to advantages and disadvantages in the existing health OER materials and projects. The opportunities and threats sections will explore the advantages and disadvantages which surround the wider adoption and use of health OER.
Strengths in current Health OER materials and projects
- Wide variety of resources available
- Participation of prestigious institutions ensures high-quality materials
- Business model is less threatened by OER
- International collaboration on the creation of materials increases the likelihood the material generated will be contextually appropriate.
- Materials often include factual representations of data (such as x-rays and chemical structures), which though 3rd party, are not protected by copyright, meaning we can keep more of the original content.
Weaknesses in current Health OER materials and projects
- Material is arcane and requires a medical professional to translate or provide context
- Most materials are in English. However, due to the licensing structure, which is often under Creative Commons, translation is permitted and in fact encouraged. The challenge is finding entrepreneurs and/or volunteers to translate the materials. At Tufts, eighteen courses have been translated to Chinese. In order to mitigate concerns about the accuracy of translations, the institution offers a split screen to view the original and the translated material simultaneously.
- Poses additional privacy concerns in the clearing process
- Searching is difficult – need additional metadata, a method to search across repositories as well as by competency.
- Most of the current resources are at the higher education level
- Little assessment done so far. One of Tufts’ goals is “tom measure the impact of the [OCW] initiative in a systematic way."  – Use web analytics, online surveys, and interviews with contributors. It is difficult to capture user feedback, especially from those who may have access to the Internet only for the limited time that it takes to download the resources.
- “Limited global awareness of OCW has precluded widespread use, particularly within health sciences communities.” 
- Fulfills a market demand by providing necessary training materials to narrow the gap between the demand and supply of healthcare workers
- Distance learning
- Generous funding opportunities for global health are available from foundations
- Health science schools within universities generally have more research funding than the humanities departments and have more funds for investing in efforts such as OER
- Broadband connectivity
- Limited hardware availability
- Communication across distance is difficult for co-authors
- Competition between medical institutions makes sharing of materials unlikely
The previous section identified projects which have been in existence for at least one or two years. The resources generated from those projects are at least partially published. There are, however, two projects in their early stages that are worth noting.
Search across health OER repositories
It is difficult to search health OER materials. University of Michigan is currently investigating a framework to search across health OER repositories. This interface would serve as a central location for dynamically searching a variety of health OER repositories, from universities to professional associations from courses to image libraries. This is an ambitious project and the short-term goal is to create user scenarios, identify necessary metadata for functionality, and develop a functional architecture for this interface. This research is complementary to Creative Commons' work on DiscoverEd , an aggregated search across large cross-subject OER search engines such as OER Commons.
OER as curriculum foundation for the first Dental School in Liberia
In 2007, Nejay Ananaba, a Liberian student from the University of Michigan School of Dentistry, had a dream to establish the first dental school in Liberia. The West African nation of Liberia suffered fourteen years of civil from 1989 to 1993. This political upheaval resulted hundreds of thousands of refugees. Ananaba's family is among the many who left the country during that time. Safety was a much higher priority than health and oral health. As as result, according to World Health Organization estimates, there are only three dentists in the country.  Through the Student Leadership Program at the School of Dentistry, Ananaba is able to carry out her plan. With 2014 as the target opening date for the school, Ananaba has been begun planning every detail of the school from architecture to funding to staff to curriculum. She plans to use OER as the basis for the curriculum in order to save costs and build on the existing Dental OER from University of Michigan, KNUST, and Tufts University.
This chapter has provided an introduction to health OER, a specialized field of OER focusing on the health sciences (medicine, dentistry, nursing, public health, and kinesiology). There is a diverse collection of individuals and groups involved in the development of health OER, from universities to nonprofit organizations to professional associations. They have equally diverse motivations, including the improvement of materials, personal or institutional reputation, strengthening professional development, and cost savings. Though the field is relatively new, the breadth and depth of projects in this field is rapidly growing. Our evaluation demonstrates that there has been great progress made and even more potential possible in the impact of health OER on professionals, students, and patient outcomes and educations. There is, however, much more to be done in terms of assessment, ease of searching, distribution, and contextualization (e.g. translating, audience-level) - especially in developing countries.
- Stern, David and Ted Hanss. "Outline for OER in Health Whitepaper," http://docs.google.com/Doc?id=ah736fgqh95c_143gc2wv4gr
- Ted Hanss, ET Staff meeting (find another source)
- citation - Global Reach?
- World Health Organization. Working Together for Health: The World Health Report 2006. WHO Publications: Geneva. 2006.
- “The nursing shortage in the United States of America: an integrative review of the literature.” Journal of Advanced Nursing.
- Add link to glossary and/or link to another chapter that discusses dScribe in more depth.
- Nejay Ananaba
- OCWC Health: http://www.ocwconsortium.org/health/
- Outline for OER in Health White Paper: http://docs.google.com/Doc?id=ah736fgqh95c_143gc2wv4gr
- Ted's Health OER Presentation, available http://mediaonion.com/si521/images/f/f6/20090312HealthOER.ppt
- "U-M receives grant to provide free and open, online electronic health professions educational materials." http://www2.med.umich.edu/prmc/media/newsroom/details.cfm?ID=207
- Ngugi, Catherine. "OER Africa A Rationale for Health OER in Africa."
- Ellaway, Rachel, Poulton, Terry, Fors, Uno, McGee, James B. and Albright, Susan (2008) 'Building a virtual patient commons',Medical Teacher,30:2,170 — 174: http://dx.doi.org/10.1080/01421590701874074
Appendix 1: Participating Institutions
- United States
- Medical School
- School of Dentistry
- School Kinesiology
- School of Nursing
- School of Public Health
- School of Pharmacy
- School of Social Work
- Johns Hopkins University
- Johns Hopkins Bloomberg School of Public Health: http://ocw.jhsph.edu/
- Massachusetts Institute of Technology
- Harvard-MIT Division of Health Sciences and Technology http://ocw.mit.edu/OcwWeb/Health-Sciences-and-Technology/index.htm
- Mt. Sinai
- Tufts, http://ocw.tufts.edu/
- School of Dental Medicine
- School of Medicine
- Friedman School of Nutrition and Science Policy
- University of Argentina
- University of Ghana
- Kwame Nkrumah University of Science and Technology
- South Africa
- University of Cape Town
- University of the Western Cape, http://freecourseware.uwc.ac.za/
Appendix 2: Participating Organizations
- OER Africa, http://www.oerafrica.org/Default.aspx?alias=www.oerafrica.org/health
- Peoples Open Access Education Initiative, Peoples-uni http://peoples-uni.org/, http://courses.peoples-uni.org/
- OERC, Open Educational Resources for Cancer http://teachingcommons.cdl.edu/oerc/index.html
- MERLOT, Multimedia Educational Resource for Learning and Online Teaching http://www.merlot.org/merlot/index.htm
- Health Sciences
- Technical Allied Health
- MedEd Portal, http://www.aamc.org/mededportal
- Campus Virtual de Salud Pública, http://www.campusvirtualsp.org/
- Health Sciences Online, http://www.hso.info/
- MedScape, http://www.medscape.com/
- U.S. Dept of Health and Human Services: Health Resources and Services Administration (HSRA) Literacy, http://www.hrsa.gov/healthliteracy/training.htm
- International Institute of Medicine, http://www.iom.edu/
- GHEC: Global Health Education Consortiumm http://globalhealthedu.org/Pages/Default.aspx
- Canadian Association of Continuing Health Education, http://www.cachecanada.org/index.php?option=com_docman&task=cat_view&gid=45&Itemid=33
Appendix 3: Funding Sources
- Hewlett Foundation
- Gates Foundation
- The Development Gateway Foundation
- Clinton Global Initiative, http://influence.forumone.com/index.php?url=archives/266-Who-is-Using-Open-Education-to-Support-Global-Health-Are-You.html