I

TELEMEDICAL EDUCATION:
TEACHING SPIROMETRY ON THE INTERNET
Esther H. Lum and Thomas J. Gross
Division of Pulmonary, Critical Care, and Occupational Medicine, Department of Internal Medicine,
University of Iowa Hospitals and Clinics, Iowa City, Iowa 52242

dvances in portable equipment have led to routine spirometry testing outside of

formal pulmonary function laboratories. Practitioners ordering these tests are not
formally trained in spirometry interpretation. Providing effective off-site training
can be challenging. Our objective was to develop a remotely accessible computer-based
tutorial for teaching spirometry interpretation to nonpulmonologists. We designed an
educational module that was accessible via the Internet and tested by 65 medical trainees
at a major university medical center. In addition, the module was posted within the
Virtual Hospital on the World Wide Web. Increases in spirometry interpretative skills
were assessed using pre- and post-tests submitted electronically. The spirometry module
significantly improved spirometry interpretation by nonspecialist trainees. This improvement included a broad increase in knowledge base and was observed independent of
training level and prior spirometry reading experience. We conclude that computerbased tutorials can effectively train off-site practitioners in spirometry interpretation.
This technology allows for the dissemination of educational material from a central site of
expertise and provides a valuable adjunct to limited teaching resources.

AM. J. PHYSIOL. 276 (ADV. PHYSIOL. EDUC. 21): S55S61, 1999.

Key words: pulmonary physiology; pulmonary function tests; Virtual Hospital; medical
education

The practitioners ordering these tests, however, may

not have had formal training in the performance or
interpretation of spirometry. Whereas automated interpretation programs are available, these rigid algorithms cannot, at present, fully replace an experienced reader (3). Educating primary caregivers in
spirometry interpretation could lead to more appropriate test acquisition, data utilization, and specialty
referral (4, 15, 16). Providing convenient, effective
educational opportunities for these off-site practitioners can be a daunting task. Increased personal and
institutional access to the information superhighway,
the Internet, offers new opportunities for the remote
delivery of computer-aided instruction (7).

Pulmonary function tests (PFT) are among the first

diagnostic studies employed in the evaluation of suspected lung disease. Indeed, the measurement of expired
airflow by simple spirometry is invaluable in many
clinical settings including the diagnosis and management of bronchial asthma, evaluation of chronic cough,
and quantification of disability impairment. Recent
innovations in PFT equipment have made portable
spirometry devices reliable and accurate (19). This has
allowed for the increasing use of simple spirometry in the
primary care setting. Thus spirograms can now be
performed routinely outside of traditional PFT laboratories in outpatient office practices, industrial clinics,
and community hospital emergency rooms (13, 19).

1043 - 4046 / 99 $5.00 COPYRIGHT r 1999 THE AMERICAN PHYSIOLOGICAL SOCIETY

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The University of Iowa has developed and instituted

an electronic medical education forum, The Virtual
Hospital (11). This multimedia, integrated teaching
package is accessible through the Internet (http://
indy.radiology.uiowa.edu/) and is also available to
University of Iowa-affiliated clinical outreach centers
via a statewide telemedicine network (17). We have
developed a computer-based educational module to
test whether such a teaching network could be used
to effectively improve spirometry interpretation skills
for off-site nonpulmonologists.

grams. The spirograms and clinical identifiers were

used as stems for R-type multiple matching questions
using the same list of interpretations as possible
answers for each question (5). A lead-in instructed the
students to choose the single best interpretation and
stated that each answer could be used once, more
than once, or not at all. The spirograms and the
designated correct answers were reviewed by clinical
experts in PFT interpretation (see above). These
questions were grouped as a pre-test that was taken
before reading the educational module. The same
series of spirograms was relabeled with different
clinical vignettes, randomly reordered, and presented
with the same set of potential answers as a post-test
immediately on completion of the educational module. Completion of each test triggered submission of
the results to a dedicated electronic mailbox. Feedback on performance was provided via electronic mail
to those who requested it.

METHODS
Educational module. Using published American Thoracic Society (ATS) guidelines, we designed a computer-based tutorial on the interpretation of simple
spirometry (1). In addition to stressing recognition of
specific disease patterns, standards for assessing spirogram quality were also addressed (2). To ensure that
our recommendations were consistent with standard
practice, the guidelines were reviewed and approved
by the University of Iowa Hospitals and Clinics PFT
laboratory director as well as an outside expert
reviewer (Dr. William Eschenbacher, Baylor College
of Medicine, Houston). Textual content was composed on the authors personal computer and then
transferred by electronic mail to the Virtual Hospital
librarian for conversion into hypertext markup language (HTML) files. Representative spirometry tracings were obtained from clinical spirograms performed at the University of Iowa PFT laboratory.
These figures were scanned into Adobe Photoshop
v3.0 (Adobe Systems, San Jose, CA) using a HewlettPackard ScanJet IIc and inserted within the text
document. To aid reader visualization, a normal volunteer (E. H. Lum) performing spirometry and the
flow-volume loop accompanying this effort were video
recorded (Sony Handycam, 8 mm). These video images were digitized and inserted with hot text buttons
within the body of the spirometry module.

Subjects were recruited from among the medical

students, interns, and more senior house staff rotating
through the Department of Internal Medicine according to a protocol approved by the University of Iowa
Institutional Review Board. Subjects were diverted
from scheduled noon conferences to an educational
resource center complete with multiple personal
computer stations that provided Internet access with
bookmarks directing them to the Virtual Hospital.
After a brief introduction, participants were free to
complete the pre-test, module, and post-test at their
own pace with the option of submitting their test
scores under pseudonyms. Those who completed the
exercise were compensated with a free meal.
Remote distribution of spirometry module. A site
was created on the Virtual Hospital that contained the
pre-test, module, and post-test. This site was posted
within the Pulmonary Core Curriculum section without specific advertisement or promotion. Respondents to the module who submitted the pre-test
and/or post-test were asked to identify themselves by
level of training and/or health care occupation using a
drag-down menu. Those who provided electronic
mailing addresses were given their test results and
explanations of any incorrect answers.

Spirometry interpretation testing. A series of 12

spirograms representing the entire range of material
reviewed in the educational module was collected.
For each, a brief clinical scenario was composed
detailing a fictitious patients age and sex and the
reason for ordering the patients spirogram. A series of
nine possible interpretations accompanied the spiro-

Data analysis. Test scores were reported as the

number correct out of a possible score of 12. The time

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are useful for both those in training as well as primary

caregivers in practice. Therefore, the change in preand post-test scores was examined for each trainee
subgroup to determine how previous knowledge base
influenced the effectiveness of the module. At all
levels of training, post-test scores increased significantly (Fig. 2). The greatest gain in scores was
observed among the medical students, who also
manifested the lowest average pre-test scores as expected on the basis of their limited experience with
the clinical use of spirometry (Fig. 2). Subgroups with
higher pre-test scores and, presumably, more experience with interpreting spirometry, still showed significant improvement in post-test scores (Fig. 2). Similarly, nearly all individuals improved their post-test
scores whether the pre-test score was above or below
the median for their respective trainee subgroup (Fig.
3). Thus spirometry interpretive performance improved
irrespective of training level or prior experience.

required to read the module and submit post-test

results was derived from log-on records and recorded
in whole minutes. Pre- and post-test scores were
analyzed using paired, two-tailed t-tests (Microsoft
Excel 5.0 for the Macintosh) with a P value of 0.05
considered a significant difference between population means. To limit the influence of outlying values,
data were also examined using median scores.
RESULTS
The spirometry module improved spirogram interpretation by trainees. The spirometry module was
administered to 65 participants, including 20 thirdyear medical students, 17 interns, and 28 senior house
staff. The test score results followed a normal distribution (Fig. 1) with scores improving from 6 0.3
(mean SE) on the pre-test to 8 0.3 correct answers
out of 12 on the post-test (P 0.001). Furthermore, the
median test score increased from 5 to 8 correct answers
out of a possible 12, demonstrating that the increase
in post-test mean score reflected overall group improvement and not simply individual high scores.

The spirometry interpretative skills improved

across a wide range of topics. The observed improvement in spirometry interpretation skills could
have resulted from learning a few novel facts or from a
more global educational enrichment. Analysis of individual test answers showed that for nearly every
question the percentage of correct responses increased (Fig. 4). The greatest gains appeared to

The spirometry module improves test performance at all levels of training. We are interested in
developing educational tools for off-site teaching that

FIG. 1.
The spirometry module improves spirogram interpretative skills. The spirometry module, with pre- and
post-test assessments, was administered to 65 participants. Test scores are distributed normally with improvement from 6 0.3 correct responses on the
pre-test (mean SE) to 8 0.3 correct responses out
of 12 total on the post-test (P F 0.001). Median score
also increased from 5 to 8 correct responses, confirming that improvement occurred across much of the
group.

FIG. 2.
Spirometry interpretation skills improve at all levels
of training. Test scores were subgrouped by participant training level. Data are displayed as median no.
of correct responses out of a possible 12; n no. of
participants. Note that the greatest improvement in
post-test scores was observed in the group with the
lowest pre-test values (medical students); however,
significant improvement was observed for all 3 subgroups (*P F .001, post-test vs. pre-test median).

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involve learning the grading schema for airways obstruction, recognizing variable upper airway obstruction, and identifying uninterpretable tests. Overall,
participation in the module improved spirometry
interpretation across the entire range of disorders
tested.
The spirometry module was brief and simple to
use. To model the experience of a remote user, our
test group gained access to the spirometry module
using the University of Iowas Internet provider. The
time required to read the module and complete the
post-test ranged from 25 to 30 min; those participants
at advanced training levels required less time (medical
students 30 2 min, senior house staff 25 2 min).
During the test sessions, few problems were encountered using or accessing the module, and most participants did not require additional directions. Thus this
self-directed educational tool was effective, time efficient, and user friendly.

FIG. 3.
The spirometry module improved interpretive performance independent of prior experience. Pre- and
post-test scores are shown for intern subgroup as no.
of correct responses out of a possible 12, where AQ
indicate individual participants; arrowheads depict
pre- and post-test median scores for entire intern
group. All but 2 participants (A and C) had an improved post-test score after completing the spirometry module. Individual post-test scores improved
whether the associated pre-test score was initially
above or below the group median. Similar findings
were observed for other groups tested (data not
shown).

The spirometry module was effectively disseminated via the Internet. The spirometry module was
incorporated within the Pulmonary Core Curriculum

FIG. 4.
Computer-based tutorial produced broad improvement in spirometry
reading skills. Analysis of submitted answers for individual test questions
showed that the percentage of correct responses increased for nearly
every question tested. The largest increase in correct answers appeared to
involve the learning of classification schema for grading airways obstruction (questions 1, 4, 10, and 12), recognizing variable upper airway
obstruction (UAO; question 11), and identifying uninterpretable studies
(questions 2 and 9). mod, Moderate; r/o, rule out.

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of the Virtual Hospital. The module was posted for 12

wk without specific advertisement. Despite this lack
of solicitation, the site received 4,000 hits representing the number of times the module was accessed. A pre-test was submitted by 122 participants
who identified themselves as medical students (53%),
house staff (12%), respiratory therapists (11%), and
others such as community physicians, nurses, and
non-health care workers. From those who offered
information up front and/or responded to follow-up
electronic mail, we were able to identify participants
from Canada, the United Kingdom, Italy, Malaysia,
Brazil, the Hawaiian Islands, and numerous sites
within the continental United States. We received 17
completed pairs of pre- and post-tests. All 17 respondents increased their scores, with a median improvement of 2 correct responses (range 1 to 4). Thus, with
the use of an existing electronic teaching network, the
spirometry module was internationally displayed and
accessed. For those motivated to submit pre- and
post-tests, use of the module improved spirometry
interpretation.

adhere to ATS guidelines (4). Thus there is an educational deficit among primary care providers in recognizing proper indications for and the correct interpretation of PFT that could negatively impact the delivery
of efficient, cost-effective health care.
In response to this educational need, we have designed a computer-based tutorial to teach spirometry
interpretation that is brief, effective, and widely accessible via the Internet. The criteria and guidelines set
forth by the ATS are emphasized in a user-friendly,
multimedia format. Our analysis demonstrates that the
spirometry module is educationally effective. Participants completing the module improved their ability to
correctly interpret spirograms (Fig. 1). This improved
performance was observed among all participants
independent of level of training or prior experience in
reading PFT (Figs. 2 and 3). Interpretative skills
improved across the range of patterns covered by the
module, demonstrating a broad-based increase in
knowledge beyond the acquisition of a few novel facts
(Fig. 4). Furthermore, the spirometry module can be
completed with minimal time commitment (30 min)
and little supplementary instruction, which will hopefully encourage additional sessions as needed.

DISCUSSION
As spirometry becomes more readily available outside
of traditional pulmonary function laboratories, it will
more frequently be ordered by caregivers who may
never have been formally trained in proper interpretation. This lack of instruction combined with an
emphasis on shifting diagnostic evaluations away from
specialized centers could lead to both misdiagnoses as
well as missed diagnoses. Indeed, the need for improved understanding of PFT indications and interpretation has been documented in other studies. A review
of PFT ordering patterns by primary care internists
and house staff at a community hospital found that up
to two-thirds of the studies requested were not fully
appropriate (16). Another study estimated that nonpulmonologists misinterpret spirometry up to one-third
of the time with errors in disease classification,
overreading of normal spirograms, and misreading of
abnormal studies that illustrated restrictive defects or
upper airway abnormalities (15). These authors suggest that standards for interpreting spirometry need to
be more readily available to primary care physicians
(15). Similarly, a recent Canadian study of PFT laboratories in British Columbia found marked interobserver
variability in interpretation of standard spirograms.
This variability was attributed primarily to failure to

The durability of the knowledge gained through

participation in the spirometry module was not assessed. The effectiveness of this computer-based tutorial was not directly compared with that of more
traditional printed texts or standard lectures on spirometry interpretation. Numerous other studies, however,
have confirmed the effectiveness of similar educational tools for teaching radiograph interpretation,
pulmonary auscultation, pediatric pulmonary diseases, and well-newborn care protocols (8, 1013).
Many of the participants in these studies preferred
computer-based techniques over more traditional devices with similar educational efficacy. We envision
computer-assisted learning serving as a welcome and
effective adjunct to more traditional curricula.
Certainly, computer-assisted learning has been integrated into the medical educational arena, and its
potential applications are seemingly limitless (7, 12,
14, 23). However, the real challenge lies in disseminating these educational opportunities to students and
practitioners who may not have immediate physical

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ing medical education offering through the Virtual

Hospital (http://www.vh.org/Providers/Simulations/
Spirometry/SpirometryHome.html).

access to the training center. Since computers entered

the medical workplace, their use has become increasingly routine, in both the office and the hospital. After
the spirometry module was posted on-line within the
Virtual Hospital, off-site trainees and primary care
practitioners from various countries around the world
accessed the tutorial. Pre- and post-tests submitted via
electronic mail were received, processed, and responded to without further user costs above those for
Internet provider access. Thus an effective educational intervention was distributed internationally using technology that allows for central quality control
and updating, around-the-clock access, and, if automated, immediate feedback to the participant.

In summary, we used a computer-based educational

intervention to effectively teach spirometry interpretation to nonpulmonologists. With the use of the Virtual
Hospital as a central repository, this information was
distributed to trainees and primary caregivers all over
the world. This teaching service is now provided to
many off-campus referral centers and outreach clinics
as part of a University of Iowa information network.
Soon such tutorials may be linked to computerized
pulmonary function reports, facilitating combined
distribution of clinical data and relevant educational
materials. Our preliminary study is not intended to
prove that electronic educational tools are necessary
or superior to current teaching practices. However, as
time and resources for medical education continue to
shrink, computer-aided instruction via the Internet
offers promising, cost-effective adjuncts to traditional
modes of education. In the future, we anticipate
greater development and implementation of similar
educational interventions.

Our study highlights several areas of concern that

must be addressed for remotely accessible computerbased learning to realize its full potential. First, the
quality of presented material must be assured. Although we incorporated the central features of the
ATS recommendations for spirometry standardization
into the module, clinical interpretative skills are subject to personal biases of the teacher. To maintain the
quality of its material, the Virtual Hospital has initiated
a peer review system akin to that used by standard
published journals. All material is confidentially critiqued on-line and submitted by electronic mail to
minimize response time; reviews are repeated with
scheduled regularity to ensure that material remains
current (Dr. Michael Peterson, Virtual Hospital Editorial Board, personal communication). Second, we
received several comments noting great variability in
the quality of displayed graphics and response times
for viewing video images. Thus the usefulness of a
multimedia educational tool may be limited by the
equipment available to the end user. This limitation
stresses the importance of striving to find applications
that function across multiple-user platforms. Finally,
although we were pleased to receive nearly 4,000
visits at the spirometry module site, completed test
pairs represented 1% of the total audience. To fully
engage the target audience, additional carrot-and-stick
incentives such as continuing medical education credits or special certification may be required (6, 9, 22).
Toward this end, the spirometry module has recently
been incorporated into a medical student minicourse along with other similar modules on acidbase interpretation and respiratory pathophysiology.
In addition, the module is also available as a continu-

We thank Teresa Knutson-Choi, Nola Riley, and the Virtual Hospital

support staff for expert technical assistance.
This work was supported, in part, by the American Lung Association of Iowa and a grant from the National Library of Medicine.
Address for reprint requests and other correspondence: T. J. Gross,
Room C33-GH, Div. of Pulmonary, Critical Care, and Occupational
Medicine, Univ. of Iowa Hospitals and Clinics, Iowa City, IA 52242
(E-mail: thomas-gross@uiowa.edu).
Received 23 July 1998; accepted in final form 10 February 1999.

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