Chapter 62
Distance education
J. Tobey Clark
WHO Collaborating Center for Health Technology Management, Technical Services Partnership,
University of Vermont, Burlington, VT, United States
Introduction
Distance education has existed for nearly 300 years since
Caleb Phillips from Boston, USA offered training in short-
hand via weekly lessons communicated via US mail. This
was the start of “correspondence” courses. Distance learn-
ing degrees were established in 1858 at the University of
London as part of its external program offering (Wikipedia,
n.d.). An advantage of this type of learning was that it served
the less-affluent student. In addition, Open Universities
formed to support this learning alternative.
The first electronic distance learning took place over the
radio airways beginning in the 1920s. In the United States,
public school systems and universities began to use radio
broadcasts for education. When television was established
as a common media source, this was also used for educa-
tion. Although educational television initially was not suc-
cessful, efforts by the California state universities were
productive in establishing telecourses via TV with later
successes put forth by the US Public Broadcasting Service
(Wikipedia, n.d.).
The first quality interactive video/audio distance edu-
cation began to take place over proprietary networks and
high-speed phone lines in the 1990s. Multiple high-speed
Integrated Services Digital Network (ISDN) phone lines
were ganged together to provide enough throughput for
smooth video and audio communications. Companies such
as Polycom were major players during this time frame.
The institution of the Internet has caused a paradigm
change in distance education. When the standard Internet
Protocol (IP) was first created, local area networks at vari-
ous colleges and companies began to be interconnected
into the global Internet. This allowed email to be sent and
received globally. The next technological step was the cre-
ation of the World Wide Web which allows properly for-
matted “web pages” to display text and pictures via the
Internet. However, the speed of the Internet did not allow
practical interactive communications until the 21st century.
Internet-based distance education has grown exponentially
410
during the current century. Although the distance learning
initially started in publicly funded state schools and com-
munity colleges along with private schools, it now is of-
fered by top universities such as Harvard and Stanford. In
the United States in 2011, a study showed at one-third of
all the students enrolled in postsecondary education had
taken an accredited online course (Growth for Online
Learning, n.d.).
Methods of distance education
The two primary modes exist for distance education over
the Internet: synchronous and asynchronous. Synchronous
education is scheduled educational sessions which may be
or not be interactive. This modality initially started with
a “talking head” approach with video of instructor lectur-
ing in the classroom. Added to this approach was the in-
clusion of PowerPoint slides, videos, or other multimedia
and, most importantly, interactive capabilities. Most have
interaction via a chat line with the instructor although voice
communication and polling of the participants is now read-
ily available. The distance learning event may be recorded
for asynchronous presentation. A common synchronous
method utilized typically for short courses and single pre-
sentations is the webinar.
Asynchronous education is not scheduled with online
materials, quizzes, exams, and interactive activities avail-
able on an unscheduled basis. The 24 × 7 availability of these
courses offers maximum flexibility time wise for learning
and is well suited for adult, working learners. Interaction in
the course takes place via written messages or audio/video
posts to discussion boards, forums, wikis, and blogs.
It should be noted that for today’s classroom courses,
there is also typically an online component. Materials for
the course, assignments, schedules, etc. may be online,
while classroom activities focus on activities best suited to
the live classroom. This movement is called blended or hy-
brid learning. This has also led to a significant movement to
the “flipped” classroom where students learn the concepts
Clinical Engineering Handbook. https://doi.org/10.1016/B978-0-12-813467-2.00063-8
Copyright © 2020 Elsevier Inc. All rights reserved.
 Distance education Chapter | 62  411

and topics online and then come into the classroom to com- Biomedical Anglia Ruskin Masters
plete their assignments, work in interactive groups, or per- Science MSc University
form laboratory exercises in the classroom. (n.d.-b)
A second differentiation of Internet-based distance Biomedical Nottingham Trent Masters
learning is paced versus self-paced courses. Paced courses Science MSc University
are education where readings, assignments and, for synchro- (n.d.-c)
nous courses, lectures, and presentations are all scheduled. Nano- University of Certificate
This is the most common method for university courses biotechnology Kaiserslautern
to allow completion over semester periods. Self-paced (n.d.)
courses typically allow complete flexibility in completion Risk University College
of individual assignments, but often have a course due date. Assessment and Cork
Everything is online with quizzes and exams typically au- Implementation of
tomatically graded with pre-written feedback regarding Health and Safety
incorrect answers. Students involved in self-paced courses Management
Program (n.d.)
typically are self-motivated to take the course to learn and
have the self-discipline to complete the course by the due Biomedical Ulster University BSc Honours
date. Science BSc (Hons) articulation
(n.d.) pathway for
biomedical
Healthcare technology distance learning science sub
degree graduates
A number of educational institutions, associations, and
Medical and University of Courses
other organizations have distance learning courses in the diagnostic devices Bergamo
area of healthcare technology. The course topics and degree Also, general
(University of
engineering
programs include technical training, biomedical and clini- Bergamo, n.d.)
courses
cal engineering, healthcare technology planning and man-
agement, and biomedical equipment technician education. Study portal/ Variety of US Twenty-one
distance learning universities masters level bio
Here are some of the offerings for healthcare technol-
portal courses and biomedical
ogy distance learning courses, certificates, and degree (Bio & Biomedical engineering
programs: Engineering courses
Masters, n.d.)
Program name Institution Type
Electrical Stanford Graduate
Clinical University of Masters in engineering University, Center certificates
Engineering Connecticut Engineering biomedical for Professional
(University of in Clinical courses (Stanford Development
Connecticut, n.d.) Engineering University, n.d.)

Biomedical University of Course sequence University of University of Programs in

Equipment Vermont with three 100% Management and Management and engineering
Technology online courses Technology (n.d.) Technology management,
Sequence and one lab information
(University of course technology,
Vermont, n.d.) and health
administration
Biomedical and University of Leeds Postgraduate
Healthcare Ethics Certificate Bioengineering University of Masters of
(n.d.) (Distance Maryland Engineering
Education
Health Technology University of Masters, diploma, Graduate
Accrediting
Assessment Glasgow and certificate certificate in
Commission, n.d.)
Program (n.d.) programs engineering

Biomed Online London Short course,

(n.d.) Metropolitan continuing In the United States, ABET accreditation is the standard for
University professional engineering. ABET has criteria for evaluating online pro-
development
grams. As of 2018, there are no online programs accredited
Biomedical University of Masters, diploma, by ABET for biomedical or clinical engineering (ABET,
Science MSc Greenwich and certificate n.d.) although 30 plus other engineering and engineering
(n.d.-a) programs
technology programs (disciplines) are accredited. There
412  SECTION | 6  Professionalism, education, and ethics
is an organization that accredits online programs—The
Distance Learning Accrediting Commission (University of
Maryland, n.d.).
Webinar training is a common way for primarily work-
ing clinical engineers and other biomedical technology pro-
fessionals to learn. Some of the webinars and webinar series
are coordinated by:
● American College of Clinical Engineering (ACCE)
– Educational Webinar Series
– Clinical Engineering Certification review course
● Atlantic Canada Clinical Engineering Society for
Clinical Engineering Professionals
● Association for the Advancement of Medical
Instrumentation (AAMI)
– AAMI University—topics for CE, BMET, industry
delivered primarily via live webinars and on-demand
webinars
● ECRI Institute
– Various health technology topics
● MD Publishing
– Webinar Wednesday—various biomedical technol-
ogy topics
● Engineering for Change
● Healthcare Information Management Systems Society
(HIMSS)
● University of Vermont, CertNOW CBET certification
review course
Example online training program:
University of Vermont
Capacity building in the area of biomedical technology and
clinical engineering is greatly needed. As online training is
rapidly advancing worldwide due to the availability of com-
munication networks and devices including computers, tab-
lets, and smartphones, this can be a viable option with the
great advantage of accessibility. By using the information
resources of the World Wide Web, the training can be robust
using online platforms. In addition, online training has no
costs or lost time for travel to a classroom, and asynchro-
nous training allows maximum flexibility.
Virtual education was successfully applied by the
University of Vermont in technical courses for the Americas
(Clark, 2012). Beginning in 2006, the University of Vermont
began development of basic and advanced online, interac-
tive courses. The course development was funded by the Pan
American Health and Education Foundation. These bilin-
gual (English and Spanish) courses were primarily for tech-
nical staff in hospitals—facilities, electricians, electronics,
maintenance, and other technical personnel. They were also
suitable for those educated as engineers but without train-
ing in medical equipment. Other healthcare staff such as
nursing, clinicians, and managers also would benefit from
the courses. The two bilingual courses developed—Patient
Care Equipment and Technology, and Advanced Medical
Equipment Systems, resulted from a collaboration between
the University of Vermont (Burlington, USA), Pontificia
Universidad Católica de Peru (Lima, Peru), and Universidad
CES (Medellin, Colombia). The courses were offered by all
three universities and later put on the online platforms at
Universidad Technological Nacional (Mendoza, Argentina)
and the Pan American Health Organization (PAHO) Virtual
Campus for Public Health (Washington, DC). The PAHO
course was taught in both English and Spanish.
The course learning objectives are to:
1. provide a basic understanding health technology life
cycle, environment of care, regulations, preventing and
correcting equipment problems, anatomy/physiology,
engineering concepts, and common medical equipment
technologies,
2. help students better communicate with clinical and other
healthcare staff involved with medical devices, adminis-
tration, and equipment vendors, and
3. develop the student’s interest, and prepare them for further
study and more advanced application of the principles.
Methods
The course utilizes web-based content including text, pho-
tos, diagrams, flow charts, other figures, video, audio, links
to other websites, interactive tools, and other web attributes
to deliver content to students. The course is 100% online.
The areas covered for each medical technology included
in the courses are:
1. Device principles
2. Proper clinical application
3. Patient safety
4. Common device/technique problems and resolution
5. Maintenance and quality assurance
6. Technology management (Table 1)
Student evaluation and grading
Ten quizzes—one for each module of one or more topics.
Two exams—cover the first and second half of the
course.
Five discussion questions and responses—the discus-
sion questions require research and may cover con-
troversial subjects. They promote engagement as each
student has to not only answer the questions but also
offer a response to another student’s answer.
Over 1000 students from Colombia, Peru, Mexico,
Venezuela, Uruguay, Costa Rica, Bolivia, Brazil, Uruguay,
Paraguay, Chile, Argentina, Puerto Rico, Dominican
Republic, Barbados, Jamaica, Grenada, Antigua, St. Lucia,
 Distance education Chapter | 62  413

TABLE 1  Topics covered in the Univ. of Vermont online biomedical technology courses.
Patient care equipment (basic course) Advanced medical equipment systems
Healthcare technology overview Advanced technology in health care

The environment of care Imaging: image quality

Regulations and standards Imaging: radiography

Quality assurance and preventative maintenance Imaging: fluoroscopy

Preventing and resolving equipment problems Imaging: computed tomography (CT)

Anatomy and physiology Imaging: nuclear medicine (NM)

Engineering concepts Imaging: magnetic resonance imaging

Electrocardiography (ECG) Imaging: ultrasound

Blood pressure monitoring Medical imaging networks

Pulse oximetry Telemedicine

Apnea monitoring Electronic health record/medical device interoperability

Fetal monitoring Radiation therapy equipment (RT)

Incubators and infant warmers Clinical lab equipment—basic

Phototherapy Clinical lab equipment—advanced

Defibrillators Surgical systems: minimally invasive/robotic

External pacemakers Surgical systems: electrosurgery

Infusion therapy devices Surgical systems: lasers

Ventilators Physical therapy equipment

FIG. 1  The planning and management course topics follow the diagram.

Belize, British Virgin Islands, St. Vincent, St. Kitts, Turks
& Caicos, France, Spain, China, Trinidad and Tobago,
Dominica, Barbuda, Guyana, Bahamas, Anguilla, Honduras,
Cuba, El Salvador, Panamá, Ecuador, Nicaragua, and the
United States have taken these courses.
In 2008, a third 100% online course was independently
developed covering healthcare technology planning and
­ anagement and has been taught annually at the University
m
of Vermont, USA. In 2015, the course was then taught on the
PAHO’s Virtual Campus for Public Health (Clark et al., n.d.).
The original English course was translated to Spanish and
adapted to Latin America with additional content created by
Rossana Rivas. Rivas and Clark coordinated and taught the
Spanish and English versions of the course, respectively (Fig. 1).
414  SECTION | 6  Professionalism, education, and ethics
The Healthcare Technology Planning and Management
online course provides students with a basic understand-
ing of the principles of healthcare technology planning and
management using the life-cycle diagram developed by the
Technical Services Partnership at the University of Vermont—
assessment, replacement, budgeting, acquisition, deployment,
education, patient safety, and maintenance. Planning and
management is focused on not only medical equipment, but
also clinical information systems and converged technolo-
gies. Clinical engineering department setup, attributes and re-
sources are also presented along with professional and global
CE activities. Although quizzes and exams play a role in this
course, the discussion forum and reports are graded at a higher
weight for the planning and management course.
In the most recent course taught on the PAHO platform in
2017, the student selection process was coordinated from the
PAHO Washington DC office and involved interaction with
the WHO regional and country offices in the Americas. In
all, 64 successfully completed the course with 49 graduating
with excellence or distinction. The most engaging aspect of
this asynchronous course was the quality and volume of dis-
cussion board question answers and response to other partici-
pants. Students used real-world examples of their healthcare
technology planning successes, challenges, and experiences
in their countries in posting to the discussion board and for
the three required reports. Feedback from course participants
indicates that they wish to use the course learning to train oth-
ers in their health system in the concepts presented, apply the
knowledge for projects such as implementation of electronic
health records, policies for acquisition requests, criteria for
equipment replacement, and expanded resources for mainte-
nance based on justification from the course.
Advantages and limitations of distance
learning
Asynchronous distance learning has many advantages. The
list below covers some of these:
● 24 h/day, 365 days’/year access as online educational re-
sources always available
● Learning can take place such that it does not interfere
with work or other activities
● Cyberspace—no limitation on the location of the learn-
ing, you just need a computer and connection
● No travel time or travel costs—gas, parking, tolls, or
tickets are required
● A major advantage is that you have the full use of the
World Wide Web resources
– Documents
– Tutorials
– Case studies
– Scenarios
– Videos
– Academic, YouTube, Industry
– Computer-based simulations
Synchronous distance learning offers most of the
same advantages with the exception of participants hav-
ing to be available based on a schedule. However, inter-
active activities such as live discussions, group projects,
and timely question and answer are an advantage over
asynchronous learning. Also, participants can see from
the talking head lecturer areas of emphasis from voice
and body language. The same is true for video chat rooms
and project groups.
Disadvantages of distance learning fall into two primary
buckets. The most commonly cited issue is the impersonal
nature of distance learning. Not being in person with the
instructor and classmates takes away the human interac-
tion. Communication can be immediate regarding whatever
question pops into the student’s head or what idea the stu-
dent wants to share with his group. Live classes promote
comradery. The second disadvantage is related to the lack of
hands on activities including laboratory exercises including
building, testing, and repairing medical equipment. There
have been some advances which try to provide a laboratory
experience in distance learning though simulations, tactile
feedback systems, and virtual reality.
Future trends
Distance learning will continue to expand in its use particu-
larly for useful purposes in blended/hybrid courses, for topics
which lend themselves to online education such as computer
science, mathematics, medical terminology, and other courses
involving concepts that can be fully presented on a computer
screen or involve significant memorization. Interactive courses
will expand is use while self-paced, noninteractive courses
may lose their appeal. One area sure to expand is learning
technologies geared for smartphone use. Smartphones are
highly prevalent even in the low- and middle-income coun-
tries where the cellular networks provide better communica-
tion channels than wired or wireless Internet.
New areas of endeavor include virtual and augmented
reality. This is a technology being utilized not only by medi-
cal professional for clinical simulation training but also for
training biomedical equipment technicians how to repair
equipment (Hayhurst, 2018). Another area of interest is the
creation of a virtual world which is a computer-based simu-
lated environment which may be populated by many users
who can create a personal avatar, and simultaneously and
independently explore the virtual world, participate in its ac-
tivities and communicate with others (Virtual World, n.d.).
Summary
Distance learning has expanded exponentially from the
time of correspondence courses due to the power of the

Internet and high-speed communications of video and au-
dio. The expansion will continue with the move to smart-
phone use, virtual and augmented reality, and as a tool for
advancing blended-hybrid and flipped course structures.
With the advent of distance learning options for clinical en-
gineering through degree programs, online globally avail-
able courses, and webinars, the benefits will be increasing
for our field.
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