BRIEF
Stanford School of Medicine
E-Book Pilots
January 2013
Jamie Tsui, Stanford EdTech
Joe Benfield, Stanford EdTech
Dana Lin, MD, Stanford Department of Surgery
Julie Williamson, DO, Stanford Department of Pediatric Anesthesia
»» To investigate the rapidly growing field of e-books, Stanford School of Medicine
piloted the development and use of e-books in two residency programs.
»» Although e-books show much promise in usefulness and functionality, their authoring
process leaves much to be desired and file format standards are fragmented.
»» Residents who used the surgery residency e-book found it overall to be useful
and would recommend it to other residents.
Traditionally at the Stanford School of Medicine,
interns and medical students learn by immersion
in busy residency services. Often, residencies
provide residents with a “pocketbook guide”
to carry in their coats. However, the guides are
usually more than 100 pages, are awkward to
carry, and are not readily searchable. For these
reasons, residents might choose not to carry
the pocketbooks, and the appearance of insufficient use can deter some residencies from
even creating such a pocketbook.
The School of Medicine wanted to assess the
potential usefulness and viability of e-books
as replacements for the paper pocketbooks
in such real-world settings as the clinics and
the bedside. E-books are electronic book files
that can be opened using a variety of software
and hardware. Software for e-book readers can
be desktop- or laptop-based, can be specific
to operating systems such as Windows and
Mac OSX, or can be an “app,” which is software typically specific to mobile devices (such
as smartphones or tablets) that run a mobilespecific operating system (e.g., Android, iOS).
On the hardware side, popular devices such as
the Amazon Kindle and Barnes & Noble’s Nook
are specifically intended for e-book reading.
The Educational Technology group (EdTech)
at the Stanford School of Medicine offers annual
mini-grants to faculty and students at the
School of Medicine. For the 2011/12 academic
year the group selected two hospital residency
groups—surgery and pediatric anesthesia—
to try out e-books as replacements for the
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traditional pocketbooks. The project focused
on the authoring and publishing processes as
well as the response of the residents who were
to be the eventual users. This led to an assessment of which document formats (EPUB, MOBI,
PDF, etc.) and authoring tools (iBooks Author,
Vook, Microsoft Word, etc.) made the best fit
for faculty-created content.
Neither the surgery residency nor the pediatric
anesthesia residency had its own Stanfordspecific residency pocketbook, whereas other
residencies typically did. The surgery and pediatric anesthesia residencies sought to create
their own residency pocketbooks in an electronic format to correct these shortcomings,
with content suitable for other institutions as
well as a separate Stanford-specific section.
Surgery Residency Pilot Project
For the surgery residency, the project team—
which consisted of Jamie Tsui (Stanford EdTech)
working with Dana Lin from the Department of
Surgery—created a “Surgery Residency Survival
Guide” to address the critical point of transition
from clerkships to residency by providing a concise,
instantly accessible, action-oriented guide to clinical situations that residents and medical students
encounter daily in the surgical wards. Also, to
elevate the relevance and utility of the guide in the
Stanford context, the last portion of the e-book
included logistics and content specific to the
Stanford surgical training program, which further
orients the trainees and enables them to navigate
the system with greater ease and efficiency.
©2013 EDUCAUSE. CC by-nc-nd. 1
EdTech first met with the residency groups
to analyze and compare several different
e-book platforms and created a comparison
table of e-book file types and their features, as
well as a comparison table of e-book readers
and features.
On the basis of our assessment, EdTech
suggested the EPUB file format for the surgery
group because it is a free and open-source
electronic (e-book) standard widely used
around the Internet. EPUB files are readable by
a variety of devices and programs, including
computers, smartphones, and mobile tablets.
The format also supports embedded images
and hyperlinks, and many applications support
enhanced annotation and navigation functions for browsing EPUB files. By using the
Vook authoring tool, we would also be able
to easily generate a MOBI file (a file format
specifically for the Amazon Kindle application and devices) from our source content.
The idea was to offer residents the option of
using the Amazon Kindle device or application
if they preferred. After considering their needs,
the surgery group chose the EPUB and MOBI
file formats. Figure 1 shows the guidebook as
viewed on an iPad.
especially when it came to nested unordered/
ordered lists and Vook’s limited formatting
functions/options. The specific issues that
arose included the following challenges:
„„ Vook uses only Heading 1 and cannot create
subheadings within the ToC.
„„ Only one style was available for bulleted
lists.
„„ There was no capability to “redo” (Ctrl+Y
in Word) to expedite repetitive formatting
processes, so formatting large amounts of
similar-style text was labor intensive.
„„ There is no easy way to create a table
within Vook.
„„ Greek
characters
and
mathematical
symbols were lost and had to be added
manually after the formatting issues were
corrected.
„„ If changes were made after the Vook session
“timed out” and the author was unaware
(there is no indication that a session has
logged out automatically), edits since the
last autosave would be lost.
„„ Although adding anchors and hyperlinks to
text was seamless, Vook allowed anchors to
link only to text within the same section—
not to anywhere within the book, which
would have been useful.
„„ After the EPUB/MOBI files were uploaded
onto the e-readers, there were minor
differences in display (font sizing, display,
colors). Table formatting was often lost and
looked messy because many e-readers use
their own style to display them.
Figure 1. The Surgery Residency Guide E-Book in
iBooks on the iPad
Content Authoring with Vook
For the surgery e-book we chose Vook for
the ease with which it allows shared authoring
and the publishing of EPUB files, as well as
the bonus of outputting MOBI files. Its sharedauthoring capability let the content authors
work remotely from any web browser and
helped expedite both authoring and editing.
However, importing the text from its original source as a Microsoft Word document
into Vook’s web interface proved troublesome,
Ultimately, we were able to work around
these issues. Dana Yip, the surgical fellow
authoring the content for the surgery e-book,
summarized the process this way: “The Vook
platform is versatile and relatively straightforward to use.... It definitely has some limitations
requiring creative ways to organize and display
the text. In the end, the product appeared polished and professional.” Because our goal was
to overcome the shortfalls of traditional books,
we did not offer a print version of the e-book.
Evaluation by Surgical Residents
The surgery residency e-book was completed
and delivered to all new surgical residents
(more than 50 people) in both EPUB and
MOBI formats when they arrived in July 2012.
Approximately two weeks later, we conducted
a usage survey. Overall, residents found the
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guide useful but wished they could have had
access to it before starting their surgery residencies, which would have given them more
time to review the content before they were
inundated with their residency obligations.
„„ Residents overwhelmingly (94 percent)
said that they would recommend the
guide to other surgery residents outside
Stanford.
„„ Although other apps were also used, 70
percent of respondents said they used the
iBooks app to read their e-books.
„„ Thirty-eight
percent of respondents
reported finding the contents of the guide
extremely practical (rating of 5/5 on a
Likert scale), and the remaining 62 percent
said they found the contents very practical
or moderately practical (ratings of 4/5 and
3/5, respectively). No residents reported
that the content was not very practical or
not practical at all (ratings of 2/5 and 1/5).
„„ Ninety-four
percent reported that it
was moderately easy (rating of 3/5) to
extremely easy (rating of 5/5) to locate a
particular topic within the e-book. Only 6
percent reported that it was not very easy
(rating of 2/5) to locate a particular topic
within the e-book.
Although not all EPUB readers support syncing of annotations, we found storing the file
on a cloud storage system, such as Dropbox,
sufficient for most user situations. We also
found that the MOBI file worked well with the
Amazon Kindle’s Send-To-Device service and
that the annotation sync across devices also
worked seamlessly. Figure 2 shows annotations
on the iPad.
Figure 2. Sample Annotation in iBooks on the iPad
Pediatric Anesthesia Pilot Project
For the pediatric anesthesia residency, we
created an e-book for residents in the eightweek pediatric anesthesia rotation at Lucile
Packard Children’s Hospital at Stanford. The
e-book consolidates information from several
sources, including an informational website,
electronic textbooks, a journal club, and occasional simulation activities. With demanding
service requirements and work-hour restrictions, residents have little time to gather for
face-to-face teaching sessions. Additionally,
case exposure can vary dramatically from
month to month, and coordinating a longitudinal and consistent experience over the
rotation is difficult. The e-book was designed
to provide a site-specific rotation orientation
and curriculum that brings the resources of
Stanford’s education technology to Stanfordbased learners while remaining applicable to
any physician training in anesthesia.
Creating Content with iBooks Author
The pediatric anesthesia group—which
consisted of Joe Benfield (Stanford EdTech)
working with Julie Williamson from the
Department of Pediatric Anesthesia—chose the
iBooks Author format. The project group chose
iBooks Author largely because it can accommodate a wide variety of media types and
interactive elements in the e-book, which was
an important consideration for the pediatric
group, and also because EdTech was interested
in trying a different system for comparison with
Vook. iBooks Author is the word processing software on Mac OS; it exports .iba files for viewing
via the iBooks app on Apple’s iOS devices (e.g.,
iBook, iPad, iPhone). iBooks Author allows the
use of images, image galleries, audio, video,
animations, HTML widgets, and even simple
quizzing. In addition to its multimedia capabilities, iBooks Author is a fairly polished and
easy-to-use authoring tool with a relatively low
learning curve and several ready-to-use but
customizable book templates.
We used a standard iBooks Author template
as the base for a pediatric anesthesia rotation
orientation manual and a chapter on pediatric airway management. Figure 3 illustrates
the authoring tool. Most content authors were
comfortable with Microsoft Word. Importing
text from a Word file, however, required a level
of reformatting that made it easier to actually
recompose the document within iBooks Author.
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Quizzes were incorporated as pretest measures
of learning, but results cannot be saved, individualized, or graded. We hope the quizzing
capability will be expanded, as the current
workaround is to link to an online assessment
system website for these features. “Interactive”
images are more accurately described as annotated images.
We found the main advantages of iBooks
Author to be the beautiful format of the end
product and the relative ease of composition
without technical expertise in graphic design
(see Figure 5).
Figure 3. Creating Content in iBooks Author
A goal of the project included incorporating
all of the available iBooks Author widgets as a
means of testing each of their features. These
widgets include photo galleries, embedded
Keynote slide presentations, quizzes, embedded
video clips, “interactive” images (see Figure 4),
HTML links, and models that the reader can
manipulate to make them appear three-dimensional. Apple offers little official online support
for these widgets, but a growing amount of
third-party documentation is available through
iTunes.
Figure 5. Content from the Pediatric Anesthesia
Guide, Viewed in iBooks
Room for Improvement
Figure 4. Pediatric Anesthesia Guide Viewed in
iBooks, with Interactive Elements
Embedding slide presentations (used for
case studies) and video was straightforward
and highly effective. Hyperlinking was likewise simple and allowed for linking to private
content, such as faculty e-mail addresses
or pager numbers, behind authenticated
websites. Embedding photo galleries required
much more manipulation to achieve a consistent, professional aesthetic. The interactive
images (Collada files with the .dae extension)
had few applications for our purposes; they
are not widely available and were not used.
While iBooks Author did allow for several
content types, those types and their interactivity did not always live up to our expectations.
For example, images occasionally disappeared
spontaneously from the page when the orientation of the iPad changed. Other media types
remained on the page but required different
actions or gestures to engage interactive functionality. For instance, a “flick” may launch an
image gallery to full screen but will not expand
a still image to full screen. Changing a video to
display in full screen requires pressing a button
instead of using a gesture.
There were disadvantages beyond the
difficulty of importing Microsoft Word files.
Collaboration is relatively difficult compared
with simpler word processing applications,
such as Microsoft Word or Vook’s online
shared-authoring system. iBooks Author files
can be exported and e-mailed, but the e-mailed
files did not always display multimedia features
correctly when exported to iPads. Also, iBooks
Author e-books must be viewed with the
iBooks app (see Figure 6), which limits their
distribution; moreover, if a fee is to be charged,
the e-book can be distributed only by Apple.
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not yet known, as our pediatric anesthesia residency e-book is still in development.
Future Directions
Figure 6. Sample Pages from the Pediatric
Anesthesiology Residency E-Book, Viewed in
iBooks on the iPad
Although the e-book content itself belongs
to the author, the iBooks Author (.iba) format
is proprietary and uses undocumented extensions to XML and CSS. Furthermore, we have
concerns about how to control distribution
of the e-book and whether it is possible to
limit access to the e-book to a specific audience. Moreover, at this point there is no way to
collect data on how the book is used.
In summary, the iBooks Author software can
serve to create an attractive document with
rich multimedia content, but it is difficult to use
in a collaborative manner and Apple controls
distribution. The current level of true interactivity with the reader is low, but potential for
development is promising. User response is
The number of mini-grant applications that
EdTech has received shows a clear interest
among faculty for content development on
e-books. Faculty have requested videos,
quizzing, and other interactive elements in
e-books—features that are not all widely
supported in a standard format. Although we
looked at additional proprietary, feature-rich
platforms such as Kno and Inkling, we liked the
openness of the EPUB format, which lets users
choose how they want to peruse the content.
We also liked the MOBI format through
Amazon Kindle, which allowed the automatic
cloud syncing of annotations across devices.
Initial impressions are that iBooks Author is
promising, but as a standard it is somewhat
premature for adoption. Inconsistencies with
gestures, lack of documentation and tutorials,
and a limited distribution channel make us hesitant to recommend iBooks Author.
Overall, it is clear that the available e-book
authoring tools cannot fully meet faculty and
content-creator expectations for ease of use.
Because the e-book field is rapidly expanding
and developing, we expect to see better, more
user-friendly tools in the future. Also, until there
are compelling features to govern the choice of
a proprietary platform, such as iBooks Author,
we will continue to recommend EPUB as the
primary e-book format for content creators,
with the MOBI format a close second.
The EDUCAUSE Learning Initiative (ELI) is where teaching and learning professionals come to learn, lead, collaborate,
and share in the context of an international forum. Members benefit from the expansive emerging technology research
and development that takes place collaboratively across institutions. To learn more about ELI, visit educause.edu/eli.
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