Learning through computers and applying technology to clinical care will increase over time (1), particularly through the infusion of medical informatics (2, 3). Portable devices and software reduce the need for memorization and facilitate the process of decision-making by putting the knowledge that can reduce errors at one’s fingertips (4). This is important because medical students worldwide spend 33% to 50% of their total time learning basic science and then report the information is soon forgotten. Physicians also note they often do not use much of their previous knowledge in practice (5). Portable devices and software improve quality of care, safety, and documentation (6).

“Which technology should be used?” and “How should it be used?” are key questions for medical educators and administrators. The right context is needed for technology to succeed. Faculty and administration must examine mission(s), needs, attitudes, and technology infrastructure to best use technology in health care. Like other educational endeavors, trainee, faculty, and institutional goals must be aligned. Substantial change to the current methods of medical education is needed, though, and change is not easy to effect (7). Faculty development in the use of technology is needed to integrate technology into the curriculum. Financing new technologies and managing the change that technology will bring to medical education are serious challenges.

This article will provide a brief overview of key issues for educators and administrators related to the use of technology in medical education. It will discuss how to assess students', faculty's, and administrators’ knowledge, skills, attitudes, and experience with technology. Suggestions are provided to integrate technology into the curriculum by developing competencies in faculty (8) and managing change. Technology can help integrate education and administrative tasks. These issues will be explored in more depth in subsequent articles in this edition.

Most medical schools do not teach technology directly or assess its use, despite recommendations from the Association of American Medical Colleges (AAMC) Medical School Objectives Project (MSOP) and the General Professional Education of the Physician (GPEP) and College Preparation for Medicine report (9, 10). Schools instead focus on other important items future physicians “need” to know. They are also quick to determine whether a student will require summer training before school to satisfy prerequisites but do not formally consider fluency in technology a prerequisite. Some schools “add on” a technology course but do not integrate the technology into the curriculum.

Faculty, departments, and medical schools have a shared responsibility in the education of medical students, including the use of technology. This implies a potential shift in culture, from technology as an adjunct service to part of the primary mission. The first step is an assessment of knowledge, skills, attitudes and other experiences with technology. They also need to examine how technology affects the process of medical education, psychiatric education, and administration.

The integration of medical education and informatics programs can improve learning and clinical care (Appendix 1). Among the major changes on the horizon for programs, preferred or not, are the following:

Needs Assessment of Computer Literacy

A needs assessment is a starting place for setting priorities regarding technology. Systematic assessments are very limited to this point. An assessment generally measures participants’ knowledge, skills, behaviors, and attitudes related to technology (12). Faculty also need to assess their own learning and teaching styles and adapt them to technology (13, 14).

Faculty and trainees may have different needs. Faculty are less confident and have more anxiety than trainees when using handhelds or PDAs in their practice (15). The use of PDAs is on the rise, but only 26% to 50% of faculty use one on a regular basis (16–18). Faculty are able to see potential applications of virtual simulation exercises in medicine (19), but they have had negative experiences with technology (e.g., tedious computer systems). A lack of infrastructure, time, and skills contributes to faculty frustration. They do not “computerize” their teaching or practice without support (20).

Technology is most useful when it helps faculty “function” better or more efficiently (Appendix 2). Therefore, an assessment should focus on how the technology will help them perform and how they “collaborate” with it.

Learning How to Teach With Technology

Most medical schools need demonstrations, lectures, small-group tutorials, hands-on labs, and task-based assignments on technology for faculty, not just students. Rather than taking a CME course, faculty may learn better longitudinally with an informatician, librarian, or other computer staff. One way to address trainee and faculty needs is through a longitudinal seminar of evidence-based medicine, co-led by a faculty member and a technology expert, and through employing technology every step of the way. This format meets the MSOP’s plan, which suggests featuring lifelong learning through technology in health care management. The “technology educator,” an expert in the department, can mentor these faculty and serve as a role model for students.

Teaching With Technology

Teachers have to decide how and when to use technology. It may be used as an organizing tool or as a supplement, but it must be integrated into curricular content (Appendix 3). Investment in computer-aided instruction with multimedia and simulators could pay off significantly. Computers can help skill acquisition in many fields, including novice and intermediate levels of instruction (21, 22). Psychiatric educators believe that such programs could demonstrate symptoms, teach diagnostic skills, and provide feedback on communication skills (23). A computer-assisted assessment program has been applied to teach communication skills in an objective structured video examination (OSVE), and for problem-based learning tasks, as well (24). This format is more reliable and valid than oral examinations and more reproducible than objective structured clinical examinations (OSCEs) (25). Quota systems are starting to guarantee that students have enough clinical encounters with patients of a given diagnosis, and computer simulations make this easier to accomplish (e.g., using virtual reality for a psychosis tutorial rather than sending students off-site to see patients with schizophrenia) (11).

PDA technology and other innovations are becoming commonplace in practice. PDA software has been evaluated on at least 40 clinical and 40 nonclinical parameters (26–29). It has also been used to enhance communication, house drug databases and guidelines (30–31), write prescriptions (e.g., iScribe) (28), and reduce documentation errors (32). Programs can specifically collect data on depression and anxiety (33) and assist with diagnosis (DSM-IV-TR software, DepressQ and ManiaQ, and DiagnosisPro).

Hospitals are now automating assessments of patients (e.g., telephone, Web, and other) and computerizing all medical records, prospectively. Difficulties include changing handwritten tasks to a technological format and integrating information between technologies. These obstacles are being overcome, however, and soon electronic medical records will become the standard (11, 34). In the business world, hard-copy newspapers had to make this shift or risk losing advertising revenue to e-newspapers and their Web resources.

Academic institutions have limited resources, change missions, and skew priorities toward revenue. Though schools have more faculty now than in the past, fewer are actually “available” to teach or practice medicine. Faculty report too many demands on their time and view technology as another “problem” or budgetary item rather than as help. A lack of computer literacy in leadership, changes in technology, and fear of technology itself are also barriers. Costs mount with each change.

An integrated approach with incentives for all parties is needed. A collaborative academic network based on technology is in place at several institutions (Figure 1). The overall framework uses technology to integrate materials, methods, and administration. The trainee is the centerpiece of a collaborative learning environment, assisted by the computer, faculty, and system.

Cost analyses used in other areas of medicine apply to technology. Economic assessment methods include cost description, cost comparison, cost minimization, cost-effectiveness, and cost-benefit analysis (35, 36). The results of such assessments vary for the institution, department, faculty or trainee. The bottom line is that there needs to be a return on investment. Cost analyses become less worrisome if users see high value in the use of technology. Similarly, if analyses seem more favorable when a “critical mass” is reached (e.g., number of computers purchased, high utilization of technology), which leads to integration of information, reducing requirements on less efficient procedures of the past. In some instances, e-integration could save a lot of money, though initial investments are often needed (6).

Institutional change occurs at multiple levels, ranging from the administration to trainees (7). Faculty, staff and trainee change requires a buy-in, rewards, defined leaders, and accountability. Institutions change based on their mission, funding, (re-)organization of leadership (e.g., assistant dean of informatics), and faculty. Opportunities may also come from changes in the curriculum, such as Liaison Committee on Medical Education (LCME) “suggestions” and AAMC recommendations. Too often, with all that is going on, administrators “depend” on these outside agencies to promote change, or are newly willing to “bend” when pressure is applied.

For a medical school, some technology interventions add quality control, automated decision-making, and other advantages. User-friendly computerized protocols, clinical pathways and guidelines can reduce resistance while improving the delivery of care, educating physicians and automatically providing administrators with data. Access to patient information from multiple points-of-service helps improve delivery of care. However, practice and feedback are needed, along with further incentives to learn the new technology and clearer definitions of exactly how that technology will benefit the faculty member (20, 37).

Physician response to technology also depends on personal styles, attitudes, and familiarity with technology, to name a few. Most learners (80%) have some anxiety trying something new, but will do it if there is a good reason to do it. The definition of “good” is obviously important. About 10% of learners will avoid technology at about any cost and 10% are enthusiastic early adopters. Those who enjoy learning to use a new technology generally report excitement, see opportunities of what it can do, feel “better” for doing it, and link it with past positive experiences (7). Naturally, learners gauge others’ responses, with negative attitudes reducing the likelihood of progress (38).

Medical schools, departments, and faculty have little choice but to examine how technology can be integrated into education and clinical, administration and research activities. An assessment of knowledge, skill needs, interests, and experience is critical to identify barriers and solutions to technology implementation. The use of technology should also “fit” participants’ needs. Faculty development programs should try to embrace technology as much as possible. Change is difficult, but it is necessary to keep up with discovery and improve health care delivery. Institutions must also reassess their mission, priorities, existing resources, and funding to increase the use of technology in medical training and education.