Education and Information Technologies

, Volume 21, Issue 5, pp 991–1005 | Cite as

Didactic and technical considerations when developing e-learning and CME

  • Ellen te Pas
  • Margreet Wieringa-de Waard
  • Bernadette Snijders Blok
  • Henny Pouw
  • Nynke van Dijk


Several usability issues were encountered during the design of a blended e-learning program for a course in evidence-based medicine for general practice trainers. The program was developed in four steps. We focused in this article on step 2 and 3. Step 2 focused on which educational principles to apply, that is, which learning theories, instructional designs and other theories should influence the program. Step 3 focused on the design elements, namely whether to use hypermedia and/or multimedia, and what screen design and which font to use. This article presents the important issues in designing an e-course and provides an impression of the complexity of designing high quality e-learning in particular for continuing medical education (CME).


Medical education Postgraduate education Pedagogical theory Pedagogical methodology Multimedia/hypermedia application 


Notes on contributors

Ellen te Pas is a registered nurse, educationalist and PhD student in the Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, the Netherlands.

Margreet Wieringa–de Waard is a GP and a professor of General Practice in the Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, the Netherlands.

Bernadette Snijders Blok is an educationalist in the Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, the Netherlands.

Hendricus Theodorus Pouw is a GP and a GP trainer in Health Center “Op maat”, Almere, the Netherlands and a former lecturer in General Practice in the Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, the Netherlands.

Nynke van Dijk is a clinical epidemiologist. She holds a Master’s in Health Profession Education, and works as an assistant professor in General Practice in the Department of General Practice/Family Medicine, Academic Medical Center, University of Amsterdam, the Netherlands.

Conflicts of Interest

This study was financed by CASH (commission to stimulate activities regarding GP training) of the SBOH. The SBOH is the employer of GPs in training, and finances all Dutch GP training programs.


  1. Bliuc, A. M., Goodyear, P., & Ellis, R. A. (2007). Research focus and methodological choices in studies into students’ experiences of blended learning in higher education. The Internet and Higher Education, 10(4), 231–244.CrossRefGoogle Scholar
  2. Brandsford, J. D., Brown, A. L., & Cocking, R. R. (2000). How people learn: brain, mind, experience, and school. Washington: National Academy Press.Google Scholar
  3. Calcaterra, A., Antonietti, A., & Underwood, J. (2005). Cognitive style, hypermedia navigation and learning. Computers & Education, 44(4), 441–457.CrossRefGoogle Scholar
  4. Case, R., & Bereiter, C. (1984). From behaviourism to cognitive behaviourism to cognitive-development - Steps in the evolution of instructional-design. Instructional Science, 13(2), 141–158.CrossRefGoogle Scholar
  5. Chandler, P., & Sweller, J. (1991). Cognitive load theory and the format of instruction. Cognition and Instruction, 8(4), 293–332.CrossRefGoogle Scholar
  6. Clark, R. C., & Mayer, M. E. (2008). E-learning and the science of instruction. San Francisco: Jossey-Bass.Google Scholar
  7. Cook, D. A. (2007). Web-based learning: pros, cons and controversies. Clinical Medicine, 7(1), 37–42.CrossRefGoogle Scholar
  8. Czabanowska, K., Klemenc-Ketis, Z., Potter, A., Rochfort, A., Tomasik, T., Csiszar, J., & Van den Bussche, P. (2012). Development of a competency framework for quality improvement in family medicine: A qualitative study. Journal of Continuing Education in the Health Professions, 32(3), 174–180.CrossRefGoogle Scholar
  9. Ellaway, R., & Masters, K. (2008). AMEE Guide 32: e-Learning in medical education Part 1: Learning, teaching and assessment. Medical Teacher, 30(5), 455–473.CrossRefGoogle Scholar
  10. European Health Forum Gastein. Possible shortage of up two million health care workers by 2020 - EU taking action to prevent impending crisis in providing health care. Website
  11. Fisser, P. (2001) Using Information and Communication Technology. Universiteit Twente. PhD Thesis, available:
  12. Furmedge, D. S., Iwata, K., & Gill, D. (2014). Peer-assisted learning - Beyond teaching: How can medical students contribute to the undergraduate curriculum? Medical Teacher, 1–6Google Scholar
  13. Gagne, R. M., Briggs, L. J., & Wager, W. W. (1992). Principles of instructional design (4th ed.). Fort Worth: Harcourt Brace Jovanovich College Publishers. Available: Accessed 29 September 2014.Google Scholar
  14. Garrison, D. R., & Kanuka, H. (2004). Blended learning: Uncovering its transformative potential in higher education. The Internet and Higher Education, 7, 95–105.CrossRefGoogle Scholar
  15. Hannafin, M. J., & Hooper, S. (1989). An integrated framework for CBI screen design and layout. Computers in Human Behavior, 5, 155–165.CrossRefGoogle Scholar
  16. Illeris, K. (2003a). Towards a contemporary and comprehensive theory of learning. International Journal of Lifelong Education, 22, 396–406.CrossRefGoogle Scholar
  17. Illeris, K. (2003b). Adult education as experienced by the learners. International Journal of Lifelong Education, 22, 13–23.CrossRefGoogle Scholar
  18. Jarvis, P. (2006). The theory and practice of teaching (2nd ed.). London: Routledge.Google Scholar
  19. Jochemsen-van der Leeuw, H. G. A. R., van Dijk, N., Etten van-Jamaludin, F. S., & Wieringa-de Waard, M. (2013). The attributes of the clinical trainer as a role model: A systematic review. Academic Medicine, 88(1), 26–34.CrossRefGoogle Scholar
  20. Keller, J. M. (1987). Development and use of the ARCS model of motivational design. Journal of Instructional Development, 10(3), 2–10.CrossRefGoogle Scholar
  21. Knowles, M. S., et al. (1984). Andragogy in action: Applying modern principles of adult education. San Fransisco: Jossey Bass.Google Scholar
  22. Koroghlanian, C. M., & Sullivan, H. J. (2000). Audio and text density in computer-based instruction. Journal of Educational Computing Research, 22(2), 217–230.CrossRefGoogle Scholar
  23. Mayer, R. E. (Ed.). (2005). The Cambridge handbook of multimedia learning. New York: Cambridge University Press.Google Scholar
  24. Mayer, R. E., Heiser, J., & Lonn, S. (2001). Cognitive constraints on multimedia learning: When presenting more material results in less understanding. Journal of Educational Psychology, 93(1), 187–198.CrossRefGoogle Scholar
  25. Melis, E., Weber, M., & Andrès, E. (2003). Lessons for (pedagogic) usability of eLearning systems. In A. Rossett (Ed.), Proceedings of World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education 2003 (pp. 281–284). Chesapeake: AACE.Google Scholar
  26. Merriam, S. B., Caffarella, R. S., & Baumgartner, L. M. (2006). Knowles’s andragogy, and models of adult learning by McClusky, Illeris, and Jarvis. In Learning in adulthood: A comprehensive guide (pp. 83–104). 3th ed. San Francisco: Jossey-BassGoogle Scholar
  27. Merrill, M. D. (1983). Component display theory. In C. M. Reigeluth (Ed.), Instructional design theories and models: An overview of their current status (pp. 279–334). Hillsdale: Lawrence Erlbaum Associates.Google Scholar
  28. Merrill, M. D. (2002). First principles of instruction. ETR&D, 50(3), 43–59.MathSciNetCrossRefGoogle Scholar
  29. Merrill, M. D., Drake, L., Lacy, M. J., & Pratt, J. (1966). Reclaiming instructional design. Educational Technology, 36(5), 5–7.Google Scholar
  30. Mishra, P., & Koehler, M. J. (2006). Technological pedagogical content knowledge: A framework for teacher knowledge. Teachers College Record, 108(6), 1017–1054.CrossRefGoogle Scholar
  31. Moreno, R., & Mayer, R. E. (2002). Verbal redundancy in multimedia learning: When reading helps listening. Journal of Educational Psychology, 94(1), 156–163.CrossRefGoogle Scholar
  32. Mousavi, S. Y., Low, R., & Sweller, J. (1995). Reducing cognitive load by mixing auditory and visual presentation modes. Journal of Educational Psychology, 87(2), 319–334.CrossRefGoogle Scholar
  33. Nadolski, R. J., Kirschner, P. A., & van Merrienboer, J. J. G. (2005). Optimizing the number of steps in learning tasks for complex skills. British Journal of Educational Psychology, 75, 223–237.CrossRefGoogle Scholar
  34. Nilsson, M., Ostergren, J., Fors, U., Rickenlund, A., Jorfeldt, L., Caidahl, K., & Bolinder, G. (2012). Does individual learning styles influence the choice to use a web-based ECG learning programme in a blended learning setting? BMC Medical Education, 12, 5.CrossRefGoogle Scholar
  35. Ormrod, J. E. (2009). Human learning (5th ed.). Upper Saddle River: Pearson Education, Inc.Google Scholar
  36. Ruiz, J. G., Mintzer, M. J., & Leipzig, R. M. (2006). The impact of E-learning in medical education. Academic Medicine, 81(3), 207–212.CrossRefGoogle Scholar
  37. Scheiter, K., & Gerjets, P. (2007). Learner control in hypermedia environments. Educational Psychology Review, 19(3), 285–307.CrossRefGoogle Scholar
  38. Siemens, G. (2005). Connectivism: A Learning Theory for the Digital Age. International Journal of Instructional Technology and Distance Learning, 2.Google Scholar
  39. Squires, D., & Preece, J. (1996). Usability and learning: evaluating the potential of educational software. Computers Education, 27(1), 15–22.CrossRefGoogle Scholar
  40. Steinberg, E. R. (1989). Cognition and learner control: A literature review, 1977–1988. Journal of Computer-Based Instruction, 16(4), 117–121. Validated: ACM Digital Library, Scholar
  41. Strickland A.W. (2006) ADDIE, Idaho State University College of Education Science, Math & Technology Education. Website Accessed 29 September 2014.
  42. Sun, P., Tsai, R. J., Finger, G., Chen, Y., & Yeh, D. (2008). What drives a successful e-Learning? An emperical investigation of the critical factors influencing learner satisfaction. Computers & Education, 50, 1183–1202.CrossRefGoogle Scholar
  43. Sweller, J. (1988). Cognitive load during problem solving: Effects on learning. Cognitive Science, 12, 257–285.CrossRefGoogle Scholar
  44. Sweller, J. (2005). The redundancy principle in multimedia learning. In R. E. Mayer (Ed.), The Cambridge handbook of multimedia learning (pp. 159–167). New York: Cambridge University Press.CrossRefGoogle Scholar
  45. Sweller, J., van Merrienboer, J. J. G., & Paas, F. G. W. C. (1998). Cognitive architecture and instructional design. Educational Psychology Review, 10(3), 251–296.CrossRefGoogle Scholar
  46. te Pas, E., van Dijk, N., Bartelink, M. E. L., & Wieringa-de Waard, M. (2013). Factors influencing the EBM behaviour of GP trainers; a mixed method study. Medical Teacher, 35(3), e990–e997.CrossRefGoogle Scholar
  47. Tindall-Ford, S., Chandler, P., & Sweller, J. (1997). When two sensory modes are better than one. Journal of Experimental Psychology: Applied, 3(4), 257–287.Google Scholar
  48. Trivette, C.M., Dunst, C.J., Hamby, D.W., O'Herin, C.E. (2009) Characteristics and consequences of adult learning methods and strategies. Research Brief, 3(1)Google Scholar
  49. University World News. Call for universities to respond to shortages of health professionals. Website 9 December 2012. Accessed 29 September 2014.
  50. van Merrienboer, J. J. G., & Kirschner, P. A. (2007). Ten steps to complex learning: a systematic approach to four-component instructional design (1st ed.). Oxford: Routledge.Google Scholar
  51. van Merrienboer, J. J. G., & Sweller, J. (2005). Cognitive load theory and complex learning: Recent developments and future directions. Educational Psychology Review, 17(2), 147–177.CrossRefGoogle Scholar
  52. van Merrienboer, J. J. G., Jelsma, J. J. G., & Paas, F. G. W. C. (1992). Training for reflective expertise: A four-component instructional design model for training complex skills. Educational Technology Research and Development, 40(2), 23–43.CrossRefGoogle Scholar
  53. Wikipedia Learning theory (education). Website Accessed August 8, 2013.
  54. Wood, D., Bruner, J. S., & Ross, G. (1976). The role of tutoring in problem solving. Journal of Child Psychology and Psychiatry, 17, 89–100.CrossRefGoogle Scholar
  55. Zufic, J., Kalpic, D. (2009) More efficient e-learning through design: color of text and background. World Conference on E-Learning in Corporate, Government, Healthcare, and Higher Education (ELEARN). Vancouver, Canada, Oct 26–30, 2009Google Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Ellen te Pas
    • 1
    • 3
  • Margreet Wieringa-de Waard
    • 1
  • Bernadette Snijders Blok
    • 1
  • Henny Pouw
    • 2
  • Nynke van Dijk
    • 1
  1. 1.Department of General Practice/Family Medicine, Academic Medical CenterUniversity of AmsterdamAmsterdamThe Netherlands
  2. 2.Health Center “Op maat”AlmereThe Netherlands
  3. 3.Academic Medical CenterAmsterdamThe Netherlands

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