Ann. Aledit. Burns Club - voL VII - n. 3 - September 1994

A MULTIMEDIA COMPUTERIZED TEACHING SYSTEM IN THE FIELD OF BURNS THE COMETT PROJECT OF THE EUROPEAN UNION

* Divisione di Chirurgia Plastica. 9 Terapia delle Ustioni, Palermo, Italy
** Service de Chirurgie Plastique et Est6tique, Rangueil, Toulouse, France
*** Unidad de Cirugia Plastica y Quemaduras, Madrid, Spain
**** Centre of Plastic Surgery and Microsurgery, Athens, Greece
***** Divisione di Chirurgia Plastica e Centro Grandi Ustionati, Turin, Italy

SUMMARY. COMETT (Community Programme for Education and Training in Technology) is an instrument proposed by the European Union to improve cooperation between universities, research institutes ang1the world of business. One of COMETT's objectives is to use this cooperation to accelerate the process of technological transfer from higher education institutions to industrial applications by promoting training courses using new technologies. In the spirit of the COME`IT project, in 1990 the Mediterranean Bums Club presented a proposal entitled "European network for the establishment of textual and iconographic documentation relative to bums in the Mediterranean area", with the objective of producing a training plan common to all the partners by the use of innovative technologies and in particular interactive multimedia applications. The main purposes of the project are to improve and make more uniform the level of professional specialization, to promote activities in the field of prevention, therapy and rehabilitation of the bum patient, and to improve care and rescue work in fire disasters. Five academic partners and one technical partner were involved in the preparation of the project. The system is a genuine teaching instrument that can be used both for training in the general field of bums and for in-depth study of specific issues. The technological solutions adopted in the project are described. The results obtained by the project can be summarized as follows: training of all the academic partners in the potentials of image processing systems; training in systems and methodologies for developing multimedia applications; production of a multimedia application on CD-ROM for use as a training instrument in Bums Centres for medical and paramedical personnel and as a teaching aid in university medical degree courses with particular reference to bums.

The European Community, now called the European Union (EU), has replaced the Common Market and now constitutes the world's second most important intergovernmental union, after the United Nations. It is a major international educational institution.

COMETT is the acronym for Community Programme for Education and Training in Technology. Launched in 1986 and renewed in 1990, it is one of the instruments proposed by the EU to improve cooperation between universities, research institutes and the world of business. One of COMETT's objectives is to use this cooperation to accelerate the process of technological transfer from higher education institutions to industrial applications by promoting training courses using new technologies.
Taking into account the special needs of small and medium-sized companies, COMETT has developed a highly efficient network of collaboration between universities, institutions and companies in EU countries in the field of training.
The Mediterranean Burns Club (MBC) was founded in 1983. An international organization comprising all the countries in the Mediterranean area, the MBC proposes to unite the capacities of all burn specialists in order to aria lyse common issues, analogies and contrasts in prevention of fire disasters and the treatment and functional recovery of bum victims.

Fig. 1 - "Burns": a multimedia teaching system in the field of burns.

These activities aim at analysing and evaluating the actual situation in the individual countries in order to promote contacts and comparisons on clinical, therapeutic, scientific, didactic and care problems, with a view to the elimination of existing divergences and weaknesses.
Among the various activities of the MBC (prevention, treatment, rehabilitation, response to emergencies, promotion of exchanges between Member countries, study, research, training and dissemination), the training of medical personnel in the various countries plays an important role by ensuring the continuous updating of specialist capacity in the sector.
In the spirit of the COMETT project, in 1990 the MBC presented a proposal entitled "European network for the establishment of textual and iconographic documentation relative to burns in the Mediterranean area", with the objective of producing a training plan common to all the partners by the use of innovative technologies and in particular interactive multimedia applications. In 1991 the European Union declared the proposed plan to be particularly interesting for approval, and gave the go-ahead for the project.
The opportunity was thus taken to rationalize all acquired knowledge by the creation of a text and image data bank through the collaboration of five European partners, to be used with appropriate multimedia instruments for the training of medical personnel working in burns cen~ tres, universities and hospitals.
The main purposes of the project are:

1. to improve and make more uniform the level of pro~ fessional specialization;
2. to promote activities in the field of prevention, therapy and rehabilitation of the burn patient;
3. to improve care and rescue work in fire disasters.

In the development of the project the MBC has played the role of the main contractor and scientific coordinator, in collaboration with the five European academic partners, which are:

1. Centre of Plastic Surgery and Microsurgery, Athens, Greece. Director, Prof. J. 10annovich
2. Department of Plastic Surgery and Burns (Unidad de Cirugia Plastica y Quemaduros), Madrid, Spain. Director, Prof. V. Garcia-Torres
3. Department of Plastic Surgery and Burns Therapy (Divisione di Chirurgia Plastica c Terapia delle Ustioni), Palermo, Italy. Director, Prof. M. Masellis
4. Department of Plastic and Aesthetic Surgery (Service de Chirurgie Plastique et Esthétique), Rangueil, Toulouse, France. Director, Prof. M. Costagliola
5. Department of Plastic Surgery and Burns Centre (Divisione di Chirurgia Plastica c Centro Grandi Ustionati), Turin, Italy. Director, Prof. G. Magliacani

The necessary technical and information technology know-how for the project. was provided by INFORMED Ltd., a leading company in the field of information technology and multimedia communication, which was thus the technological partner in the project.
For the realization of the project a consortium was set up, with a Technical and Scientific Committee for the coordination of all activities. This Committee comprises two representatives from MBC, two representatives of the partners and a representative of the company. The Committee meets regularly at the seat of the MBC in Palermo. The Scientific Editor is Prof. S. W. A. Gunn, President of the MBC.
The Technical and Scientific Committee has been responsible for the choice of teaching topics, training activities at the Centres of the partners, and the correct Progress of the various phases of the project.

Fig. 2 - European Academic Partners of COME7T Project.

The aim of the project is to facilitate communication in the field of knowledge regarding burns and fire disasters in the Mediterranean countries in order to consolidate all relevant experience and improve care. This experience will be used to improve the training of medical and paramedical personnel who specialize in the treatment of burns, in the psychological and functional recovery of burn patients and in the prevention and management of fire disasters.
To achieve the training aims of the project, an interactive multimedia application was developed on CD-ROM that can be used by anyone with access to a personal computer.
This application is a genuine teaching instrument that can be used both for training in the general field of burns and for in-depth study of specific issues. The application's multimedia interface and its case and immediacy of use make it a particularly flexible product that can be handled by various categories of users: medical students physicians specializing in burns paramedical personnel engaged in burn patient care medical, paramedical and nursing teachers voluntary workers and the general public as regards prevention, first aid and initial response in fire disasters

Fig. 3 - The aim of the project: the CD-ROM as teaching instrument.

The combination of text, graphics, animation, sound, still pictures and moving images, presented in an overall communicative system, is defined as MULTIMEDIALITY (e.g. television is a multimedia communication instrument).

Fig. 4 - A Multimedia Interactive System: Reference Standard.

User-computer dialogue is defined as INTERACTIVITY (a TV remote control is a simple kind of interactive instrument, as is also the joystick in videogames, etc.).
INTERACTIVE MULTIMEDIA SYSTEMS combine communication instruments (texts, graphics, films, etc.) with the interactive technologies of computers (keyboard, mouse, joystick, remote control, touch-screen, etc.). The multimedia products that can be developed most effectively are related to sectors involved in increasing or modifying communication in the sense of greater clarity and incisiveness, especially when directed at nonspecialist users. Computer rooms for the management of interactive multimedia courses and computer "kiosks" or information booths are good examples of this kind of product.

Multimedia communication between user and computer is therefore based on greater interactivity and the possibility of presenting the same kind of information through various media. Recent studies have shown that the greater the number of media used to transmit a communication, the longer people can remember it. Also, it is by the process of interaction - meaning the two-way transfer of information - that communication becomes particularly effective. Some applications essentially exploit the potential of hypertexts in the organization of information; others simultaneously involve several users, distributing multimedia information between various work stations; while the most advanced aim at achieving a highly realistic level in the interaction between user and computer by generating sophisticated simulations of the surrounding world (virtual reality). The key elements for the creation of an interactive multimedia system are:
Technologies based on personal computers combining text, images, sounds and animation, to form a single message that is rich in information and effective at the communication level.
A highly facilitated interaction in order to shift the emphasis of the communicative process to the user who thus participates directly in the action. A complete and well-structured program which at the opportune moment makes it possible for the video windows to fill with moving images, the icons to transform into cartoon images, and the graphic and acoustic signals (words or music) to become standard forms of communication between user and system by means of simple commands.
These systems also make it possible to assess the user's learning progress by providing objective ele ments for self-testing and reviewing of the teaching pro grams.

Five laboratories in five Burns Centres in Greece, France, Italy and Spain collaborated in the standardized collection of textual and iconographic material Each Burn Centre is equipped with personal computers, laser printer, modem for data transmission and application software for the development of the project. To render the Centres operative, the COMETT project provided for training courses to be held in turn in each of the four countries concerned. The object of the courses at the Centres has been to give training in the use of interactive multimedia programs and technology, in order to provide a common text and icon development program.
At each Centre, besides the analysis and drafting of the texts relative to the topics assigned to it, a team of specialist physicians, Computer experts and multimedia technicians supervised a procedure of selection, preliminary image digitalization and processing, producing a first print-out of the material. The five laboratories were coordinated by the Mediterranean Burns Club in Palermo, which acted as the centre for the collection and further processing of images, revision and analysis of textual and iconographic material, and assessment of the product received, preliminary to the realization of the final product. The MBC laboratory acted as a central data bank, constituting the archive for the assessment, updating and conflnuous enhancement of the multimedia application in its preparatory phase, until the achievement of the intended objectives and the actual production of the finished product.
As technological partner, INFORMED, an information technology company specializing in the medical and scientific field, collaborated directly with the scientific partners in the organization and definition of the standards neces sary for the implementation of all the interactive multimedia applications.

Fig. 5 - Effectiveness of systems communication: comparison between Multimedia and others.

INFORMED also had the task of designing and reali- 4. Toulouse zing the hypertext navigation system and the user-interface, performing the final processing of images and text, 5. Turin and producing the CD-ROM. The joint activity of the Centres, the MBC laboratory and the INFORMED company made it possible to create a complete training system that is scientifically valid and technically advanced. The project has realized the following objectives:

1. a multimedia system developed on CD-ROM that can be used as:

• a training instrument in burns care departments for medical and paramedical personnel
• a teaching aid in medical degree courses
• an educational tool for prevention, first aid, etc. for the general public and voluntary organizations

2. a network of laboratories for image filing with a central coordination base at the MBC in Palermo the training of specialized medical personnel in the treatment and therapy of burns using advanced technology systems
3. the training of technicians capable of managing technology for the processing and filing of iconographic and textual data using multimedia systems exposing non-medical firefighting personnel to burns problems The specific scientific contribution of each partner to the general issue of burns has been distributed as follows:

Fig. 6 - INFORMED, the technological partner of COMETT Project

1. Athens Enteral nutrition Pain
2. Madrid Sepsis Immunology Local therapy
3. Palermo Prevention Physiopathology Reanimation therapy Psychological and functional recovery Fire disasters Surgical therapy Parenteral nutrition

Characteristics of the "Burns Disease" CD-ROM

1. The CD-ROM on burns is an instrument that can be consulted autonomously. The hypertext offers a rapid and effective analysis of the problems arising in hospitals that admit burn patients. This organic consultation by specialists and other physicians is performed by following training modules on issues developed by the scientific partners. The modules can be compared with training courses. CDROM is an efficient computerized training tool.

Fig. 7 - Specific scientific contribution of each Partner

1. CD-ROM is a distance training tool for medical and paramedical personnel. It can be used as a specialized teaching aid in degree courses in the burns field. The product has been issued in two versions, English and Italian, and other translations are envisaged.
2. Consultation of CD-ROM requires a PC with an Intel 80386 microprocessor, MS-DOS 5.0 operating system or later versions and Windows 3.1, 4 Mb Ram, hard disk, mouse, VGA card, colour monitor, CD-ROM reader and audio card with loudspeakers. The audio card and loudspeakers are not essential but strongly recommended for better communicative results, as all the texts can be heard and/or visualized.

When a CD-ROM is installed in a CD-ROM reader -after an initial phase of guided procedures necessary for the installation of the program on the user's PC - access is obtained to the menu of the multimedia hypertext.
The user in sequence presses the buttons referring to the chosen topic, in progressively greater detail, arriving finally at the pages selected. In order to navigate in the program in general and in the context of the selected page in particular, the mouse is used to select squares called "buttons" or "icons" to be found on- every page of the program. These groups of "buttons" or "icons" on every page help users to find a series of information about the program in interactive fashion. In this way they can go deeper into the scientific teaching content of the various topics included in the program.

Fig. 8 - CD-ROM "BURNS": consultation requirements

For example: the book icon indicates the possibility of viewing the written text relative to the chosen subject; the magnifying-glass icon provides a more detailed in-depth study of the. subject processed by the same logic - a green lens means that there are in-depth studies, a red lens means that there are not; the forward arrow icon scrolls the following pages, allowing continuation of the same subject in the same fashion as the previous page; the reverse arrow icon returns the user to the previous page; the loudspeaker icon starts the spoken commentary related to the pages and images where the icon appears; the index icon, like the analytic index in a printed book, makes it possible to select the page regarding a chosen subject; and the menu icon is for return to the general menu in order to set out again from the starting point of the program.

Fig. 9 - The "Icons": The program navigation multimedia system

One section of the program shows in detail the meaning of all the icons; this section can be called up from any page by pressing the question-mark icon. At every page selected an image appears which can then be integrated, using the loudspeaker and book icons, by an animation and spoken commentary and by a written text. At the end of the description the navigation icons can be used to interact with the program for in-depth studies of the subjects treated.
All these steps are normal and usual procedures in computer-based training systems.

The results obtained by the project can be summarized as follows:

• training of all partners in the potentials of image processing systems
• training in systems and methodologies for developing multimedia applications
• production of a multimedia application on CD-ROM for use as a training instrument in Burns Centres for medical and paramedical personnel and as a teaching aid in university medical degree courses with particular reference to burns.

These results correspond to the results planned in the drafting phase of the project.
The project has thus achieved its dual target of training personnel in the use of multimedia information technology instruments and of producing a publication on burns based on experiences in the Mediterranean area in the form of an interactive multimedia hypertext developed on CD-ROM.
Innovative technologies have been employed to integrate the expertise possessed by the partners in the various Mediterranean countries in burn-related themes. The overall information assembled in the project constitutes a single corpus of knowledge that can be used for the training of large numbers of persons in university medical structures (medical researchers and university students) specializing in the field of the prevention, treatment and functional recovery of burns, in countries that are Members of the Mediterranean Burns Club.
As a subsidiary benefit, the product will make it possible, on the one hand, to guarantee the continuous training of specialized medical personnel working in burns centres in various hospitals and, on the other, to educate the general public in terms of prevention and service.
The various partners have been actively engaged in promoting the use of interactive multimedia applications, especially as regards training in schools and university courses, and the European Union has acknowledged its utility.
A traditional-type text on burns is being written in collaboration with the various partners in the project. In printed form this will cover the same subjects as those treated in the multimedia product.
It is expected that INFORMED will market the multimedia application not only as an autonomous teaching aid for specialist training but also as an information technology support for the companion book that we intend to publish. This is a joint forward-looking effort in education.

RESUME. COMETT (Programme Communautaire pour l'Education et la Formation Technologique) est un instrument proposé par l'Union Européenne pour améliorer la coopération entre les universités, les centres de recherches et le monde industriel et commercial. Un des buts que le projet COMETT s'est fixé est d'utiliser cette coopération pour accélérer le processus de la transmission de la technologique de la part des centres d'enseignement supérieur vers les applications industrielles, en favorisant les cours de formations qui utilisent les nouvelles technologies. Dans l'esprit du projet COMETT, le Club Méditerranéen des Brûlures en 1990 a présenté un projet intitulé "Réseau européen pour la constitution de documentation textuelle et iconographique relative aux brûlures dans la région méditerranéenne", avec le but de produire un plan de formation commun à tous les partenaires à travers l'emploi de technologies innovatrices et en particulier les applications multimédiales. Les objectifs principaux sont d'améliorer et d'uniformiser le niveau de spécialisation professionnelle, de promouvoir les activités dans le champ de la prévention, la thérapie et la rééducation des brûlés, et d'améliorer les soins et les opérations de secours dans les catastrophes d'incendies. Cinq partenaires académiques et un partenaire technique ont collaboré dans le projet. Le système est un instrument authentique pour J'enseignement que l'on peut utiliser pour la formation dans le champ général des brûlures et pour les études. approfondies des problèmes spécifiques. Les solutions technologiques sont décrites. Les résultats obtenus sont en bref les suivants: formation de tous les partenaires académiques dans les potentialités des systèmes d'élaboration de l'image; formation dans les systèmes et les méthodologies pour le développement des applications multimédiales; production d'une application sur CD-ROM pour utiliser comme instrument de formation dans les Centres des Brûlés pour le personnel médical et paramédical et comme outil pédagogique dans les cours universitaires qui s'occupent en manière particulière des brûlures.

MULTIMEDIA BIBLIOGRAPHY

1. J. A. Waterworth, Multimedia. tecnologia e applicazioni, Padova: Muzzio 1992.
2. Massimo Giustiniani, Roberto Bonazzi, Comunicazione e multimediatiO. Guida teorico-pratica alla realizzazione di sistemi multimediali efficaci. Collana informatica domani, Franco Angeli, Milano 1992.
3. Gaetano Kanizsa, Grammatica del vedere, 11 Mulino, Bologna 1980.
4. Barbara Minto, Dall'idea at testo, Isedi, Torino 1988.
5. Josef Albers, Interazioni del colore, Pratiche editrice, Parma 1991.
6. Giorgio Fioravanti, 11 manuale del grafico, Zanichelli, Bologna 1987.
7. Massimo Giustiniani, Macchine parlanti, Franco Angeli, Milano 1990.
8. Pierluigi Ridolfi, Multimedialit~: Tecnologie e applicazioni, Collana informatica domani, Franco Angeli, Milano 1992.
9. Philip Shaddock, Multimedia in pratica, Mcgraw-Hill libri italia srl, Milano 1993.
10. Multimedia - Comunicazione, formazione e tectrologie, Torino.
11. Annuario italiario del multimedia 1993, Torino.
12. Virtual - Mensile di realO virtuale e immagini di sintesi, Milano.
13. Multimedia personal computing, Milano.

The interactive multimedia application, involving all the medical and scientific aspects of the project, had to be produced on a support that would allow maximum diffusion among the intended target users, i.e. medical and paramedical personnel in university and hospital structures.
In the first version of the project it was planned to issue the application on CD-I, which has certain advantages. But considering the limited diffusion of CD-I readers, it was decided to examine the alternative of issuing the application on CD-ROM. CD-ROM technology is today decidedly more mature than CD-I technology, as a result of being on the market for some ten years.
CD-ROM technology requires memorization of information on a support similar to an ordinary audio CD, but it can be read by using a special reader connected to a PC.
For this reason, the CD-ROM target user is a person who already uses or has access to a PC. With this technology it is now possible to integrate alphanumeric characters, graphics, animated graphics, still images, moving images and audio, reaching and in some cases exceeding CD-I potential. The interactivity of the user-PC relationship is provided by the keyboard, mouse, touch-screen, etc.
Advantages: widespread diffusion of PCs in scientific circles; better quality of video interface; implementation of the applications through development environments on PC.
Disadvantages: use possible only on PC with CD reader.
In the light of comparison between the two technologies available, and considering the poor diffusion of CD-I, it was decided - at parity of cost for the development of interactive multimedia applications and also bearing in mind the target user to opt for CD-ROM, for the following reasons:

• it is better suited for a medical and scientific text
• CD-ROM readers are now available on any PC at reasonably low cost
• more and more classrooms are now equipped with PCs equipped with CD-ROM readers and multimedia peripherals